Patrick Flood: An affordable health care system for a healthier Vermont 

This commentary is by Patrick Flood, former commissioner of the Department of Mental Health and the Department of Disabilities, Aging and Independent Living, and former deputy secretary of the Agency of Human Services. He is now retired and lives in Woodbury. This is one of three commentaries about health care; one was published Nov. 4 and the last will be published Nov. 18.

In her recent commentary, Julie Wasserman described in detail how health care reform efforts in Vermont have failed over the past six years. They have failed chiefly because they have not focused on the right issues and solutions. 

Health reform has been a thinly veiled effort to maintain the status quo while tinkering around the edges. Our state’s reform effort has been an initiative led by the hospitals, primarily the UVM Health Network, to protect the hospitals’ funding and dominance of the health care system. 

The reality is that Vermont will never achieve rational cost control, universal access and better health for its population until our reform efforts shift dramatically to focus on primary care, prevention and other health-related community services. 

It is a well-established fact that most health care systems in Europe guarantee universal access to health care as a right and achieve better health outcomes for much lower cost. What explains the latter? For starters, these health care systems dedicate more resources to primary care and to addressing social issues (like mental health, hunger and homelessness) that create or worsen health problems. 

In this country, including Vermont, we do just the opposite. Most of our health care dollars are directed to hospital care and high-cost services, much of which can be avoided with more medical and social intervention at the community level. As Ms. Wasserman pointed out in her commentary, a significant percentage of hospital services in Vermont is avoidable. 

There are four things we can do immediately to avoid unnecessary hospital treatment and, thus, bring down the cost of health care. 

First, expand and strengthen primary care services and remove financial barriers, like high deductibles, which prevent people from accessing it. Everyone in health care knows that primary care is foundational to a high-quality, affordable and equitable health care system and we have known it for a long time. Yet, primary care capacity in Vermont is grossly inadequate. 

Statewide, we urgently need more primary care doctors, physician assistants and nurse practitioners, and nurses. Reimbursement rates for primary care need to be increased, working conditions improved, and more medical students incentivized to choose primary care as a profession. None of this is a mystery or complicated. 

Second, expand and improve mental health services. Mental health problems like anxiety and depression, left untreated, cause or worsen many physical health problems and drive-up costs. Yet, our mental health system is also in crisis. More hospital treatment beds are not the answer. A more preventive approach, including more crisis response, community support and counseling, is the answer. It is far cheaper and cost -effective to fund prevention and community-based intervention than to increase and fill more beds. 

Third, expand and strengthen home health services. Home health caregivers regularly care for chronically ill people in their homes and reduce the number of unnecessary hospital stays. Home health also offers hospice services, which keep terminally ill people out of hospitals for expensive end-of-life care that they may not want. 

Yet, home health agencies struggle to maintain the staff they need due to funding cuts at the federal level and inadequate funding at the state level. So, instead, many people needlessly spend time, including their final days, in hospitals. 

Fourth, we must effectively address what are called the “social determinants of health,” such as hunger, homelessness and abuse. These issues have huge impacts on people’s health, yet we treat them as if they are separate from the health care system. We underfund them, then wait until people have severe and untreated medical conditions and end up in the hospital. 

How would Vermont fund such improvements? 

First, the state should stop funding the failed accountable care organization, OneCare Vermont, and reassign that funding to these initiatives. Seventy-eight percent of OneCare’s operating costs are paid with publicly funded Medicaid funds and could be redirected to better use. 

If properly implemented, these four initiatives would result in lower hospital and emergency room admissions by reducing avoidable care. That alone would not suffice. However, savings from those reductions could be redistributed to further expand the initiatives above. 

This redistribution would continue until Vermont reached the best balance between funding for hospitals and funding for community services and achieved a well-balanced, affordable health care system. 

There is no magic to designing a high-quality, affordable and fair health care system. We know what needs to be done, and we’ve known it for a long time. We need to restructure our hospital system to limit its cost (remember how much of the care is avoidable) and, instead, reallocate funding poorly spent in that system to support the prevention-oriented services and programs described above. 

Of course, we need and want an adequately financed, high-quality hospital system, and we certainly can have one with all the money we are spending on it today. But a lot of that money is being spent unwisely and ineffectively. As a result, many Vermonters can’t get or afford the care they need. We can do better, and we need to begin now.

On Nov 18, in the third and final installment of these commentaries, Mark Hage will describe systemic steps that can be taken to restructure hospital funding to make it more equitable, affordable and understandable. 


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