I was recently asked if there was an easy way to keep track of our health care system. My “simple” answer was, “Yes, count the number of people in emergency rooms, homeless shelters, and jail cells.”
In fact, I was answering another question that focused on “population health” rather than the success or failure of the health care system itself. Although they should be aligned, they encompass different purposes in practice.
The essential question we must answer is: are we measuring the success of the health care system and infrastructure, or are we measuring the well-being of the population they serve?
In the first case, is the measure of success based on balance sheet strength or on mission delivery? If it is the financial and systemic well-being of the health infrastructure itself, we are failing.
If it’s on-mission delivery—“population health,” as they call it—we fail as well, and the two main issues are access and cost, which are intertwined.
If “early diagnosis and treatment” is the “standard of care” in health care, then access becomes critical. If the cost prevents access, then we need to regulate the cost.
We recently visited some new Vermonters in central Vermont, both health care system navigation professionals, and they, too, expressed their confusion. They were told by their local hospital that they would need a primary care doctor for referrals, but were then told they were 219th on the wait list for a local primary care doctor.
Current estimates place the United States short of somewhere between 20,000 and 50,000 primary care physicians, and to effectively cover all rural areas, the number nearly doubles to 90,000.
As for the cost, the stories are legion. I’ve had three close family members, all professionals, who have turned down raises to keep their Medicaid option, but increasingly find that even that cost is beyond their capacity.
Most people in Vermont currently cannot afford health care. (see slide 44) Data shows that 44% of Vermonters with private insurance are underinsured and cannot afford health care costs. More than half of Vermonters have private, employer-assisted insurance as their primary source (329,800), but shared costs, deductibles, copayments and runaway inflation make this insurance unaffordable for many.
Meanwhile, the current round of hospital budget hearings has the University of Vermont Medical Center seeking a 20% increase in commercial insurance rates, Rutland Regional Hospital is seeking a 18% and Central Vermont Hospital is asking for 14.5%.
If double-digit increases are granted, access to health care services will decline further. In addition, federal aid for insurance premiums is due to expire in December. Given the congressional gridlock in health care funding, the likely loss of those grants will push even more Vermonters into the uninsured realm.
Hospitals account for half
It is high time to rethink all of this.
But, as I have indicated in previous columns, the currently deployed infrastructure of 13 regional hospitals and two tertiary care hospitals, UVM and Dartmouth-Hitchcock, is prohibitively expensive. Hospitals account for about half of all health spending, leaving less money for essential community services that keep people healthy and divert them from costly hospitalizations.
With demand far outstripping capacity for mental health, addictions and home health services, to name a few, some hospital funding needs to be redirected to these services – the only reasonable path if we want to reduce costs in the long term.
If we cling to the goal of maintaining all of this infrastructure with a positive net income (all are non-profit organizations), we will have lost focus on the welfare of those the system is designed to serve.
Population health goes well beyond emergency rooms. It starts with neonatal care, early childhood education, care and play, trauma-informed family counseling and support, access to health care (mental and physical), healthy eating and l access to education, safe housing, employment and a healthy environment.
Back to the future?
If we redesigned a health care system to focus on population health, it would not reflect what has evolved over the past 50 years in Vermont. In fact, it might be more like what came before it in my childhood, with community doctors in small practices, local clinics and support services, and tiny community hospitals.
Meanwhile, UVM Health Network is consolidating its dominance and governance, eliminating longtime local community board members from each of these hospitals and reducing their ability to make strategic decisions based on the needs of their community. .
From now on, decisions will be made based on the network’s corporate needs. How does consolidating the governance (finances, budgeting, and strategic planning) of a dispersed network of six hospitals in two states improve local delivery?
Is UVM’s expansion model to create a clone of the Geisinger Network, a huge healthcare company not without its own challenges?
If we are ever to provide accessible and affordable health care within the broader framework of population health, it will be with a properly funded local primary care network, supported by regional secondary and tertiary care hospitals designed uniquely to accommodate trauma, specialties, and high acuity cases.
We will need to invest in several generations of new primary care physicians and nurse practitioners. The economy – including waiving tuition fees and adequate compensation – must work so they can afford to live in their communities.
We need to reverse the number of nurses leaving hospitals or becoming “travellers” (hired by agencies) as well as the number of physicians leaving and starting “concierge” practices or retiring early.
When I was young, our family doctor, Phil Goddard, was one of three independent family doctors in our small community of 4,000 people. They knew everyone in town, their strengths and weaknesses, their health, background, and ability to pay for a home or office visit, and they charged accordingly. Unlike Dr. Phil, today’s concierge doctors charge a flat annual fee for access when needed, a fee out of reach for many.
We have to make choices about what matters in our society. Population health encompasses almost every aspect of the social safety net. If health care is to target the health of the population, it must begin with supportive services in the communities served and then expand to regional secondary and tertiary care facilities with increased acuity or specialization.
As the UVM Health Network revamps its governance and dominance, in the absence of any clear state health care policy, we are putting the “health of the population” at greater risk.
Where is the direction?
Governor Scott appears to have washed his hands of health care and is AWOL. The Department of Health, which is responsible by law for health care policy, has been absent since Governor Shumlin brought him into his office and has never returned.
The Green Mountain Care Board grapples with its own job description, oscillating between healthcare policy architect and healthcare policy regulator. He will have to choose one or the other; he cannot ethically or practically do both.
The Legislature just passed Bill 167, directing the Green Mountain Care Board and the Social Services Agency to engage communities and providers to develop a more sustainable health care system. When will public engagement begin? Will it be sturdy? Will management listen?
Meanwhile, the state’s largest health care entity, UVM Health Network, is navigating through the ice floes with no clear policy or regulatory navigation, other than its goal of growth and consolidation.
If we truly believe in population health and hope to care for our aging population, leaders must have the courage to make tough decisions.
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