Editor’s note: This commentary is by Allan Ramsay, MD, who has been a family physician in Vermont for 38 years. He is currently medical director of the People’s Health and Wellness Clinic in Barre. Dr. Ramsay was a member of the Green Mountain Care Board from 2011-2016.
[A]s the 2018 Vermont legislative session begins, there is significant concern about health care policies proposed by the federal government. These concerns should not cause Vermont’s legislators and health care leaders to lose sight of critical issues facing Vermonters. We cannot have a blind spot for new ways to approach improving the health care system.
Since 2015, Vermont has decided delivery system and payment reform efforts would be based on a statewide accountable care organization model (OneCare). Payment will gradually transition from fee-for-service to value-based payment for all payers (Medicare, Medicaid, commercial insurance). Paying for value to improve the health outcomes of a population certainly makes sense and over time may stabilize the growth in health care costs.
Those of us who are providing health care know that value should primarily be defined by the patient. If there is any divergence between what evidence shows is best for the patient and what will be paid for, clinicians will soon feel hopeless about reform. We cannot be blind to this concern. In addition, as the federal government continues to erode gains in health care coverage achieved over the past five years, many Vermonters may lose their insurance coverage and become part of another blind spot in health care reform. Paying for value makes little difference to someone without health insurance.
There are proven ways to improve value in health care. One way is to invest more in primary care, mental health, and community-based services. OneCare understands how important this is and proposes increased funding for these services. Without this investment, the primary care workforce shortage in Vermont will get worse. Gov. Phil Scott mentioned the aging of Vermonters in his State of the State address. The aging of the primary care workforce should be of equal concern.
Passage of a universal primary care bill in the Legislature this year (S.53, H.248) is a new opportunity to both improve value and attract primary care clinicians to Vermont. Universal primary care legislation would assure that OneCare, the Green Mountain Care Board, and the Legislature all have a role in assuring access to primary care for Vermonters. The goals of a universal primary care program and OneCare are compatible. This legislation would give Vermonters more voice in the overall primary care delivery and payment process. Universal primary care would not replace the individual mandate of the Affordable Care Act; however it would mean Vermonters could rely on a state primary care “mandate.”
The Legislature will be concerned about how to pay for a universal primary care program and how to administer it. They should be. However they should recognize that we are already spending most of this money for Vermonters who have commercial insurance, Medicaid or Medicare. Only 4-5 percent of Vermonters do not have health insurance now, but many are underinsured when copay and deductibles are considered. A universal primary care program could gradually decrease the burden of these out-of-pocket costs. This would encourage Vermonters to seek preventive and mental health services when needed. Also, let’s not be blind to the fact that this state has the foundations in place, including the Green Mountain Care Board, the Department of Vermont Health Access, and the Department of Financial Regulation to administer a universal primary care program. No other state has this capability.
Will investing more in primary care be the only solution to controlling the growth in health care costs? No it won’t. Almost every Vermont hospital budget from year to year predicts increases in utilization of services as the reason for health care cost increases. However, many policy experts are now confirming what Uwe Reinhardt, a noted Princeton health care economist, wrote 15 years ago: “It is the prices, stupid,” not just the utilization of health care services that drives cost. Several studies have found that the spending growth for treating patients is mostly due to the growth in prices, not the growth in the number of services provided. Compared to other countries we pay too much for everything in health care, except primary care.
The Green Mountain Care Board has the authority to control how much we pay for specific services, a provision of Act 48. Setting a payment rate is a complicated process, requiring analysis of historical trends, payment reform pilots, workforce issues, and utilization projections. It is time for the Green Mountain Care Board to use this authority. A first step could be to establish and regulate a total primary care spending rate. The current spending on primary care and mental health services by all payers is estimated to be 7-10 percent of all health care expenditures. This is not enough to assure a high value health care system in Vermont.
I have spent my life providing primary care to Vermonters. I know we can attend to only so much change at once. Nevertheless health care reform in Vermont cannot succeed if we have a blind spot for things we may have missed in our efforts to improve the health care system or to new opportunities that are before us.