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 good if you can afford it or access it when you need it. That is, the quality of care provided by medical personnel, from nurses to nurse practitioners to physician assistants to physicians, is generally good.
But an important legal principle 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 waited eight to 13 months between entering the help-seeking system and an eventual diagnosis of late-stage prostate cancer 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. Although he has proven himself to be a solid crisis manager during the pandemic, Governor Scott is not naturally one to address complex strategic issues and has not used his leadership voice to address and correct systemic flaws at the policy and regulatory levels .
Instead, he focused on his “affordability agenda” – a false economy, as it continues to generate cost-ineffective health care expenditures at the remedial level. Our out-of-scale investments in healing sick people and our willful resistance to adequately funding mental health and addiction treatment, prevention, education, and regulation fill our emergency rooms and our prisons. 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, MD,. states in his classic “Moral Determinants of Health”: “Circumstances outside of health care foster or impair health… (Most hospitals and doctors’ offices are repair shops that attempt to repair the damage from causes collectively referred to as ‘social determinants of health.’) Shift a significant fraction of health spending from an overbuilt, expensive, wasteful and frankly confiscatory system of hospitals and specialty care to instead address social determinants.”
Here in Vermont, poverty—expressed as a lack of access to housing, adequate nutrition, physical, dental, and mental health care, substance abuse treatment, early childhood care, and a non-toxic environment—contributes to the stressors that cause the diseases that persist. our hospital businesses.
We must shift our investment upstream to education, prevention and serious regulation of pharmaceuticals and the chemical and industrial food industries if we are to improve population health. This is the only way to reduce the chronic diseases that now cause so many health care costs.
The Legislature is trying 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 at the sides of a floundering behemoth, stretching it further and make more expensive.
In theory, a governor would convene expert voices and stakeholders to reach a consensus and shape a vision for population health in Vermont. This vision will inform and integrate all agency initiatives across state government.
The Vermont Department of Health is a public health agency. Its mandate does not involve ensuring “population health” or setting policy related to designing a functional health care system, but instead focuses on protecting and promoting Vermonters’ health as it relates to clean air and water, environmental hazards, vaccinations, stop smoking/drug abuse initiatives, safe driving initiatives such as seat belts and infant car seats, and the collection of mortality data.
It is not funded or equipped to envision and deploy an effective and cost-accessible health care infrastructure from doctors’ offices to clinics, hospitals, and nursing and residential care facilities.
So who owns the vision and sets policy for health care infrastructure in Vermont? Today it is a legal non-profit distribution of free market enterprises.
The Green Mountain Care Board should regulate health care infrastructure based on health care policy. But it is a vision we have yet to articulate. The lack of a boundary between policy and regulation and the need for it to come from different agencies confounds the care board’s understanding of its role today.
Furthermore, the medical profession’s “guild mentality” separates physical from spiritual care, as well as from dental care and treatment, even though established research and brain imaging have scientifically shown that they are physiologically integrated.
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 pave the way for chronic disease.
We must finally put to rest the self-serving falsehood that these are separate channels of health care and move toward a fully integrated system that supports population health.
A model for Vermont
Deploy a spectrum of services, ranging from solo 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, eight of which are critical-access hospitals, we probably only need six geographically dispersed hospitals and trauma service ERs with assigned specialty practices such as dialysis and joint replacement.
The others could 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 good example of rural health care delivery.
A patient’s entry point will be based on symptomatic acuity, the first and best choice in non-traumatic injury is a local primary care facility. Major trauma cases will be taken to a tertiary care trauma center by air or surface ambulance.
True cost-effective care and timely access is achieved by directing patients to local services from where they can be referred on the system to more sophisticated services based on diagnosed acuity. Emergency rooms should only be used for true emergencies, not for primary care.
Telemedicine for certain presentation systems may add system capacity.
There is also strong evidence on the effectiveness of self-care interventions in the areas of communicable diseases, non-communicable diseases, mental health, and sexual and reproductive health and rights. There are guidelines that cover depression, drug and alcohol use, stress management, migraines, hypertension, coronary heart disease and HIV, among others.
And emerging capabilities in artificial intelligence, combined with electronic health record systems, can help address data entry accuracy and the need for more doctor-patient time together.
In summary, I am increasingly convinced that investing in alleviating the stressors we continue to tolerate as a society is our most cost-effective long-term approach to health care.
We already know that enough money has been 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 amounts 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 all of Vermont state government.
No other country in the world spends what we spend on a healthcare system that delivers outcomes ranked 28thst in the world.
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