A process, not an event

Vermont’s health care reform effort has much yet to do

WHITINGHAM — Now that the U.S. Supreme Court ruled that the federal Affordable Care Act is constitutional, Vermont can continue its own health care reform effort secure in the knowledge that the necessary federal dollars will flow to the Green Mountains.

Last year, the Vermont Legislature passed Act 48, a health care reform bill that puts the state on a course for a unified and universal health care system.

The Legislature followed that up this year with Act 171, which outlines the implementation and the creation of the Green Mountain Care Board to help oversee the reform process.

On its Health Care Reform website, the Agency of Administration writes, “These laws recognize that health care is a public good, much like electricity. They put Vermont on a path toward an integrated health care delivery system with a budget regulated by the new Green Mountain Care Board, universally available health insurance coverage that is not linked to employment and a single system for administration of claims and payments to providers.”

Federal funds are due to arrive for the Green Mountain Care unified health system in 2017. Meanwhile, the how and what of Vermont's new health coverage are in the early stages of being shaped.

The board has not officially voted on a route forward. It's at the idea stage, said Dr. Karen Hein, a resident of Whitingham and one of six Green Mountain Care Board members.

Hein is an adjunct professor of family and community medicine at Dartmouth Medical School and former president of the William T. Grant Foundation. Other boards she has served on include RAND Health, Consumers Union, the Robert Wood Johnson Foundation Clinical Scholars Program, the International Rescue Committee, and ChildFund International.

She earned her degree from Columbia University and is a board-certified pediatrician. As a Columbia University and Albert Einstein School of Medicine faculty member, Hein taught pediatric residents and fellows for 25 years while researching adolescent HIV and AIDS.

Redefining health

The outcomes of the new health system will depend on how broadly or narrowly the board defines terms like “health” or “benefits,” Hein said.

“It changes the conversation by having a broader definition of benefits,” Hein said.

Traditionally, health care benefits depend on what a health insurance plan offers. A broader definition could include well-being, Hein said.

Another possibility is expanding the definition of health beyond clinical services, she added.

“Health is more than the absence of disease,” she said.

Hein would like to see an integrated system where clinical care, public health, population health, and an individual's personal goals weave together for a thriving Vermont.

The model Hein describes places patients in the center of their care with insurance, employers, the community, policy, and the patients themselves contributing actions, not only money, to the population's well-being.

Health care is as much about distribution of resources as insurance premiums, she said, adding, “[Vermont] has scarce health care resources.”

The state's spending of $5.3 billion on health care does not reach all Vermonters equally, Hein said.

When treating prescription drug abuse, a huge problem for the state, she said, some people get help while others don't. Even when a person seeks treatment not all doctors have the training to help.

According to Hein, health care takes 18 percent of the state budget, averaging an annual $8,000 per person. This is higher than the national average.

Some of this cost stems from Vermont's slightly-higher-than-average population age.

“We could do a little better here for the price,” Hein said.

Value over volume

Traditionally, hospitals and doctors receive money based on volume - money for each test run, or bone set - rather than value, said Hein. Health care reform presents the state with the option to enact value-based funding - or funding outcomes based on patients' goals.

For example, a check list for a patient with COPD (Chronic Obstructive Pulmonary Disease) might include breathing and medication, explained Hein. But the patient's goal for his or her condition might include feeling strong enough to attend a grandchild's graduation.

She acknowledges that goals-based outcomes delve into delicate and personal issues like end-of-life care. And it can be hard to measure whether goals are being met.

“How do we build into a health care system ways to support peoples' choices?” she asked.

Then, how can the state, employers, or the community build a culture that daily supports individuals' healthy decisions, she asked.

Hein said she envisions changing hospitals' job descriptions so they are not “the end of the line,” but part of a whole.

The money would come to the hospital in a chunk rather than per procedure. Hospitals would assume the risk that insurance companies once held, she said.

“It's their loss if patents don't improve,” Hein said.

This pay structure would allow hospitals more freedom to work with an individual's treatment plan, she said.

Developing a “care culture” where patients get to outline their own goals and care plan will mean that Vermonters will keep their freedom of choice, she said.

The time spent in a doctor's office contributes to a “tiny percentage of your life,” said Hein.

According to Hein, multiple factors contribute to whether a person dies early from diseases such as heart disease or diabetes. Interaction with the health care system contributes 10 percent against early death. A person's genes make up 30 percent of the equation.

That 10 percent includes people with health insurance. For the estimated 47,000 Vermonters without insurance and lacking adequate access to care, this percentage could be higher, said Hein.

Behavioral choices are the biggest contributor at 40 percent. Public health factors like water quality and social circumstances come in at 20 percent. Changing these two factors provide the “biggest bang for the buck,” said Hein.

Blaming obese people for being overweight or smokers for being addicted to tobacco is not a solution, said Hein. But, instead, she suggested building a community that helps people overcome or prevent those problems.


Legislation also calls for the board to create the Green Mountain Care budget.

Developing a unified health budget could mean analyzing the $5.3 billion the state spends on health care and allocating it based on past spending, Hein said.

“[But] that's a cop out,” said Hein. “All that budget is is [based on] how it's been going.”

Nationwide, an estimated 95 to 97 percent of health care dollars got toward clinical services, while the remaining 3 to 5 percent goes to public health, said Hein.

Public health initiatives and actions, however, provide the “biggest return on investment,” she said. “What if Vermont reversed the percentage?”

The state could build a budget around its population's needs, she said.

This budget could include benefits like bike paths or Federally Qualified Health Centers.

The unified health budget won't encompass every penny of the overall state budget but Hein said she hopes the process will recognize the interplay between health and a thriving Vermont.

A healthy population touches every aspect of Vermont, said Hein. Economic development initiatives depend on a healthy workforce.

Interdisciplinary health

Vermont also has an opportunity to look at health “drivers,” Hein said.

For example, with a health concern such as obesity, the state could recognize how the intersection of departments such as clinical services, agriculture, transportation, and education could contribute to a healthy weight, rather than having doctors respond with bariatric surgeries.

Bringing together these normally disparate disciplines and their corresponding - often siloed - agencies, will depend on Vermont's definitions of health and benefits, Hein said.

“We do not have all the answers,” she said. “This is a process not an event.”

Hein said the Green Mountain Care Board and state will hold public meetings to gather community input over the coming year. The big issue, in her mind, will be ensuring that the state manages to engage its citizens in the process. Lacking full input will translate into a plan that does not fit all Vermonters, she said.

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