Bill Schubart: The slow-motion implosion of the Vermont healthcare system


A postcard from the early years of Mary Fletcher Hospital in Burlington.

The oldest exposed reef fossils in the world are found at Isle LaMotte, Vermont, where they came to rest 480 million years ago after one of the most violent tectonic plate shifts ever on the surface of Earth. The fossils originate from Africa.

A less violent but equally destructive disruption is occurring in health care. Here in Vermont, we are witnessing the slow-motion implosion of our healthcare system driven by several increasing pressures: the lack of available staff at all levels, an aging and increasingly obese patient population, a global pandemic. that killed more Americans than the 1918 flu (of which we seem to have learned nothing), the lack of vision and leadership, and the overwhelming inertia of a system that evolved to protect the interests and privileges of all those who benefit from it, rather than fulfilling its mission of health and care of the population.

Let’s ignore the strangeness of the fact that the United States is virtually the only country in the civilized world without a national commitment to comprehensive health care for the people and some of the worst health outcomes, despite spending $ 4.2 trillion. dollars per year (18% of GDP) while enriching the insurance, pharmaceutical, medical device and hospital industries that feed on them.

Meanwhile, the average U.S. citizen paid $ 1,122 out of pocket last year for expenses like user fees for doctor visits, prescription drugs, or health insurance deductibles not covered by the ‘assurance.

Cuba, with one of the poorest economies in the Western Hemisphere, has a free national health care system considered a basic human right, and its health indicators are comparable to those of developed countries. It has an innovative community care model and the highest number of doctors per capita – one doctor for every 400 citizens.

When I traveled there in the early 1990s, I saw that they made regular home visits, educating Cubans on how to promote health and prevent disease – a stark contrast to our dismal investment in primary care. Today, Cuba is at the forefront of medical research in many countries and has authorized a vaccine against lung cancer in the United States.

Why are we so out of place when health care is a critical determinant of quality of life and longevity?

Although the current mainstream community complaint focuses on long wait times for appointments – a problem, as such delays can negatively affect outcomes (early diagnosis and treatment is the gold standard) – the issues affecting Vermont’s only tertiary care hospital system run much deeper. These include a lack of clear vision, poor governance, built-in conflicts of interest, and an acquisition strategy that consolidates power, creating an unchecked monopoly with no compensatory regulatory force.

Created in 2011 under the visionary leadership of recognized leaders in the health care system, the Green Mountain Care Board was to use its regulatory authority to “improve the health of Vermonters through a high quality, accessible, affordable and sustainable health system.” Since then, it has been largely politicized, serving supplier networks better than Vermonters.

Vermonters have significantly less access to care in the very institution responsible for implementing Vermont’s all payers model, and the affordability of health care continues to decline.

Acquisition mode

Over the past few years, UVM Health Network has acquired a large network of providers: six hospitals and all their physicians (UVM Medical Center, Central Vermont Medical Center, Porter Medical Center, plus three hospitals in upstate New York) ; OneCare Vermont, which is Vermont’s only responsible care organization; retirement homes (Copley Woodlands, Woodbridge, Starr Farm); Chittenden County Home and Palliative Care Visiting Nurses Association; as well as certain for-profit entities – Yankee Medical Equipment, Valcour Imaging LLC, Mediquest Corp. and PET Scan LLC.

The combination of these nonprofit and for-profit services – and the lack of clarity as to whether healthcare is a business or a civil right – only highlights the lack of regulatory safeguards governing monopoly health care. in Vermont.

The responsible care organization model of all payers in Vermont is the driving force behind health care reform. The two are interdependent. The all payers model cannot be successful without a functioning and accountable care organization. The state’s ACO, OneCare Vermont, receives money from payers (Medicare, Medicaid, and commercial insurers) and pays providers (hospitals, doctors).

The main goal of the all payers model is to move from fee-for-service to risk-based ACO payments (aka capitation). Still, OneCare has shifted less than 2% of total Vermont health care spending from fee-for-service to fixed-capitation forward-looking payments.

According to the Green Mountain Care Board’s own report:

“In 2019, of the value-based payments going through the ACO, only 13% of them were true fixed potential payments, meaning less than 2% of total health care spending in Vermont went through from fee-for-service to capitation of a fixed potential. Payment.”

The state auditor’s report on the costs of implementing the all-pays ACO model found that OneCare’s operating costs exceeded its savings, with net losses of $ 30.3 million.

OneCare has not met the required federal goals for the number of lives covered for four consecutive years (2018-2021). He also missed a major clinical goal, reducing suicide rates.

Other health professionals have also weighed in on the inherent flaws of ACO.

Virtual control

Conflicts of interest are now ubiquitous in the system. Since August 25, OneCare Vermont has been integrated into the UVM health network and Dartmouth-Hitchcock has left the partnership.

UVM Health Network now has virtual control over how Medicare, Medicaid, and commercial insurer money is spent. It will essentially pay itself through its ACO (the only ACO in Vermont implementing the all state payers model).

Dr. John Brumsted is President and CEO of UVM Health Network, Member of the Board of Directors of UVM Medical Center and Chairman of the Board of OneCare.

Al Gobeille, former chairman of the board of directors of Green Mountain Care and former secretary of the Vermont Agency of Human Services, is now executive vice president of hospital operations for the UVM Health Network, which owns and operates the UVM Medical Center and OneCare. As Brumsted’s second in command, Gobeille is considered by many to be his successor.

The board of directors of the UVM medical center – responsible for ethical and fiscal integrity, mission execution and annual performance review of the CEO of the UVM health network – is responsible for highly paid employees of the medical center and the network. Almost half of the 20 directors are directly or indirectly employed by the organization they govern.

One of the primary responsibilities of a board is to establish a compensation philosophy and, as such, all but one or two highly paid employees are excluded from board governance. The network’s board of directors is also in conflict.

In a system with such conflicts, who is driving the vision for health care in Vermont? If not the Green Mountain Care Board, is it the Social Services Agency, Department of Health, Department of Health Access (Vermont Medicaid Agency), or Department of Health? mental health ?

Does this diffuse ministerial architecture elude the central question of who owns vision and responsibility?

Another element is the guild mentality of healthcare, allowing doctors and dentists to control their numbers and protect their economic privileges. What would be the additional cost of training another 75 primary care physicians at UVM Larner School of Medicine or UVM College of Nursing and Health Sciences of 100 more nurse practitioners, RNs or medical assistants?

Meanwhile, the $ 4.2 trillion national healthcare industry is aligning its lobbying forces and millions to ensure that President Biden’s “human infrastructure” bill, in which concerns health care reform, never sees the light of day.

As in the $ 800 billion defense industry, those who feed off our tax dollars will not go “easy on this good night.”

I was chairman of Fletcher-Allen Healthcare in 2004 after its then chairman was kicked out, then charged with lying to regulators and started serving a two-year prison sentence. I am disheartened to see yet another implosion emerge in Vermont health care.

The many dedicated clinicians and nurses who are pawns in this multi-billion dollar game of chance have provided exceptional service to the people of Vermont since Mary Fletcher funded and opened a hospital in Burlington in 1879 for the welfare of her. community.

And when does self-interest metastasize into corruption?

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