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Vital Signs: Vermont Charts A New Course For Health Care
Vermont Edition has spent the past few weeks gathering ideas from doctors, legislators, listeners and health care administrators about what they see as the biggest problem in our health care system.
We got a lot of different answers to that question. But there were some common threads when it came to identifying problems with the health care system. Not surprisingly, cost is high on nearly everyone’s list.
Governor Shumlin says health care costs in Vermont are increasing at a rate of one million dollars a day. Double digit increases in health insurance premiums aren’t uncommon. What’s the answer? Well, we heard many. For example two listeners, Tim and Lynn, had different ideas about it.
Listener Tim Davis "We have made many, many technical and scientific advances in treatment of various diseases. However, we haven’t come up with the much needed financial mechanisms to pay for those advances. For any of the average citizens, they’re currently carrying a health insurance premium that is approaching the cost of second mortgage."
Lynn from South Burlington:
"Doctors are allowed to charge way too much, and prescribe all kinds of expensive tests and scans, even when someone is at the end of their life."
But Tom Huebner, CEO of Rutland Regional Hospital, and Dr. Joe McSherry, of Fletcher Allen Health Care in Burlington, pointed to other reasons for high costs:
Tom Huebner: "For me the central problem is matching what we want from our health care system with what we can afford. We want everything it feels like most days, but we’re not always willing to pay for it."
Dr. Joe McSherry: "The excessive expense in the system does come about because of excessive utilization and that comes about both because doctors can be practicing more efficiently if they have a simple test that gives them an answer rather than spending time eliciting that information. And also, patients on the Internet come up with all sorts of possible needs, and ask the doctor for it."
But at least one listener says the system makes it difficult for patients to avoid high-cost care – this is Denis in Tunbridge:
Listener Denis in Tunbridge: "They always talk about it’s very expensive to have care in Emergency Rooms in hospitals. But in many cases there are no other options because it’s after 6 o’clock at night or it’s on Saturday and there’s no where to go to see a doctor."
The U.S. spends more on health care than any other country. And costs are rising here faster than nearly anywhere else. Dr. Peter Hogenkamp, a primary care physician in Rutland, drives that point home by comparing American lifestyle choices and health care costs with those of other western countries.
Dr. Peter Hogenkamp: "Take a look a Scandinavia. If you take a look at how they are able to provide such excellent care for so little money, you will see that they have a healthy population to begin with. In other words, the Scandinavians have understood as a people, as a population, that they have to take good care of themselves. A lot of Americans want to relinquish the responsibility of taking care of themselves to his or her physician. Think of it from my standpoint. Someone comes into me and sees me, let’s say I’m seeing them for a physical, in a ½ hour I’m supposed to undo all the bad they did to themselves over a year."
Several other experts also pointed out that lifestyle choices are a big part of the health care problem. Dr. William Roberts practices at Northwestern Medical Center in Saint Albans, and Jill Berry Bowen is the CEO there:
Dr. William Roberts: "Some of the problem is personal choices that just aren’t ok. And that makes it not a personal choice anymore. As soon as your personal choices start to affect the cost of my health care, then it’s not a personal choice anymore."
Jill Bowen: "We’re investing a lot at Northeastern Medical Center in wellness and prevention, but we don’t get paid for it. But that’s where we need to teach folks, and it’s basic to eating right, not smoking, exercising, and how the consumer becomes responsible and accountable. We’ve got to change the expectation and the ease of access to our system."
Some say the system needs to change to support better personal choices. Stronger preventative programs and incentives for healthy lifestyle choices can reduce the number of people who end up with chronic conditions. Those conditions account for about 80 percent of health care spending in Vermont. Two hospital CEOs expressed that sentiment:
Kevin Donovan, Mount Ascutney Hospital:
"The system doe not reward primary care and preventive services in the way that it should. And I think as a society we need to put more of an emphasis on primary care and the payment for those services."
