by Hamilton E. Davis
About a month ago, Greg Robinson, the executive director of the Community Health Centers of Burlington, was fired by his Board, the latest manifestation of the turmoil in Vermont’s primary care community as it prepares to enter the new world of health care reform.
A week ago, Robinson took his story to The Burlington Free Press. He said he had been “blindsided” by the Board’s action, which took place just five months after he took the top job; he added he had no idea why he had been dismissed. As evidence for that, he produced a series of e-mails from the Board chair, the substance of which was that the Board approved of his work and where he was taking the organization.
As it happened, I had interviewed Robinson at some length before he got fired, and while I was surprised when it happened, there was no difficulty at all figuring out what had gone wrong. Robinson had a very ambitious plan to partner with HealthFirst, a group of independent physicians, and to build the combination of his group and HealthFirst into a very strong force in the health reform environment.
His first problem was that there really wasn’t a path to that outcome. A second was that HealthFirst apparently realized that--even though Robinson didn’t--and was moving toward an accommodation with the main body of healthcare providers in the region. The third was that while Robinson had sold his plan to the Board, he hadn’t sold it to his doctors. So when the Community Health doctors sent a letter to the Board saying they had lost confidence in the leadership of the front office, Robinson was toast.
The Robinson experience was just the latest indication of the huge stresses that have tied the primary care community in knots over the last year and a half. Indeed, it was uncanny the way events at the Community Health Centers mirrored those at Porter Medical Center in Middlebury a year or so earlier.
The Porter Board spent a full year doing a national search for a new president for their hospital. They came up with a very-well-credentialed young executive named Lynn Boggs and they told Boggs that her job was to turn around a dangerous financial situation that threatened the hospital’s survival. Porter was losing several million dollars a year because they were paying some of their doctors more than the hospital could afford.
When Boggs took office, she went right to work on the problem, informing the doctors that their pay would be cut, and she didn’t sugar coat the pill at all. The result: the doctors at Porter revolted and told the Board they would have choose between Boggs and the doctors. Result: Boggs was gone in six months or so.
The reality is that if you have a company or any organization whose business is to deliver health care by doctors, and your doctors quit on you, then your business is gone. Medical care organizations all have boards and the boards are important, but the real power lies with the doctors. Boggs found that out in Middlebury, and now Robinson has discovered it in Burlington.
The Primary Care Conundrum
The Burlington and Middlebury examples are just highlights of the way that health care reform is upending the long-standing relationship between primary care on the one hand the hospital and specialist elements of the overall system on the other. Primary care providers have always been the poor relations in the health care family.
Obamacare itself, as well as the Vermont reform project, has conferred enormous new political power onto primary care providers. I have laid out this structure out in the last few blog posts on this web site. A summary thread goes like this: the key to health care reform is getting costs under control; the only way to get costs under control is to shift reimbursement from fee-for-service to block financing, or capitation; and the only way to do that is to integrate the disparate delivery units into a new type of organization called an Accountable Care Organization. (ACO).
The linchpin in this mechanism is the Obamacare provision that the only way to move patients into an ACO is to have them referred there by a primary care physician. So, primary care doctors are in the process of becoming the gatekeepers of reform. You can’t even get started down the road to cost containment without “attributed lives” from primary care providers. There is a huge political difference between a poor relation and a gatekeeper and that fact has not escaped the notice of the primary care doctors themselves.
So, for a year and a half or so, the primary care doctors have been trying to position themselves in the most advantageous way. It’s worth noting that there are about 700 primary care doctors in Vermont. (They are not the only such providers; nurse practioners and some others deliver primary care also, but the doctors are the centerpiece of the system.)
Of the 700, roughly 300 are employed by hospitals and their fortunes are tied to their employers: if their hospital is part of an ACO, then the patients of the primary care doctors in that hospital are “attributed” to the ACO. (Some community hospitals are in the ACO, but will not get fully involved in reform in Vermont until 2018 or even 2019, but that is a wrinkle I’ll get to later).
The second largest group are members of Federally Qualified Health Centers (FQHCs) that get some federal funding to ensure the availability of primary care in rural and lower income areas. Eight of the FQHCs, with a total of 44 sites across the state, have formed an organization called Community Health Accountable Care (CHAC) that is engaging in the reform project as a unit. CHAC has some 275 or more primary care docs. The Burlington health centers are an FQHC, but not part of CHAC.
