Owen Foster, the new chair of Vermont’s Green Mountain Care Board, didn’t start out working in health care.
Soon after graduating law school in 2007 and joining a large firm, he was tasked with representing one of the hedge funds that fed billions of dollars to Bernie Madoff’s infamous Ponzi scheme.
“There were a lot of lawsuits,” Foster said. “When you lose $4 billion to Bernie Madoff, you get sued a lot.”
In 2014, he was offered a position at the U.S. Attorney’s Office in Vermont. Foster, who was born and raised in Middlebury, jumped at the opportunity to return to his home state. From there, one thing led to another.
His first health care case was a medical malpractice suit. Annette Monachelli, a 47-year-old inn operator from Stowe, had died from a brain bleed. Monachelli’s husband, Randy Stern, sued her doctor, arguing that a brain scan would have saved her life. Monachelli’s doctor worked at a clinic that qualified for federal legal protections, and Foster became the clinic’s attorney.
But as Foster dug into the case, he noticed something weird: Monachelli’s doctor had, in fact, ordered a brain scan. But she never got one.
“Something didn’t look right, and I wanted to know why,” Foster recalled in an interview. His investigation uncovered glitches in the health records software.
The investigation snowballed, and Foster began finding problems with other records companies. One, Practice Fusion, gave its electronic medical records system to doctors for free. This didn’t make sense to Foster, so he tracked down the company’s corporate pitch decks. They were full of “bogus” corporate jargon, with descriptors like “synergy,” Foster said.
Prosecutors later learned Practice Fusion was selling ad space within its software to several big pharma companies. These ads would pop up on doctors’ screens and encourage them to prescribe more opioids, at higher doses.
“When I saw what they were actually doing, I was sickened and disgusted,” Foster said.
Under U.S. Attorney Christina Nolan, prosecutors continued investigating health records companies. (Nolan called this “the new frontier of health care fraud” in 2019.) Foster went on to become one of the lead prosecutors in a case against Purdue Pharma, the maker of oxycontin. The company pleaded guilty to conspiracy and anti-kickback charges in 2020 — related to its manipulation of electronic medical records software — resulting in an $8 billion settlement.
Foster is the fourth person to chair the Green Mountain Care Board since it was founded in 2011, and he’s the first to bring a litigator’s background to the role. In the course of an hour-long interview, he declined to stake out positions on the trends and reform proposals that have defined the board’s work for the past decade-plus and said he would first need to see the evidence.
“One of the important things about this job is you come in as a neutral arbiter,” Foster said.
The board has the power to regulate hospital budgets and insurance rates, with a goal of controlling costs in a sector that comprises roughly a fifth of the state’s economy. The board also helps to oversee the state’s healthcare reform efforts. This year, that includes working with Gov. Phil Scott’s office and the Vermont Agency of Human Services to negotiate an extension of the all-payer model.
Scott appointed Foster to the board on Sept. 9. Foster assumed leadership as the board embarked on a massive research endeavor: Earlier this year, the Legislature appropriated $4.1 million to the board to commission a study on “hospital system transformation.” The law, Act 167, directs the board to conduct a “community-inclusive engagement process” and identify ways to lower costs and inefficiencies within the system.
This research will conclude with a report. The work comes on the heels of a 65-page hospital sustainability study, submitted to lawmakers in February 2022.
Asked what he sees as the main challenges to health care affordability, Foster said, “From my perspective, in terms of where we are today in Vermont, the challenge is affordability, access and quality. Those things are in competition with each other. To get those, you have to pay for it. It costs a lot of money.”
The following Q&A has been edited for length and clarity.
What do you think about OneCare?
The truth is, I’ve been here three weeks. I haven’t been through the budget review process. One of the important things about this job is you come in as a neutral arbiter.
In this role, I don’t have any opinions on anyone we regulate until I see the matter that comes before me. We have their budget materials now. I’ve been reviewing them.
The OneCare contract ends Dec. 31. What happens next?
We have been working with our partners at (the Vermont Agency of Human Services) on negotiating an extension to the all-payer model agreement. It was a five-year agreement. … We’ve been working on negotiating an extension to that, and it looks like it will probably be a two-year extension. So stay tuned. That’s important, because if we don’t come to an extension on the all-payer agreement, there will be significant disruptions to how providers are paid.
The reason that we’re having that extension is we’re working on a new model for that all-payer agreement. We’re negotiating that today, yesterday, every day.
As you’re negotiating a new all-payer model, what would a good contract look like for Vermonters?
One that assures aligned incentives. If you’re looking at fee-for-service, things get reimbursed at different rates. A good agreement for Vermonters would be one that provides a shift to more of a focus on preventative care, management of chronic diseases.
