A balancing act

A member of two state health-reform boards discusses health-care issues

WILMINGTON — I am honored to be appointed to two advisory positions in relation to Vermont's evolving health-care system, whose workings I hope to share with my neighbors.

The Green Mountain Care Board Advisory Committee (GMCBAC) is comprised of 41 Vermont residents. We serve as a public sounding board for the five Green Mountain Care Board Members who are responsible for planning Vermont's roadmap to a health-care system that improves health and moderates costs.

The charge of the Medicaid and Exchange Advisory Board (MEAB) is to advise and inform Vermont's Department of Health Access (DVHA) on policy development and program administration for the state's Medicaid-funded programs and the Vermont Health Benefit Exchange that is being developed.

This board is comprised of 30 Vermont residents, evenly divided between beneficiaries of Medicaid or Medicaid-funded programs, individuals, self-employed individuals, and representatives of small businesses, large employers, insurance carriers, brokers, and agents, advocates for consumer organizations, health-care professionals, and representatives from a broad range of health-care professionals.

As the only person to sit on both advisory boards, my goal is to facilitate communication between the two groups as well.

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Vermont spends approximately $5.3 billion a year on health care, and that care does not reach all Vermonters equally. Both GMCB and DVHA are charged with helping Vermont do a better job: GMCB by creating a path to health care for all Vermonters, and DVHA by creating the Health Care Exchange as a step on that path.

Our current “fee for service” system rewards volume over value, and the system is often problematic, with over-diagnosing, over-prescribing and over-treatment.

Without knowing the costs of various tests and procedures ordered in the name of preventing malpractice lawsuits, providers do not have the opportunity to weigh options and find the path that leads to the best health outcomes. With this system, there is no intrinsic need to coordinate care.

GMCB is investigating and evaluating alternative systems, including those of other states, other countries, and Vermont's own IBM. The focus of 2012 is to review both hospital and insurance rates, and establish pilot projects, testing different methods to pay for and improve the quality of health care in Vermont. These methods include:

Bundling, the process of having one fee for all costs associated with a procedure. Rather than paying the surgeon, anesthesiologist, hospital, physical therapist, and those responsible for all followup care individually for their respective parts in a procedure (say, a hip replacement), there would be one fee - period. This method of payment would incentivize the group of practitioners to collectively do their best for the patient.

Population-based payment gives a budget to a hospital, for example, for the number of people it serves with expectations for a limited level of services that must be met. The hospital can then manage its funds accordingly.

GMBC is poised to submit a State Innovation Model grant application next month for federal funds to implement and test some of these methodologies.

The hospital budget review process typically evaluates how much money was spent providing health care the previous year and projects those costs into the next year's planning. The GMCB goal is to ask, instead: How can better health care be provided next year? This year, a 3.75-percent target was set to signal the need to moderate cost.

GMCB's new Hospital Budget Review publication is available for download.. GMCB is seeking public comment until Aug. 31.

Please check it out, add your comments, concerns, or ask your questions. Alternatively, email GMCB Administrative Assistant Sam Lacy at [email protected].

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GMCB is also working to establish Essential Health Benefits (EHB), per the federal Affordable Care Act, that will be universally available to all Vermonters once the Exchange is in place.

DVHA is making recommendations regarding this program to include hospitalization, maternity and newborn care, mental health, prescription drugs.

The full focus of these health-care-reform initiatives is to assist Vermont in developing a culture of care by moderating cost and improving health.

It is a balancing act between making quality health care available to each Vermonter and paying providers fairly. It is also a process of changing our collective vision to focus on positive health outcomes rather than procedures performed or drugs prescribed.

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