Bill Schubart: Vermont needs a new model for its health care system

Ella Castle

A nurse peers into a Covid-19 patient’s room before entering at the emergency department at the Southwestern Vermont Medical Center in Bennington on Monday, Dec. 13, 2021. Photo by Glenn Russell/VTDigger This commentary is by Bill Schubart of Hinesburg, author of nine books of fiction, a former VPR radio commentator […]

A nurse peers into a Covid-19 patient’s room before entering at the emergency department at the Southwestern Vermont Medical Center in Bennington on Monday, Dec. 13, 2021. Photo by Glenn Russell/VTDigger

This commentary is by Bill Schubart of Hinesburg, author of nine books of fiction, a former VPR radio commentator and a regular columnist for VTDigger.

The Vermont health care system, infrastructure and vision are broken, and Vermonters of all economic strata are the losers.

The soul of the system is fine if you can afford it or access it when you need it. That is, the quality of care provided by medical staff from nurses to nurse-practitioners to physicians’ assistants to doctors is generally good.

But a major legal tenet of health care is “standard of care,” which is early diagnosis and treatment. If a Vermonter can’t afford or get timely access to care, the existence of a health care system is meaningless to them. 

I have several male friends who, between their entry into the system seeking help and an eventual diagnosis of late-stage prostate cancer, waited from eight to 13 months because appointments were so hard to come by. What, if any, is the health care system’s liability?

Failure to address such a critical statewide problem trickles down from the top. While having proven himself a solid crisis manager during the pandemic, Gov. Scott is not by nature one to address complex strategic issues and has not used his leadership voice to address and correct system failures at the policy and regulatory levels.

Instead, he has focused on his “affordability agenda” — a false economy, since it continues to generate cost-inefficient health care expenses at the remediative level. Our out-of-scale investments in curing sick people and our willful resistance to adequately funding mental health and addiction treatment, prevention, education and regulation are filling our emergency rooms and our jails. There is no more expensive way to fund population health.

Our failures elsewhere are integral to our failures in health care. A world authority on health care, Don Berwick, M.D,. states in his classic “moral determinants of health”: “Circumstances outside health care nurture or impair health … (M)ost hospitals and physician offices are repair shops, trying to correct the damage of causes collectively denoted ‘social determinants of health.’ Shift some substantial fraction of health expenditures from an overbuilt, high-priced, wasteful and frankly confiscatory system of hospitals and specialty care toward addressing social determinants instead.”

Here in Vermont, poverty — expressed as lack of access to housing, adequate nutrition, physical, dental and mental health care, substance abuse treatment, early child care, and a non-toxic environment — contributes to the stressors that produce the sicknesses that sustain our hospital businesses.

We must move our investment upstream to education, prevention and serious regulation of pharma and the chemical and industrial food industries if we want to improve population health. That’s the only way to reduce the chronic diseases that drive so much health care expense now.

The Legislature tries hard, but with little policy and research support and a two-year window for action and a one-year budget cycle, it can do little more than tinker around the edges of a floundering behemoth, making it more expansive and expensive.

In theory, a governor would convene knowledgeable voices and stakeholders to derive a consensus and form a vision for population health in Vermont. This vision would inform and integrate all agency initiatives across state government.

The Vermont Department of Health is a public health agency. Its obligation does not rise to ensuring “population health” or setting policy as it relates to designing a functional health care system, but rather focuses on protecting and promoting Vermonters’ health as it relates to clean air and water, environmental hazards, immunizations, stop smoking/drug abuse initiatives, safe-driving initiatives like seat belts and infant car seats, and collecting mortality data. 

It is neither funded nor equipped to envisage and deploy an effective and cost-accessible health care infrastructure from physician offices to clinics, hospitals, and nursing and residential care facilities.

So, who does own the vision and set policy for health care infrastructure in Vermont? Today, it’s a legally nonprofit sprawl of free-market businesses.

The Green Mountain Care Board should regulate health care infrastructure based on health care policy. But that is a vision we have yet to articulate. The lack of a boundary between policy and regulation and the necessity that they come from different agencies muddles the care board’s understanding of its role today.

Furthermore, the medical profession’s “guild mentality” segregates physical from mental care, as well as from dental care and treatment, even as established research and brain imaging have shown scientifically that they’re integrated physiologically.

By way of example:

  • Periodontal disease causes congestive heart failure.
  • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) inflammation tests show us how psychological stress, anxiety, depression and other mental health conditions compromise the immune system and open the way for chronic disease.

We must finally lay to rest the self-serving falsehood that these are distinct channels of health care and move to a fully integrated system that supports population health.

A model for Vermont

Deploy a spectrum of services, running from sole practitioners to small group practices to community health centers (including federally qualified health centers) to critical-access community hospitals to secondary-care hospitals such as Rutland, Berlin, Copley and Southwest, and finally to our two tertiary-care hospitals UVM and Dartmouth-Hitchcock.

Of Vermont’s 14 hospitals, of which eight are critical-access hospitals, we probably need only six geographically-dispersed hospitals and trauma-service ERs with allocated specialty practices such as dialysis and joint replacement. 

The others can be repositioned as expanded community health centers with a broad focus on access, urgent care, diagnostics, chronic-disease management, nutrition and mental health counseling, dentistry, prevention and education. 

The Health Center in Plainfield is a fine example of rural health care delivery.

A patient’s point of entry would be based on symptomatic acuity, the first and best choice in non-traumatic injury being a local primary-care facility. Major trauma cases would be air- or surface-ambulanced to a tertiary-care trauma center. 

True cost-effective care and timely access are achieved by directing patients to local services from whence they can be referred up the system to more sophisticated services, based on diagnosed acuity. Emergency rooms should be used only for true emergencies, not for primary care.

Telemedicine for certain presenting systems can add system capacity. 

There’s also strong evidence on the effectiveness of self-care interventions in the fields of communicable diseases, noncommunicable diseases, mental health, and sexual and reproductive health and rights. Guidelines exist covering conditions including depression, drug and alcohol use, stress management, migraine, hypertension, coronary heart disease, and HIV, among others.

And emerging capabilities in artificial intelligence, combined with electronic health record systems, may help address data-entry accuracy and the need for more doctor-patient time together.

In summary, I’m increasingly convinced that investing in alleviating the stressors that we as a society continue to tolerate is our most cost-effective, long-term approach to health care.

We already know there’s enough money invested in treating the dire results of these stressors to fund most of these societal needs.

Upstream investments in health care education, prevention, regulation, primary care, mental health, chronic disease management, addiction prevention and recovery will reduce the staggering sums we spend on fixing sick people, often with mediocre outcomes.

A national program of universal health care is ultimately the only way to reduce the $4.1 trillion — $12,530 per person — we now spend annually on health care. Here in Vermont, we spend $6.5 billion — $10,442 per Vermonter — not that much less than the $8 billion annual budget for the entire Vermont state government. 

No other country in the world spends what we spend on a health care system that produces outcomes ranked 28th in the world.

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