A good agreement for Vermonters would be one that recognized the importance of preventative care.
What from the past six years suggests that OneCare is a good model for the next eight to 10 years? What successes do you see there?
I haven’t regulated OneCare until three weeks ago. So I don’t think I’m in enough depth from the past six years to answer that question. I haven’t lived in OneCare until now, so I can’t opine on how great or how poorly they’ve been doing.
What do you see as the most important tools for making health care affordable? Accountable care organizations (ACOs), or something else?
I don’t think I see an answer for what that would be at this time. Specifically as to an ACO, or one particular entity, I don’t really have an opinion.
What do you think about single payer, or Medicare for All?
I’ve never been involved with either of those things. I think to have an informed opinion you have to study them. And I wasn’t the regulator.
Wait times continue to be a problem for Vermonters wanting to see a doctor. What should hospitals be doing about that, and what is the board’s role in maintaining that kind of accessibility to health care?
I do think the board has an important role in that. And the first part of that is the Act 167 work we’re doing. We have put out a (request for proposals) for a contractor to assist us. We’ll get that data, analyze that data and do a report on that data to see where the problems lie. We don’t have the authority to prescribe how hospitals operate on a service-line level, but we can, through the Act 167 work, identify the problems and try and come up with solutions.
If you’re looking at primary care providers, a big part of what they’re struggling with is a big portion of their patients are on Medicare and Medicaid, and Medicare and Medicaid don’t pay as much as the private insurers. So when you’re treating the sicker and sicker and poorer and poorer people in the state, you’re making less money. And the primary care providers have much less negotiating power than the hospitals. You have a smaller population from which to cover those losses.
(Hospitals try to cost-shift) by trying to charge more from commercial payers. If you’re looking at hospital budgets, a lot of those increases will be on commercial payers. It ultimately, disproportionately impacts the commercial payers, people with large group and small group health plans.
Our job is to be in the middle and look at the system holistically, and think about what that budget increase will do to costs, and also quality.
Do you think the care board has been effective in controlling health care costs?
That’s a great question. I think first, yes. The care board has saved, I think, $880 million since 2014 to present — when the board started reviewing hospital budgets. That’s a lot of money. So we’ve certainly tamped down the cost of health care. There’s certainly more we can always do. It’s not just saying no to people’s budgets. It’s also thinking holistically, about how we can improve the system holistically.
Back to this Act 167 work: What’s the guarantee that all this data collection won’t just become another legislative study?
I don’t know that there is a guarantee. I don’t know that there is a guarantee that there are solutions, or that we can get all the stakeholders on board to do them. We don’t know what their report will be.
I can’t guarantee that this is going to solve all the problems. But I can guarantee that it will educate us in important ways. … I anticipate and believe that the process will give us a lot of important information and move all the participants and constituents in productive ways. To improve health care we need everyone working together, and that’s hard because people have competing interests. I think it’s important to understand the problem and what you’re trying to do.
Why are hospitals struggling when Vermonters pay so much for health care, and hospitals have gotten so much public money?
I think there’s a number of factors. I think, one, the inputs into hospitals are extremely expensive. If you look at the (electronic medical records), they are very, very, very expensive. I don’t know what UVM’s spent on EMRs, but it’s a lot of money. Inflation is really hurting hospitals’ bottom lines. There’s just a world in health care that costs a lot of money. That’s a big part of it.
Second, it’s looking at how and what care we’re providing. There’s a disincentive for (providers) to go and (practice in rural areas). But guess what? The sickest and poorest communities are where we need care the most. Sick people with chronic disease need primary care providers.
There’s been a lot of consolidation in health care in Vermont, especially under the UVM Health Network. Is that a good thing for patients? How does that impact patient care?
I haven’t studied in any way whether that’s good or bad for patient care. (As to the UVM Health Network), I’ve had care there, my wife has had care here, and we’ve had some wonderful providers.
Whether that consolidation is net good for Vermonters, or net bad for Vermonters, is not something I’ve dug into in my first three weeks here.
What did you think of Kevin Mullin’s approach as chair, and what would you do differently?
I didn’t watch every board meeting, but a couple things I can take away from Chair Mullin is he created a really, really, really great work culture here at the care board.
This is a very high-performance culture. I can’t keep up with everything everyone is doing. I think I need to figure out the secret sauce he had to do that, and keep that.
There’s also a culture of transparency. There’s not many government agencies where every single deliberation we have is recorded and on YouTube, and you can look it up. Every word we say is recorded. That’s a pretty unique feature of the board. … There’s really not a whole lot of secrets, and I think that’s a good thing.
Clarification: This story has been updated to more accurately describe the negotiations for the all-payer model.