According to a presentation from the Green Mountain Care Board, “Vermont was among the states with the lowest per capita health care spending in the 1990s, and since 2010 is consistently among the highest.”
So, to envision and create effective change in our health care system, we must be honest with ourselves about the challenges and opportunities that deter or impel strategic change.
Challenges
Ineffective nonprofit board governance: Hospital boards (as well as many other nonprofit boards) rarely seem to understand that they’re ultimately responsible for the success or failure of the institutions they govern. The president or executive director serves solely at the will of the board, which oversees the leader’s hiring, firing and compensation, and does an annual 360-degree performance review based on his or her effective delivery on mission.
A data analysis by Thomas Rees of Rees partners shows that at UVM Medical Center, the cost per patient discharge is higher than the average of 46 comparable academic medical centers across the country, Anecdotes about Vermonters struggling to access care are rife. The University of Vermont Health Network’s board is accountable and liable for their institution’s success or failure.
Dr. John R. Brumsted, UVMHN’s previous president and CEO, earned more than $2 million in salary and benefits in 2015.
In December of 2023, compensation filings to the Green Mountain Care Board indicate that the UVM Health Network board approved $481,648 in additional payments on top of a yearly salary of $1,354,712 to its current president and CEO, Dr. Sunil “Sunny” Eappen. It’s not clear from the filing how much is retirement contribution, perks or a performance bonus.
One might expect this to be a reward for delivering on the mission of “population health,” meaning quality, affordability and timely access. Vermonters who’ve given up accessing the system or can’t afford health care may wonder why the board is awarding almost half a million dollars for this performance.
A culture of arrogance pervades the network of large hospital leaders, many of whom seem to believe that despite an often-touted “population health” mission, they know better than regulators, legislators and the community they serve about how best to deliver health care. They often cast a shroud of “process-complexity” over hospital operations, believing this will camouflage their business-driven principles over a nonprofit’s obligation to deliver on its mission.
In a recent commentary in VTDigger, Dr. Eappen makes the case that UVMHN is succeeding in its mission, while the impending Oliver Wyman report due Sept. 18, may indicate otherwise. Another example, and one that highlights resistance to any oversight: at the request of Delaware Republican legislators, former UVMHN president and CEO Dr. John R. Brumsted recently traveled to Delaware to make a case to that state’s Legislature against establishing a health care regulatory agency along the lines of the Green Mountain Care Board, which served as a model to Delaware legislators.
Competing government understandings about who should oversee and regulate Vermont health care infrastructure: There are four “health care” agencies inside the Agency of Human Services cabinet architecture. In 2014, the Office of Health Care Reform was lassoed into Governor Shumlin’s office and was never formally returned to AHS, although the same office exists within AHS today.
Opportunities
In spite of significant underfunding, the Green Mountain Care Board is now providing effective, strategic regulation: After some 13 years of allegiance-muddled regulation, Vermont’s health care regulatory authority, established in 2011, has taken up the gavel and is analyzing, offering guidance, regulating and holding accountable Vermont’s $6.37B-a-year health care industry. Its time has come.
A committed though seriously under-resourced bicameral legislature, hampered by ineffective and outdated traditional processes: For the most part, Vermont legislators are deeply committed to solving Vermonter’s durable problems, but they do not have access to the analytical, scientific and policy resources to make legislative headway on many of Vermont’s most daunting problems, including health care. Sadly, on many of the key issues, they rely on lobbyists deemed “educators.” At its best, this is advocacy. At its worst, it is corrupt influence-peddling. But the Vermont Legislature has the authority and the will, if not yet the resources, to solve these problems.
The Vermont Business Roundtable: A Vermont business community with over 100 members is waking to the knowledge that the accelerating cost of healthcare for their employees is an unsustainable business expense.
A seriously backlogged and understaffed judiciary system, but one that could conceivably play a role in advancing health care in Vermont: Former executive director of ACLU-VT Allen Gilbert pointed out in his 2016 book “Equal Is Equal, Fair Is Fair” the importance of the Vermont Constitution’s “common benefits” clause (Chapter 1, Article 7). It was the basis for the Vermont Supreme Court’s 1997 Brigham decision on educational funding equity, as well as the basis in 1999 for the Vermont Supreme Court’s Baker Decision on same-sex marriage benefits (civil unions). Gilbert raises the legitimate question of whether Vermont’s unique common benefits clause might also be applied to move the state towards universal health care access for all Vermonters.
Delivery
Together, we must articulate a consensus on a vision for the key design imperatives for a sustainable Vermont health care system that delivers on the mission of population health — quality, access, and affordability. Here’s what I think that consensus should be.
Legal definition: All Vermont hospitals must be nonprofits and licensed with a certificate of need (CON). They must be governed by a governing board of trustees. Nonprofit boards are self perpetuating. Trustees are not chosen by the hospital chief executive, who, in fact, serves solely at the will of the board. The independent board hires, fires, compensates and reviews annually the performance of the hospital’s chief executive with a focus on mission delivery.
Regulatory authority: Authorize a sustainable government authority to provide oversight, guidance, regulation and accountability — the Green Mountain Care Board.
Community-based: Proximity to served populations. Move current downstream investments in large, consolidated hospital systems upstream into education, prevention and funding community-level resources, the most important of which is primary care, including trauma-informed counseling.
Collaborate, don’t compete: Currently, most hospitals compete for market share by acquiring other health care facilities. Nonprofit hospitals must not compete for market share but rather collaborate and allocate services among one another to create a sustainable system that meets the goal of population health for Vermonters. The current consolidation has escalated health care costs and insurance premiums rather than creating efficiencies.
Patient acuity (seriousness of patient condition needing care) will determine point of entry into the system: Instead of urging all patients to present at urban emergency rooms where the cost of primary care is highest and wait times are the longest. Patients will generally seek help in their communities.
Scale: In a functional model, hospitals will be scaled in size and scope of services to market limitations and federal reimbursements from Medicare, on which 72% of academic hospitals generate a margin.
Tertiary-care hospitals such the UVM Medical Center and Dartmouth Hitchcock Medical Center will be no more than that and will be prevented from offering services that belong in local communities, such as primary care, hospice, chronic disease management, parent-child centers, aging and disability assistance and local and regional clinics.
Were we to chart a path from servicing a patient at home all the way up to the regional tertiary-care hospital it might look like this:
universal periodic home visits by medical paraprofessionals or visiting nurses
community-based health care agencies (parent-child centers, agencies on disability and aging, chronic-disease management, hospice) and community solo and group medical practices
local clinics and federally qualified health centers
regional hospitals
tertiary-care hospitals (UVM and Dartmouth Hitchcock)
Over the decades, we Vermonters have usually found solutions to our most enduring problems and together we can again, but only if we acknowledge what and who stands in our way.
Read the story on VTDigger here: Bill Schubart: Health care, a way home.