This commentary is by Ben Smith, M.D., of South Duxbury, an emergency physician and director of the emergency department at Central Vermont Medical Center in Berlin.
As we head into hospital budget season, Vermont remains in the throes of an ongoing debate about value in health care — how to define it, who defines it, and how we pay for it.
There are many aspects to this debate, but one significant thread is that hospital and emergency department resources cost too much, and that if resources can be redirected to the outpatient realm, the need for those resources will go down, thereby saving money.
It’s a tempting notion, and all of us can agree that primary care and other outpatient services are in desperate need of more resources. But it simply does not follow that hospitals and emergency departments — which care for our sickest and most vulnerable — need less, or that the services they provide, available to anyone who needs them, 24/7, are not worth the cost.
Critical to this discussion is an accurate understanding of how our acute care system performs.
Vermont is actually 46th out of 50 states in hospital admissions per capita. This is an astonishing number, especially when we are 10th-highest in emergency department visits (excluding the Covid years of 2020 and 2021) and have one of the oldest populations.
It’s notable that the other states with such low admission rates — Washington and Idaho, for example — have much younger (that is, healthier) populations. This suggests at least the possibility that we may not be admitting enough; that we may need more hospital capacity, not less.
And that conforms to what many of us observe on the front lines: too many people in need of inpatient care, not enough beds, and too many pushed out of acute care far too soon.
The large discrepancy between emergency department visits and hospital admissions might suggest to some that these visits are somehow unnecessary. Quite the opposite is true. The emergency department is able to rapidly deploy powerful diagnostics at a density and rate unmatched anywhere else in the system, and uses that capacity to avert admission for a great many patients who, in the past, would have required it.
Vermont emergency departments have evolved to provide an extraordinarily high-value service, in the traditional economic sense: treating and managing acute, complex and highly dynamic conditions while avoiding hospital admissions at higher rates than most other states.
This runs contrary — yet again — to conventional health policy wisdom, which tends to characterize emergency departments as inefficient and low-value. EDs also treat a disproportionate number of the vulnerable and the chronically ill, and any policy intervention that reduces resources for EDs will compromise the care and access of our most vulnerable neighbors, including those struggling with substance abuse, mental illness, homelessness, and other socioeconomic determinants of health.
The notion of value is a fuzzy one. Do we mean a simple equation of fixed, easily measured outcomes per dollar spent? Or is it something hazier, but more generous, open-ended, and patient-focused? More human?
Maybe it’s something like having reasonable access to your doctor when needed; having your team members rested, restored, and ready to do their best; having reliable emergency and acute care whenever it’s needed, a resilient system that can flex in times of disaster or strain, and which can proactively meet the needs of a rapidly changing culture and population.
Over the last two decades, we’ve lost a ton of ground on all these fronts, and none of them can be restored with the austerity mindset that permeates the health care establishment today.
Our state already uses its resources better than most. We have to start asking whether the relentless focus on reducing costs on the backs of hospitals — and, by default, the people who work there — is commensurate with safety, health equity, and resilience.
As one who continues to work in the trenches of our flawed and increasingly desperate system, I believe it is critical that policymakers and health care executives vigorously question the notion that our rural hospitals can safely sustain further downward budgetary pressure.
In health care, you can’t get more for less. Sometimes less is just less. And as we transition to a value-based system, it would behoove all of us to be attentive to just who gets to define what value actually means.
