Editor’s note: This commentary is by Ron Holland, an emergency physician and policy analyst who works at North Country Hospital in Newport. He is a Democratic candidate for state representative from Coventry, Irasburg, Newport City, Newport Town and Troy.
[O]n Oct. 7, a “White Coat Ceremony” will take place at the Ira Allen Chapel, University of Vermont. It marks the passage of UVM medical students from aspirants to participants in clinical medicine. The ceremony, open to all, is a public professing of allegiance to the values of medicine, the pledge that makes physicians professionals. The medical students take a modern Hippocratic oath affirming: “I will apply, for the benefit of the sick, all measures which are required, avoiding the twin traps of overtreatment and therapeutic nihilism.” The oath affirms that they are treating humans and not disease or symptoms, and that they are members of society with a special obligation to society. Their practices and knowledge are shared with their peers; there are no trade secrets in health care. Unspoken but assumed in physicians’ relationship with society is that they will be fairly reimbursed for their services and that their financial gain or loss does not enter into their decision-making; only the patient’s interests are addressed. The purpose of the ceremony is to clearly name the patient as their central focus and to affirm the additional responsibilities and values they assume with becoming physicians.
As physicians must be prepared to rationally support their decisions, so must many other public servants. Governors must take responsibility for and be held accountable for their decisions. A governor not seeking re-election has diminished political influence but can still take executive actions that have irreversible effects far beyond their tenure in office. Over the next few months, Gov. Shumlin will probably sign his largest contract to date with the federal Centers for Medicare and Medicaid Services (CMS). The contract will obligate some one-third of Vermont citizens to be offered participation in a six-year health-care delivery experiment.
Unlike most health-care experiments, patients will not be required to give their consent to participate in the experiment; the governor consents for them. The focus of the experiment is a new contract with a newly formed corporation. The corporation will receive $1.06 billion annually to provide health care for about 200,000 Vermont citizens. If the corporation spends less overall, it gets to keep the difference. If the corporation spends more, it is liable to some degree for the cost overrun.
One unusual feature of the new corporation is that the current laws regarding price fixing will not apply. These new corporations were enabled by the 2010 Affordable Care Act and are named “accountable care organizations” (ACOs). This experiment is being carried out in many locations throughout the country. In Vermont, the corporation will be Vermont Care Organization (VCO). VCO will employ health providers to care for the patients. The major financial backers for VCO are Dartmouth-Hitchcock Medical Center and the University of Vermont Medical Center.
In essence, rather than marshalling medical leadership, reason and the light of day to control health costs and improve quality, the Obama administration and Congress lets loose the corporate profit-motive to pursue these goals.
Decreasing the costs and improving the quality of health care will require physicians changing the decisions they make. Physicians will respond better to physician leaders who embrace medicine’s fundamental values than to corporate executives.
The goal of this experiment is admirable: to bring U.S. health-care spending more in line with that of other developed countries and to provide more cost-effective, higher-quality health care. It is fair to say that other developed countries spend about half of what the U.S. spends per capita, with better health outcomes. Since 1960, the percent of the gross domestic product consumed by health care has risen from 5 percent to nearly 20 percent and is expected to reach 25 percent by 2025. However, as knowledgeable citizens we must maintain clear distinctions between admirable goals and effective policy options to reach those goals.
What is the evidence that large hospital-centric ACOs are capable of reaching the goals?
An influential adviser to President Obama, Robert Kocker, M.D., was a strong advocate for large hospital-centric ACOs. Now Kocker says he was wrong to favor the consolidation of doctors into large groups. New evidence from five years of published research indicates that lower costs and quality improvement are generated much more often by independent primary care doctors than by large hospital-centric health systems. Independent physician-led ACOs are outperforming even the most famous hospital-centric health systems, such as Johns Hopkins. “Small businesses can learn faster without holding weeks of committee discussions and without permission from finance, legal and IT departments to make a change,” Kocker writes. “Independent primary-care doctors are able to change their care models in weeks and rapidly learn how to use data to drive savings and quality … Personal relationships of the kind often found in small practices are the key to the practice of medicine. They are the relationships that doctors want to forge with patients, and vice versa.” (“How I Was Wrong About ObamaCare” Wall Street Journal, July 31, 2016) In summary, Dr. Kocker now finds that smaller physician-led organizations are superior environments for fostering improved, less-costly health care and quality doctor-patient relationships.
While the central focus of VCO is a business contract, the central focus of the medical profession is the health and well-being of patients. VCO has been presented to the Vermont public as “provider-led” health reform, however, its major leaders are not physicians but Todd Moore and Thomas Huebner. While these men are accomplished corporate executives, they have not taken the Hippocratic Oath; they have not experienced the stress of making timely clinical decisions under conditions of uncertainty; they have not experienced the agony of a clinical mistake that harms a patient. Decreasing the costs and improving the quality of health care will require physicians changing the decisions they make. Physicians will respond better to physician leaders who embrace medicine’s fundamental values than to corporate executives.
The Affordable Care Act dramatically expanded access to health care and similarly increased health spending. It has also spawned dramatic increases in health insurance premiums. Any Vermonter would fix the holes in a sap bucket with big leaks before placing it back on the maple tree. Expanding access before addressing costs has health insurance premiums spiraling upwards and insurance companies leaving the ObamaCare market. The legislation that underlies VCO has some 900 pages of mind-numbing complexity, brought to us by the same policy apparatus that gave us the failed federal and state health exchanges. Yet building a health insurance exchange is orders of magnitude less complex than changing an entire health care system. The authors of the U.S. Affordable Care Act and Vermont’s Act 48 have given us no reason to trust their judgement.
Most agree that organizing medicine into networks that can share information, coordinate care for patients and manage risk is critical to deliver higher-quality care, generate cost-savings and improve the patient experience. Nothing in this formula, however, requires that physicians either gain or lose financially by the decisions they make. Nothing requires them to be owned by a large corporation. But building behemoth hierarchical organizations threatens the heart of medicine: relationships between providers and patients. An effective solution to controlling health-care costs must have a human scale, compatible with the community values of Vermont and the tradition of the modern Hippocratic Oath.
Fostering the positive evolution of Vermont’s health care system requires effective executive leadership that has not been evidenced at either the state or federal level. We as citizens of this fine state should not allow the future of our health and our health care system to be determined by Gov. Shumlin’s lame duck signature. He will be beyond the reach of political accountability when the effects of a new VCO contract propagate through Vermont. Vermonters should lose no time in letting Phil Scott and Sue Minter hear from them. Gubernatorial candidates Minter and Scott should either endorse and defend the VCO initiative to the Vermont electorate or ask Gov. Shumlin to leave the decision to the next governor.
In a now famous speech, shortly before leaving office in 1960, Dwight Eisenhower identified “alert and knowledgeable” citizens as the only defense against excessive corporate influence on government policy. You, voters of Vermont, are that defense. I believe, President Eisenhower would say that each Vermonter who casts a vote for governor should know the candidate’s position on the VCO experiment. VCO will fundamentally alter the values of Vermont health care, and as the evidence now shows, impede the potential rate of improvement of Vermont’s health care system.
Now is the time for new health care reform leadership.
