Bill Schubart: The slow-motion implosion of Vermont’s health care system

A postcard from the early years of Mary Fletcher Hospital in Burlington.

The oldest exposed reef fossils in the world lie in Isle LaMotte, Vermont, where they came to rest 480 million years ago after one of the most violent tectonic plate shifts the Earth’s surface ever experienced. The fossils originated in Africa.

A less violent but equally destructive disruption is occurring in health care. Here in Vermont, we’re watching the slow-motion implosion of our health care system driven by several mounting pressures: lack of available staffing at all levels, an aging and increasingly obese patient population, a global pandemic that has killed more Americans than the 1918 flu (from which we seemed to have learned nothing), lack of vision and leadership, and the overwhelming inertia baked into a system that has evolved to protect the interests and privilege of all who profit from it, rather than delivering on its mission of population health and care.

Let’s ignore the oddity that the U.S. is practically the only country in the civilized world with no national commitment to full population health care and some of the worst health outcomes, despite spending $4.2 trillion a year (18% of GDP) while enriching the insurance, pharmaceutical, medical device, and hospital industries that feed on it. 

Meanwhile, the average U.S. citizen paid $1,122 out of pocket last year for expenses like co-payments for doctor’s visits, prescription drugs, or health insurance deductibles not covered by insurance.

Cuba, with one of the poorest economies in the Western Hemisphere, has a national health care system that is free and seen as a fundamental human right, and its health indicators are on a par with developed countries. It has an innovative community-care model and the highest number of doctors per capita — one doctor for every 400 citizens.

When I traveled there in the early 1990s, I saw that they made regular home visits, educating Cubans on how to promote health and prevent disease — a stark contrast to our dismal investment in primary care. Today, Cuba leads many countries in medical research and has licensed a lung cancer vaccine in the U.S.

Why are we such an outlier, when health care is an essential determinant of quality of life and longevity?

Although the current dominant community complaint focuses on long wait times for appointments — a problem, because such delays can negatively affect outcomes (early diagnosis and treatment is the gold standard) — the problems affecting Vermont’s only tertiary-care hospital network run much deeper. They include lack of a clear vision, poor governance, embedded conflicts of interest, and an acquisition strategy that consolidates power, creating an unchecked monopoly with no countervailing regulatory force.

Established in 2011 under the visionary leadership of recognized leaders in the health care system, the Green Mountain Care Board was to use its regulatory authority to “improve the health of Vermonters through a high-quality, accessible, affordable and sustainable health care system.” Since then, it’s been largely politicized, better serving the provider networks than Vermonters. 

Vermonters have dramatically less access to care at the very institution charged with implementing Vermont’s all-payer model, and health care affordability continues its decline.

Acquisition mode

Over the last few years, UVM Health Network has acquired a large network of providers: six hospitals and all their physicians (UVM Medical Center, Central Vermont Medical Center, Porter Medical Center, plus three hospitals in upstate New York); OneCare Vermont, which is Vermont’s sole accountable care organization; nursing homes (Copley Woodlands, Woodbridge, Starr Farm); Chittenden County’s Home Health and Hospice Visiting Nurse Association; as well as some for-profit entities — Yankee Medical Equipment, Valcour Imaging LLC, Mediquest Corp. and PET Scan LLC. 

The roll-up of these not-for-profit and for-profit services — and the lack of any clarity on whether health care is a business or a civil right — only shines a spotlight on the lack of any regulatory guardrails governing monopoly health care in Vermont.

Vermont’s all-payer accountable care organization model is the driving force behind health care reform. The two are interdependent. The all-payer model cannot succeed without a functional accountable care organization behind it. The state’s ACO, OneCare Vermont, receives money from the payers (Medicare, Medicaid, and commercial insurers) and pays the providers (hospitals, physicians). 

The primary goal of the all-payer model is to move away from fee-for-service reimbursement to risk-based ACO payments (aka capitation). Yet, OneCare has shifted less than 2% of Vermont’s total health care spending from fee-for-service to fixed prospective capitated payments.

From the Green Mountain Care Board’s own report:

“In 2019, of value-based payments flowing through the ACO, only 13% of them were true fixed prospective payments, meaning that <2% of total health care spending in Vermont has shifted from fee-for-service to capitation of fixed prospective payment.”

The state auditor’s report on all-payer ACO model implementation costs found OneCare’s operating costs have exceeded its savings, with net losses of $30.3 million.

OneCare has failed to meet the required federal targets on the number of covered lives for four consecutive years (2018-2021). It has also missed a major clinical target, the reduction of suicide rates.

Other health care professionals have also weighed in on the ACO’s inherent flaws.

Virtual control

Conflict of interest is now pervasive in the system. As of Aug. 25, OneCare Vermont has been integrated into the UVM Health Network, and Dartmouth-Hitchcock has left the partnership. 

UVM Health Network now has virtual control over how the money from Medicare, Medicaid and commercial insurers is spent. It will in essence be paying itself via its ACO (Vermont’s sole ACO implementing the state’s all-payer model).

Dr. John Brumsted is president and CEO of the UVM Health Network, a member of the UVM Medical Center board, and chair of the OneCare board.

Al Gobeille, former chair of the Green Mountain Care Board and former secretary of the Vermont Agency of Human Services, is now executive vice president for hospital operations for the UVM Health Network, which owns and manages UVM Medical Center and OneCare. As second-in-command to Brumsted, Gobeille is assumed by many to be his successor.

The UVM Medical Center governing board — responsible for ethical and fiscal integrity, delivery on mission, and reviewing the annual performance of the UVM Health Network CEO — is laden with highly compensated employees of both the medical center and the network. Almost half of the 20 trustees are directly or indirectly employed by the organization they govern.

One of the primary responsibilities of a board is to establish a compensation philosophy and, as such, all but one or two highly compensated employees are precluded from board governance. The governing board of the network is similarly conflicted.

In a system with such conflicts, who drives the vision for health care in Vermont? If not the Green Mountain Care Board, is it the Agency of Human Services, Department of Health, Department of Health Access (Vermont’s Medicaid Agency) or the Department of Mental Health

Does this diffuse departmental architecture evade the core question of who owns vision and accountability?

Another element is health care’s guild mentality, enabling physicians and dentists to control their numbers and protect their economic privileges. What would be the incremental cost of the UVM Larner School of Medicine graduating another 75 primary care doctors or the UVM College of Nursing and Health Sciences another 100 nurse practitioners, RNs, or physician’s assistants?

Meanwhile, the $4.2 trillion national health care industry aligns its lobbying forces and millions to ensure that President Biden’s “human infrastructure” bill, as it relates to health care reform, never sees the light of day.

As in the $800 billion defense industry, those feeding at the trough of our tax dollars will not “go gentle into that good night.”

I served as chair of Fletcher-Allen Healthcare in 2004 after its then-president was forced out, later charged with lying to regulators, and began serving a two-year jail sentence. I am disheartened to see yet another implosion emerging in Vermont health care.

The many dedicated clinicians and nurses who are pawns in this multibillion-dollar game of chance have provided outstanding service to Vermonters since Mary Fletcher funded and opened a hospital in Burlington in 1879 for the well-being of her community.

And when does self-interest metastasize into corruption?

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