Tag Archives: Green Mountain Care Board

GMCB Adds a Dab of Lipstick, Hopes You Won’t Notice It’s Still a Pig

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Well, that didn’t take long. In fact, it couldn’t have happened any faster.

Two weeks after public comment forced the Green Mountain Care Board to defer cancellation of a plan that might have led to a badly-needed increase in inpatient mental health beds, the Board came right back and went ahead with the deal today with minimal amendment. It stands essentially as it did before: it lets the University of Vermont Health Network off the hook for designing a new inpatient facility, thus closing the door on the best opportunity to resolve our 12-years-old-and-counting* crisis on inpatient mental health care.

*That’s the generous count, starting the clock with Tropical Storm Irene. If you want to include the dilapidated, outdated old state hospital, well, the crisis goes back a lot further.

The revised plan requires UVMHN to invest $18 million in boosting “capacity of mental health services in the state.” Not “inpatient,” mind you, but “mental health services” of any sort. The Board then punted review of UVMHN’s plan to the Department of Mental Health because, as Board member Jessica Holmes put it, “we’re not the experts” and DMH is.

It also allows the GMCB to wash its hands of the whole mess, but that’s just a bonus.

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We’re Not Retreating. We’re Advancing to the Rear.

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What is an institution to do when it makes a decision that kinda blows up in their face? Well, one option is to stick with the decision but modify it just enough to quiet the critics. Or to put it metaphorically, apply enough lipstick to a pig and make people stop noticing it’s a pig.

As it happens, two august Vermont organizations are currently engaged in the messy business of searching for the minimum acceptable capitulation. Vermont State University is trying to figure out how many books it will have to preserve, not because it wants the damn things, but because it desperately needs to quiet the howls of criticism; and the Green Mountain Care Board is looking for a way to give away $18 million while convincing us that they’re not giving away $18 million.

VSU’s nascent leadership continues to fumble its plan to close the campus library system… sorry, create something better than libraries… no wait, they’ll still be libraries but unencumbered by books… oops, now we’ve got a “refined plan” that will select the most academically important volumes while disposing of the rest. (You can tell they’re proud of their plan because they posted it online last Thursday with no formal announcement or public event of any sort.)

Gee, it’s almost as if the original plan was thrown together in haste with minimal forethought. Which inspires no confidence in the ability of this administration to lead a troubled system out of its current straits and into a better tomorrow. The future of VSU’s library system is way down on the list of critical issues to be addressed. If they can’t handle this without it blowing up in their faces, how will they address a massive structural deficit when they’ve already squandered their credibility dicking around with the library plan?

And all the while, they insist they’ll implement this vaguely defined thing by the end of June, come Hell or high water.

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Green Mountain Care Board Prepares to Punt Away an Investment in Inpatient Mental Health Care

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Our health care guardians at the Green Mountain Care Board are trying to sneak through a bit of business that combines bad policy with questionable procedure.

Well, I guess that explains the “sneak through” part. They can’t be proud of this.

Six years ago, the GMCB ordered the University of Vermont Medical Center to take $21 million in surplus revenue and spend it on developing a plan to boost inpatient mental health care, which has been abysmally lacking since Tropical Storm Irene wiped out the old state hospital in 2011. We’re now in our twelfth year of inadequate inpatient care that has left severely mentally ill patients languishing in emergency rooms and frontline providers dealing with the consequences.

The failure to address this situation ought to be a source of embarrassment if not shame to Our Political Leaders.

Anyway, it seemed like a decent idea: Let UVMMC use the surplus to tackle a challenge that nobody else would.

Well, now the GMCB is about to let UVMMC off the hook, further delaying any meaningful response to the shortage of inpatient care. And the Board trying to rush it through with the least possible fanfare.

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What Is This “Health Care System” Of Which You Speak?

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If there was an organizational chart outlining America’s process for supplying and paying for health care, it would look something like this. It’s not a “system” as much as a mare’s nest that grows more and more complicated — and less efficient and increasingly unjust — over time.

I’m guessing here, not a health care management expert or anything, but this mess has got to be costing us untold billions that might otherwise go to, I don’t know, making people healthier? There are inefficiencies, redundancies, and a massive amount of profit-skimming at every turn. That’s why other developed countries can provide much broader and more equitable coverage at a much lower cost. I have often thought that health care in America would be cheaper if we simply left big bags of cash everywhere.

Aside from the inadequacies and inequities of our “system,” there’s also the fact that it’s completely out of our control. Decisions made at high corporate levels trickle down like warm piss upon our heads, and damn but we’d better be grateful for the golden showers.