Rob Simpson, Brattleboro Retreat
"If health care looks more preventatively, and looks more at integrating the primary care physician’s office with psychiatric and addiction medicine, I think we’ll do a much better job of stopping high-end cost care."
That was Kevin Donovan at Mount Ascutney Hospital in Windsor and Rob Simpson, CEO of Brattleboro Retreat.
As Vermont Edition begins our weeklong look at health care policy and overhauling Vermont health care system, we’re hearing comments from a wide range of people – listeners, doctors, hospital administrators and legislators about *their view of what’s wrong with the status quo.
Insurance problems were top-of-the-list for almost everyone we spoke with. Kate in Brattleboro shared this story about dropped insurance:
Kate in Brattleboro: "My mother lost her job and as a result my whole family lost their insurance. And if I had had continued insurance or access I would not be facing dire health issues become what I had was a preventable health issue."
From lawmakers Mark Larson, Kevin Mullin and Don Turner, we heard about people who are uninsured and underinsured, and how to improve those numbers:
Rep. Mark Larson: "So we have 47,000 Vermonters who have no health insurance and we have almost a 160,000 who have health insurance but where their out-of-pocket expenses are so high that they in practice can’t access the health care that their coverage would provide for."
Sen. Kevin Mullin: "But the bigger problem is that an ever-growing part of our population is underinsured and is not getting the quality of care that is consistent with best practices."
Rep. Don Turner: "When we don’t fund our federal and state programs – Medicaid and Medicare – then we cost-shift those costs to the private market. And the longer we underfund those programs the bigger that problem grows."
Providers are paid about 65% percent of their costs when they see Medicaid patients. For Medicare the reimbursement is around 85%.
And that problem of Medicaid and Medicare not paying full price for services is on the mind of CEO Kevin Donovan of Mount Ascutney Hospital:
Kevin Donovan: "Governmental payers in health care reform need to pay for their fair share of the costs of the services that they seek. The truth of the matter is, when people seek services who have private insurance they’re paying not only for themselves, but they’re paying for the people who don’t pay for themselves."
How doctors are paid and the question of how much government insurance programs reimburse physicians resonates with several more people we spoke with, including Dr. Victor Pisanelli, a general surgeon in Rutland:
Dr. Victor Pisanelli: "If we, under a new health care program in the next couple of years, are not able to reimburse certain specialty providers to the level that they deserve, then there’s the possibility that they could leave. How do we replace them if we’re competing in a national market and we can’t offer the same income or reimbursement that they might be able to get elsewhere."
And that point was driven home by a listener named Chris who practices medicine in Middlebury. He says he makes a lot less than his counterparts in many other places:
Chris in Middlebury: "I make about $85,000 a year less than they do. The main reason is because I see patients who are on Medicaid. In a rural environment a doctor has pretty much no choice but seeing those patients because that’s what the patients in the rural environment have in terms of their insurance."
And Tom Dee, CEO of Southwestern Vermont Health Care in Bennington, says payment reform could lead to better outcomes:
Tom Dee: "Providers at all level are reimbursed for doing more, not really based on how well you do, but based on the more care you provide, the more tests you order. I think you need to focus on outcomes management, focus on doing better, focus on helping to have the patients do better outcomes."
But after years of debate, the medical community itself is of different minds about healthcare reform. Here are comments from Dr. Stuart Williams and Dr. Keith Michl:
Dr. Stuart Williams: "I believe we need to get away from the insurance-based reimbursement and the current hodgepodge we now have of multiple payers, multiple processes."
Dr. Keith Michl: "We’ve got to find a system that encourages innovation, reduces the status quo. So it’s going to be a difficult trick and I’m a little skeptical as to whether our little state can take on this project alone."
Those were doctors, health care executives and lawmakers weighing in on what needs to be fixed in our health care system. We want you to add your voice, too. Record your comments by calling 1-800-258-1619.