Flood, Wasserman, Hage & Snell: Change in direction for Vermont health care reform

This commentary is by Patrick Flood, former commissioner of the Department of Mental Health and the Department of Disabilities, Aging and Independent Living; Julie Wasserman, an independent health policy consultant who worked for Vermont state government for over 25 years; Mark Hage, director of benefit programs at Vermont-NEA; and Deb Snell, a staff nurse with the Medical intensive care unit at UVM Medical Center and president of the American Federation of Teachers-Vermont and the Vermont Federation of Nurses and Health Professionals, Local 5221.

The Green Mountain Care Board recently tested in the Legislature and called for a major shift in how Vermont should pursue health care reform.

There are three major components:

  1. Design and implement global budgets for hospitals.
  2. Invest in community-based medical services that keep Vermonters healthy, productive, and out of the hospital, such as primary care, nursing, mental health, and home health care.
  3. Talk with Vermonters about what they want from their health care system and how proposed reforms should happen.

Advocates have been calling for these changes and more for years, but the state stuck stubbornly to its accountable care organization model, even as it failed to reduce costs, increase access, or significantly improve the quality of care.

Why the change? Perhaps the state has accepted at last that the accountable care organization cannot accomplish what Vermonters and our health care system truly need. This is acknowledged in recent comments to a joint legislative committee by Jessica Holmes, a longstanding member of the Green Mountain Care Board.

“We are not on a sustainable path,” she asserted. Then, more pointedly:

“But Vermonters are not winning right now. Health care is not affordable for many families. Many Vermonters don’t have access to primary care, dental care, and other essential services. Our mental health care system does not come anywhere close to meeting the needs of Vermonters and the stories we hear about people’s struggles to find care are truly heartbreaking.”

And: “It is critical that this payment reform be done in parallel with a patient-centered, community and provider-inclusive redesign of our health care delivery system.”

Kevin Mullin, the chair of the Green Mountain Care Board, also tested in support of this new direction, asking the Legislature for $5 million to implement the proposed changes and to carry out a public dialogue and planning process.

Recently, on behalf of a coalition of Vermont organizations in opposition to the accountable care organization model, we met with the leadership of the federal agency that oversees our “all-payer model” agreement. We stressed the coalition’s support for fundamental changes in Vermont’s health care planning, delivery, and financing.

Our purpose initially was to argue against renewal of the all-payer model agreement. But after the Green Mountain Care Board unveiled the general terms of its new reform plan, we chose instead to express support for the board’s latest initiatives on the condition that any changes must be anchored to the objectives of universal access, affordability, equity, public accountability , and high quality care.

The next stage of reform must prioritize the following:

  • Hospital global budgeting is a structural necessity. Simply put, global budgets are fixed annual payments to hospitals to cover verifiable operating costs and make those costs predictable and sustainable. Hospitals, if assured of funding that is sufficient to need, will not have to bill for every procedure, and so can save money on administrative expenses. And with global budgets, hospitals can be creative and more flexible in helping patients in ways the current funding streams make impossible or overly complicated. However, global budgets must not be designed to unfairly cap funding or cut vital services. Also, hospital global budgeting will require a reordering of current spending and billing practices that are found to be excessive and inefficient, so they are not “baked” into future budgets.
  • Global budgeting and other reforms mean there is no compelling reason to maintain the accountable care organization model with public dollars beyond 2023. That money is more wisely invested in delivering and improving care locally.
  • The state should oversee and regulate a system of hospital global budgeting and enhanced community care delivery with regular input from providers, patients, employers, and advocacy organizations, thus ensuring a greater level of public accountability.
  • Workforce challenges must be resolved, starting with the acute lack of primary care doctors, physicians’ assistants, nurses and nurses’ aides, and mental health professionals. For too long, the state, health care administrators, and the accountable care organization failed to tackle this problem head on, and much of the health care system is now in dire straits. The good news is that there are proven recruitment and retention solutions, including competitive wages and benefits, debt reduction programs, and improved working conditions.
  • Major investments in community care — primary and preventive, nursing directed, home-based, and mental health — are critically important to prevent or intervene early with health problems to avoid unnecessary suffering and more costly care. This is common sense. And yet for too long our health care leaders have focused chiefly on our hospitals at the expense of community-based services.
  • One of the most glaring problems is the deterioration of our mental health system, and it must be fixed. A huge percentage of physical health problems are caused or exacerbated by mental health issues and trauma. At present, our community-based capacity is so compromised that we are denying access to services and supports that both prevent people from going into crisis and reduce costs.
  • It is crucial that the Green Mountain Care Board collaborate intently with local communities and advocacy organizations to design and implement its new reform initiatives.

There will be plenty of pushback against this new direction from the powerful forces vested in the status quo. But preservation of the status quo over the last five years, while masquerading as “payment reform,” has done nothing to improve access to care or lower costs for Vermonters.

The Green Mountain Care Board’s new direction can accomplish much of this by redirecting funds from expensive and avoidable care to prevention and early intervention. Savings from that systemic shift can be used to expand essential services and further reduce costs.

We agree with Ms. Holmes: It’s time for Vermonters to start “winning” where health care reform is concerned. Let’s get to work.

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