This line of thought was triggered by VTDigger’s story about likely reform efforts in the state Legislature. A story that could have been published, with alterations in the details, just about any time in the past. Yep, our health care “system” needs reform, and by God, our elected officials are gettin’ to work.

But the scope of that work will be limited indeed.

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The Dangerous Drift of Vermont’s Health Care System

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When he was governor, Peter Shumlin made a big push on health care reform. It didn’t end well for reform or for Shumlin. Since then, the system has become less functional and more expensive but there’s been no appetite for another push.

With one major exception, and that’s OneCare Vermont. It has soldiered on in its effort to rein in health care costs by paying providers for outcomes rather than treatment. It has spent a tremendous amount of money, but so far there’s not much evidence of impact.

That’s troubling, and it’s more so when you read VTDigger’s piece about the latest Green Mountain Care Board meeting. Beyond that, there’s a broader critique of our health care system in a recent series of essays by journalist and health care policy analyst Hamilton Davis. Taken together, it looks like a huge sector of our economy (upon which our physical and financial well-being depends) is drifting along with a bunch of people who call themselves “Captain” staying as far away from the helm as they can.

The Digger article makes the leaders of OneCare look like The Gang That Couldn’t Shoot Straight. The GMCB, especially its new members, were asking questions that shouldn’t have been tough to answer. For instance, do you have any evidence that your system is working? Can you point to measurable results in terms of cost savings or improved outcomes?

OneCare leaders seemed to be taken aback by this line of questioning.

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Court Locks Black Box

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Do high courts do Friday newsdumps? It would seem so. The Vermont Supreme Court issued a ruling on Friday, July 1 — heading into a three-day holiday weekend — with massive implications for independent oversight of OneCare Vermont, our favorite too-big-to-fail institution, and for the state auditor’s office.

The newsdump worked like a charm. VTDigger cranked out a quickie same-day story that hit the Internet at a time when lots of people had stopped paying attention to the news. By Tuesday, July 5, the decision had pretty much vanished from public attention. A strong statement from Auditor Doug Hoffer blasting the decision went largely unnoticed. But I sure hope responsible parties in the Legislature have taken note, because something needs to be done to fix this.

The unanimous decision denied Hoffer access to OneCare’s payroll information. He had sought access after OneCare’s payroll and benefits expenses jumped from $8.7 million in fiscal year 2019 to $11.8 million the following year. He understandably wanted to find out why. It’s an issue that should concern us all because OneCare is (a) kind of a rolling experiment that’s (b) playing with massive amounts of public money for which it is (c) not very accountable at all.

I’ll get back to OneCare, our most mysterious of public sector black boxes, but first I want to discuss the Auditor’s part of this. The court ruled that the Auditor has no authority in statute or in contract to access OneCare’s financial records. It asserted that financial oversight belongs solely to the Green Mountain Care Board, which is essentially OneCare’s captive partner in this grand experiment.

Well then, I ask, what in hell do we have an auditor for?

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The Curious Case of the Single Intolerable Word

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Gather ’round, children, and you shall hear… how Vermont’s biggest health insurer has gotten its knickers in a twist about one single word in a Green Mountain Care Board decision. The word was so objectionable that Blue Cross Blue Shield of Vermont appealed the decision solely because of that word. It did not object to any other part of the ruling.

When the appeal was denied BCBSVT took the case to the Vermont Supreme Court, where it awaits action. Seems like a whole lot of time, trouble and billable hours for a single word, but what do I know.

Let’s go back to the beginning. On May 7, Blue Cross Blue Shield of Vermont filed a request for 2022 insurance rates with the Green Mountain Care Board. The Blues asked for a 7.9% increase on individual policies, and smaller increases for group plans.

The request meandered through a lengthy series of briefs, filings, hearings and testimony. (All can be downloaded from this webpage.) On August 5, the GMCB issued its decision, knocking down the rate hike on individual policies to 4.7%. In its decision, the GMCB characterized the 7.9% request as “excessive.”

There. That’s the fatally toxic word. ‘Excessive.”

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OneCare: “Please make us too big to fail”

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As VTDigger reported a few days ago, Vermont’s public sector unions are feeling a little dubious about turning over their health care benefits to OneCare Vermont, the accountable care organization that’s beginning to develop a record of scoring own goals. For instance, OneCare seems to be (inadvertently, one would hope) doing its best to validate the unions’ concerns.

OneCare is in the process of seeking a dominant position in Vermont’s health care marketplace, by signing up as many groups and individuals as possible to its model of paying providers for outcomes instead of services performed. It’s the current hot idea in health care, and many smart people see great promise in it.