The third largest cluster of primary care docs are the 60 or so independents gathered together in a group called HealthFirst, which I mentioned earlier in the connection with the Robinson firing. There are some others that simply stand alone.
The question for all the primary care docs is whether to join the state’s biggest ACO, which contains north of 90 percent of the medical assets. That ACO is called the Vermont Care Organization; it is fully integrated, which means that it can deliver primary care, secondary care in community hospitals and tertiary care in big academic medical centers like UVM’s medical center in Burlington or Dartmouth-Hitchcock in Hanover, N.H.
Most, if not all, of the 300 hospital-employed doctors are already there; all but four of the state’s 14 hospitals joined the big ACO when it was founded a few years ago. The 275 plus docs in CHAC maneuvered for more than a year in order to get the strongest possible role in the big ACO, but finally signed up last July. Once the integrated ACO, the Vermont Care Organization, finally merged with the FQHCs, the infrastructure necessary for reform was essentially in place.
HealthFirst is the smallest of the doctor agglomerations: the membership varies, but over the last year it included about 60 primary care docs along with a handful of stand-alone specialists. What sets HealthFirst apart from other groups is the principle that its members are independent: HealthFirst, in other words, can’t commit them as a body to any course of action.
Despite its small size and the fact that its essence stands in opposition to the proposition that integration of the delivery system is necessary to cost containment, HealthFirst has proven itself to be remarkably agile politically; it has punched well over its weight. I’ll look at that in more detail in a future post, but for today the important point is that important elements within HealthFirst have already signed up with the big ACO to deliver care to Medicaid patients in the state.
The upshot of all that movement is that virtually all the medical assets in the state are at least nominally gathered into an ACO structure. (None of that, by the way, should be construed to mean reform is assured in Vermont. The election of Donald Trump to the presidency is an obvious wildcard. And even within the ACO structure, only some of the units are prepared to go directly to capitated contracts when the ACO goes live on Jan. 1, 2017.)
The issue that apparently tripped up Greg Robinson at the Community Health Centers was in his effort to navigate through these treacherous waters. The Burlington-based organization is itself a Federally Qualified Health Center, but it remains one of the few, if only, such units not to join the other FQHCs, which have been acting as a unit.
When Robinson took the job as CEO, his plan was to remain independent—that is, not to join any ACO--and further, to link up with HealthFirst to form a stand-alone block in dealing with reform. He proposed calling the cooperating units the Population Health Alliance.
In addition to delivery primary acute care, Robinson aimed to be more than normally aggressive in dealing with population health by sending out staff members to schools, workplaces, and other gathering sites to persuade people to adopt healthier lifestyles as a way to get at health care costs. This vision attracted the allegiance of a small, but important primary care clinic called Good Health in South Burlington. The head of that group is Dr. Peter Gunther, who has already joined the Burlington centers, and who is scheduled to become the Centers chief medical officer.
The problem with this vision was that it didn’t seem to mesh with the trajectory of health care reform, in Vermont to some extent, but mainly in the U.S. Federal Medicare and Medicaid officials, with bipartisan support in Congress (very rare), are moving to squeeze primary care doctors into ACOs by getting more money to primary care docs, but only those in integrated systems that can shift their basis of reimbursement away from fee-for-service.
The Green Mountain Care Board, which has eschewed putting pressure on anyone to join an ACO, has also made it clear that the federal pressure to join such an organization will be the ultimate driver of the system. Al Gobeille, the GMCB chair, said in a dozen different forums and a dozen different ways in the last several months:
There is no way the State of Vermont or the Green Mountain Care Board can protect providers from the federal effort to move delivery systems across the country toward integration.
By mid-fall, these developments appeared to cohere in a way that would leave the Burlington Centers isolated in a world trending toward integration. That would be so even if Robinson could have pulled off the tie to HealthFirst; without HealthFirst, the Robinson plan would be dead on the launching pad…
In the wake of the firing, Kim Anderson, the spokesperson for the Burlington Centers, said that the potential alliance with HealthFirst was “on hold.” She also declined to discuss the issue on the grounds that her organization does not comment on personnel matters.
After Robinson went to the press, Anderson reiterated that the Burlington Centers would not discuss personnel matters. As for the issue of how the Centers might position themselves in the health reform landscape, however, Anderson said that her organization has established a committee to work on that question, but that it has not yet arrived at a recommendation.