Dear Editor,
We are practicing clinicians, trainees and recently retired doctors who serve on the Vermont Medical Society’s board and are deeply concerned about healthcare affordability and access in the state. Despite sharing these goals with state regulators and lawmakers, we believe many current strategies unwittingly threaten the very access they seek to improve.
As hospitals are required to quickly and dramatically reduce costs without increasing income, they have limited tools to balance their budgets other than cutting staff and services. At the same time, clinicians across the state are being asked to see more patients, often with fewer supports and in shorter appointments. Access is not improved when services are shuttered and the workforce responsible for delivering care is stretched beyond its limits.
So, what can be done? First, acknowledging that any cost-cutting measures have repercussions, we ask the Legislature and Vermont’s primary hospital regulator, the Green Mountain Care Board, to closely monitor the impact of recent decisions on employee retention, patient outcomes and access to services.
Second, we urge the board to work with hospitals to implement regulatory parameters that more directly address the cost of care, instead of relying so heavily on net patient revenue. This metric includes volume and cost, which restricts the amount of care hospitals can provide, even if there is a need for services.
Finally, we ask the board to consider a multiyear budget process to give hospitals enough time to invest in operational improvements, rather than expecting significant cost reductions within a year.
To illustrate some of the consequences of recent budget constraints on patient care and clinician well-being, we gathered input from our members working at over half of the state’s hospitals, including critical access and midsize hospitals, and the academic medical center. We submitted it in our recent letter to the Green Mountain Care Board. Over a dozen clinicians shared their experiences.
One physician reported discharging more patients who are struggling or unable to care for themselves at home but do not have an acute medical condition — patients the hospital would have historically kept. The physician said their hospital can no longer afford to be a safety net for people living on the margins, adding, “It increases the moral injury of delivering care.”
Multiple physicians shared examples where staffing reductions, caused by budget constraints, led to limited capacity to accept transfers for specialist care, procedures or critical care, and forced small hospitals to transfer patients far from home or out of state, putting rural patients at a disadvantage.
One hospital cut its team of social workers, who had connected patients with substance use disorder treatment, housing support and other community resources, and helped schedule follow-up appointments. One clinician said, “Now we have a packet of phone numbers that we give to patients.”
A surgeon at a critical access hospital said budget cuts have limited the hospital’s ability to hire support staff and backfill positions that help patients manage their care. Without these resources, “many patients will have worsening chronic conditions and likely higher ED (emergency department) visits and admissions,” they said. “This is not hyperbole. I see this with my patients.”
A primary care clinician recently retired from their practice five to 10 years early because of the movement away from value-based care and a lack of support staff, saying, “I gave up my patients of 30 years. … I am a casualty of the system.”
At another primary care office, the medical director said clinicians in their practice routinely see more than 20 patients in a day and expressed concern about shorter patient visits, saying, “Patients are already upset with less time with their PCP and take it out on us, which in turn detracts from actual patient care and erodes our ability to effectively manage it all.”
A physician described how the culture of their workplace has changed to focus on cost, to the exclusion of clinical care, saying, “I have been in meetings where we’ve talked about improving mortality, and I’ve been told we don’t have time to talk about that, we really just need to talk about how we’re going to meet our budget targets. And those are mortality and quality committees.”
Dr. Naiim Ali
Winooski, Vt., and Chapel Hill, N.C.
And members of the Vermont Medical Society board: Dr. Lauren MacAfee, president-elect, obstetrics and gynecology; Dr. Kimberley Sampson, vice president, obstetrics and gynecology; Dr. Mark Fung, treasurer, pathology; Dr. Katie Marvin, past president, family medicine; Dr. Aida Avdic, internal medicine; Dr. Alexandra Bannach, pediatrics; Dr. Becca Bell, pediatrics; Sarah Bushweller, physician assistant, internal medicine; Dr. Alison Davis, emergency medicine; Dr. Trey Dobson, emergency medicine; Dr. Donald Dupuis, general surgery; Dr. Joshua Cole, emergency medicine; Dr. Lydia Grondin, anesthesiology; Dr. Brian Irwin, urology; Rainhan Kabir, medical student; Dr. Jessie Leyse, infectious disease; Dr. Julie Lin, dermatology; Ryan Marawala, medical student; Dr. Bryan Monier, orthopedics; Lee Morissette, physician assistant, emergency medicine; Dr. Katelin Morrissette, critical care; Dr. Keith Nagle, neurology; Dr. Simha Raaven, psychiatry; Dr. Tamara Rimash, otolaryngology; Dr. Elly Riser, internal medicine; Dr. Catherine Schneider, general surgery; Dr. Ryan Sexton, emergency medicine; Dr. Robert Tortolani, family medicine; and Dr. Norman Ward, family medicine.