Of course, go back eight years and a lot of smart people saw great promise in then-governor Shumlin’s single-payer idea. And we know how well that went.

A little more than a month ago, OneCare went before the Green Mountain Care Board with a request for a $1.36 billion budget — a whopping 33 percent increase over last year’s. See, it’s been losing money and failing to produce the cost savings it promised.

OneCare’s explanation: It’s not big enough. Digger:

“We can’t measure success without scale,” [OneCare] CEO Vicki Loner told the Green Mountain Care Board at its budget hearing last month. The more people who participate, the more effective the system will be, she said.

Yeah, well, that may be true. But it’s also an invitation to pour more money down what might turn out to be a rathole. Loner is essentially saying that OneCare has to become too big to fail, merely in order to adequately test its health care model.

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I don’t know why Doug Hoffer puts up with our bullshit

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State Auditor Doug Hoffer is at it again, pointing out the turds in the carefully curated punchbowls of state government. This time, it’s OneCareVermont, the massive, publicly-funded and poorly-understood initiative that seeks to reinvent the economics of health care by paying providers per patient instead of per treatment. The idea is that providers will be incentivized to encourage health instead of waiting to treat disease. (Not that there’s any evidence whatsoever that doctors and nurses can effectively change lifelong behavioral patterns that lead to chronic conditions like obesity and diabetes, lookin’ in the mirror there.)

Of course, the entity seeking to reinvent health care is owned by the two dominant providers in the current system, University of Vermont Medical Center and Dartmouth-Hitchcock Medical Center. Kind of like the foxes guarding the henhouse, except they’re big ol’ grizzly bears.

Hoffer had the audacity to take a look at OneCare’s commitment to some creative community-based health programs, including efforts to encourage healthy food shopping and meal prep and providing palliative care. And he found — shocking, I know — that OneCare, having accepted millions in public dollars for those programs, had no evidence whatsoever that they had any effect. At all. (Link is to VTDigger’s story. You can read Hoffer’s memo here.)

In fact, the behemoth isn’t even pretending to try.

OneCare CEO Vicki Loner faulted Hoffer’s “expectation for documentation of every activity.” Instead, OneCare is evaluating the outcomes for the system as a whole.

Which, if true, is just fuckin’ dumb.

What kind of large-scale organization launches a series of initiatives with no intent to evaluate each one’s impact? If you’re evaluating the system as a whole, how do you figure out which parts of the system work and which are a waste of time and money? Do you think the good folks at Hannaford don’t bother to track sales and profit margins in each department (or in each individual store), as long as they’re getting good outcomes for their system as a whole?

Even worse, OneCare is taking public money for specific programs and refusing to be accountable for how effectively it’s being spent. Which is ironic, don’tcha think, for a so-called Accountable Care Organization?

But if you think Hoffer is getting a hero’s welcome for his work, then you haven’t been paying attention to his tenure as auditor. Because his reward never comes in the form of gratitude and promises to enact reforms. No, his work is greeted with deliberately misdirected criticism and claims that reforms are already in the works. And, as quickly as possible, his work is dumped in the circular file.

Like I said, I don’t know why he puts up with our bullshit.

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Single-payer price tag: the dollars matter less than what they bought

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Another fine “Fair Game” column by Seven Days politimeister Paul Heintz, most of which is an attempt to put a price tag on Gov. Shumlin’s failed pursuit of single-payer health care.

The takeaway number: $2 million. But that comes with some major cutouts; if you changed the ground rules, you could come up with a much higher number.

Heintz sought that number for ten weeks before the administration finally came up with it. And after all that time, all they did was add up two numbers: $597,000 to ten consultants, and $1.33 million spent on the governor’s Office of Health Care Reform.

However… the consultants and the OHCR weren’t the only people who put in time on single-payer. Work was also done by staffers in “10 offices, departments and agencies.” There was lobbying and flackery on behalf of single-payer. And many millions were spent on the Green Mountain Care Board and other entities that might not have existed, or been nearly so expensive, if not for their work on single-payer.

So, $2 million. Or a lot more, your choice.

The big question, though: was that too much? And the answer is, it depends.

If it was spent well and wisely, then $2 million or even $20 million would be a perfectly reasonable investment in research on a huge policy initiative. If it was spent poorly, then $2 million or $2,000 would be a waste.

So it depends. If you oppose single-payer, it’s an outrage. If you favor single-payer and believe the governor did his best, it’s reasonable.

And if, like me and many other single-payer supporters, you have your doubts regarding the administration’s performance, then that $2 million figure will make you a bit more queasy about the whole enterprise.

Urp.