Bill Schubart: Let’s start the dialogue on a vision for Vermont health care

The University of Vermont Medical Center in Burlington on Monday, November 23, 2020. Photo by Glenn Russell/VTDigger

It will take vision, leadership and courage to rebuild Vermont’s health care system for the next decade. I can’t offer leadership or courage, but I can, with the help of wiser voices, presume to offer a possible vision to begin the discussion.

When I last wrote about healthcare, I painted a disturbing picture of the aggressive expansion of our primary healthcare provider, UVM Health Network.

I was challenged to do so, but since my first of three columns appeared, the combined impacts of Covid, staff burnout and resignations, longer patient wait times and the acceleration of risk for Vermonters has only gotten worse and is now openly acknowledged by leaders.

Any future vision for health care must be seen through the eyes of those who need it, use it and provide it, and not just through the eyes of those who administer it or benefit from it.

As a nation, we are an outlier in the international community, still debating whether health care is a human right or a business. More than 100 other countries have long since resolved this issue, offering varying degrees of coverage, sometimes cost-shared but always more profitable.

The unresolved nature of this issue limits Vermont’s ability to truly innovate because we are embedded in a national health care economy that includes the lucrative pharmaceutical, medical device, hospital, and insurance industries. But we can do better with what we have.

Acute need should define a patient’s point of entry, from a visit to a local practitioner, group practice, or community health care center – health care centers approved by the federal government ̶̶ at a regional “critical access” hospital emergency room, or at a tertiary care hospital such as UVM Health Network or Dartmouth Hitchcock.

Currently, UVM Health Network seems to want to be everything from primary care, physical therapy, home health, pharmacy, medical supply, urgent and emergent care, and mental health provider to the insurer and the palliative care provider.

Now, by their own admission, the system is collapsing, although the messages blame external factors rather than internal ones. The scale and complexity of trying to be everything to everyone in a two-state region makes little sense. Most physical and mental health care is best delivered locally, shifting to intensive care or tertiary care hospitals only for serious medical conditions or procedures.

Another system is emerging.

A recent locally produced film, restore balanceprovides a clear vision of how best to deliver health care at the community level. The health center in Plainfield is a federally licensed health center, providing primary care to the surrounding community. As an integrated practice, it addresses dental, physical, emotional and family well-being.

More than two-thirds of Vermonters live in rural areas, and the health center model described here and rolled out across Vermont may well be the most cost-effective and patient-efficient vision for primary health care.

But to redesign a patient-centered health care system, we must resolve the conflict between financial interests and the socio-economic well-being of our citizens.

Our current socio-economic system does little to prevent physical and mental illness.

We don’t have paid medical leave where newborns can bond with their parents, or a family member can care for a dying family member and say goodbye.

We don’t have a universal, affordable early learning and child care system and, of course, no national health care system. The widely successful child tax credit is being phased out.

Simply put, there is too much money to be made to fix a steady stream of sick or injured people. Whereas investing in prevention and ensuring Vermonters lead healthy lives – health care vs health care – would be far more beneficial and cost-effective.

We are also coming to understand – and support with hard data – that the prevalence and magnitude of chronic toxic stress (trauma) drives much of the current cost of mental and physical health care, education specialist, criminal justice and correctional services.

Search in negative childhood experiences and their impacts on physical and mental health highlights the intergenerational damage to a family’s health caused by the lack of identification, intervention and nurturing care to help the child and family recover.

Our failure here has generated a mental health crisis among our young people and made diseases caused by toxic stress. Low-grade inflammation caused by toxic stress can lead to heart disease, diabetes, neuropathy, and mental illnesses such as anxiety, depression, and substance abuse, followed by self-harm, eating disorders, and suicide. Toxic stress also has lasting negative consequences on cognitive functioning, behavioral health, and immune system function.

UVM Health Network has deployed its UVM health benefit health insurance plan with all the potential for ethical conflict that entails. As UVM Health Network becomes both provider and payer, how will it balance the competing interests currently being negotiated by “denial handlers”? How does this contribute to the well-being of Vermonters?

During this time, BlueCross BlueShield Vermontnow in competition with its primary beneficiary, is refocusing its strategy on access and affordability to accommodate independent primary care practices and more flexible care coverage for their patients.

Current initiatives include collaborations with mental health providers to address the growing need for treatment options, as well as revamping its full payment model for large employers, including those who self-insure.

Chittenden County is Vermont’s biggest economic engine, but its largest hospital will never be the health care entry point for the majority of Vermonters who live elsewhere in the state. The natural tension between payer and provider benefits the people of Vermont. Such an arm’s length relationship would even benefit a government-run single-payer system, if we ever had one.

I started this column by talking about vision, leadership and courage. But there is a leadership vacuum in Vermont. Effective leadership – based on research, collective experience, and data – would lead us to consensus on an appropriate model for the delivery of health care in our state.

Leaders of change would be clearly empowered by the legislative and executive branches to enact and regulate the development of such a model and would not be deterred by the disheartening force of monetary interests (courage) that skews the whole system.

According to Journal of the American Medical Association“From 1999 to 2018, the pharmaceutical and health products industry recorded $4.7 billion – an average of $233 million per year – in federal lobbying expenditures, more than any other industry.”

As a state, we must find the will and leadership to build consensus on patient-centered, community-based health care delivery systems, with entry points based on primary care screening and lending. sharpness of presentation.

This vision and mandate are provided in law and once existed in the health department“To create a state health improvement plan and facilitate local health improvement plans to encourage the design of healthy communities and promote policy initiatives that contribute to community well-being , school and workplace, which may include assisting employers with wellness program grants, encouraging employers to promote employee engagement in healthy behaviors and encouraging appropriate use of the health care system.

This function of the Department of Health was incorporated into Governor Shumlin’s single-payer initiative and died with it. Early in its term in 2011, the Legislative Assembly passed Act 48whose intent was to “create Green Mountain Care to contain costs and provide, as a public good, comprehensive, affordable, high-quality, publicly funded health care coverage for all residents of Vermont seamlessly, regardless of their income, assets, health status or availability of other medical coverage.

Where do we see this today?

No one today has that vision of the well-being of Vermonters, certainly not the Green Mountain Care Board, which today is little more than a de facto financial regulator rather than a source of vision for well-being. be Vermonters.

Someone or an agency in Vermont must be allowed to revive Law 48 and bring it to life as it was once envisioned.

The good news is that we have an army of doctors and nurses who, day after day, provide professional and caring care. We just need an institutional and regulatory vision to support them.

And finally, Vermont politicians must have the courage to put the well-being of Vermonters ahead of the substantial monetary interests orbiting the universe of health care.

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