A note to my readers: Below is the first of a series of articles that will describe and assess Vermont’s health care reform project as it enters its second decade.
by Hamilton E. Davis
The Vermont health care reform project, which was born in 2012 and which has been grinding along a relatively consistent track for a decade, basically fell apart during the recent Green Mountain Care Board hospital budget deliberations, and now faces an entirely new policy and political landscape.
The key element in the general metamorphosis was the incompetent and irresponsible performance of the Green Mountain Care Board in establishing the hospital budgets for Fiscal Year 2023, which began on Oct. 1. The Vermont system is really two systems—the UVM Health Network, which includes three Vermont hospitals and which delivers about 60 percent of all the care; and the remaining 11 independent facilities, which deliver the rest.
In establishing those budgets, the Board lavished all its disciplinary muscle on the UVM Network hospitals in Burlington (UVMMC), Berlin (Central Vermont Medical Center) and Porter Medical Center in Middlebury. Those hospitals have the highest quality ratings in the state, and on a per capita basis are the least expensive in Vermont. I’ll lay out that whole process in a future post.
At the same time, the Board, led by the veteran members Jessica Holmes and Robin Lunge, literally ran away and hid from their own consultants’ data that showed that the non-UVM hospitals are a total mess, with huge over-capacity, major quality challenges and off-the-wall costs. (I’ll lay that data out in a post tomorrow.)
It is ironic that it was Holmes who drove the initial decision in 2019 to embark on what she called a “Sustainability” project, one that would look at structural issues like the quality and cost of complex service lines at the individual hospitals. Ignoring all that information casts a shadow over the integrity and long-term viability of the Green Mountain Care Board itself; and raises the question whether Vermont will continue to lead the nation in the search for a new high quality, low cost paradigm for American health care. That question now confronts a “new” Board, as reconfigured as of Oct. 1 of this year.
Moreover, that uncertainty will be amplified by structural changes in the whole public policy apparatus in the state. Think of them as dominos in a complex system that affects the finances and physical well-being of every Vermonter.
The Falling Dominos
No single player is more important than the Green Mountain Care Board, which has been tasked by the Legislature to manage the entire system. The Board membership that has been in place since 2017 has now has been restructured. As of a few weeks ago, the Board has a new chairperson, Owen Foster, and a new member, Dr. David Murman. Foster is a former Assistant U.S. Attorney for the District of Vermont, who specialized in health care fraud. Murman is an Emergency Department physician at Central Vermont Medical Center in Berlin. The dynamics inside the revamped Board are as complex and nuanced as a novel. I’ll lay that out in a later post. Neither had anything to do with the budget mess in September.
The Board was just the first domino. The second is the retirement this fall of Dr. John Brumsted, the CEO of the UVM Network. Brumsted is the architect of the Network, which also includes three hospitals in northeastern New York State. Since talking the helm in 2011, Brumsted has labored to recast the medical and financial framework of his system, which now has sufficient weight to play at the level of the real heavyweights of the U.S. hospital world. What Brumsted has not accomplished, however, is development of a political structure that can reverse the public narrative that casts UVMMC as too big, too greedy and domineering for Vermont.
That task will now fall to Dr. Sunil Eapen, a top executive at Brigham and Women’s Hospital in Boston, who will replace Brumsted as CEO after Thanksgiving. Eapen was a real catch for the UVM Network: He did not get the top job at the merger of Brigham and Women’s and Massachusetts General Hospital, but his credentials are superb, far beyond anyone a Vermont facility could have hoped for. Still, the regulatory and political environments are toxic for UVMMC, and reversing that will be very challenging. Meanwhile, the dominos keep falling.
Governor Phil Scott has appointed a majority of the current Board, and was recently reelected in November. Yet Scott’s leadership of the Vermont reform project has oscillated wildly between fear and disinterest to dramatically intrusive, and back again. The day-to-day management of reform falls to the Secretary of the Agency of Human Services and Scott has had three of those since 2017, all different from one another. How all that is playing out will require another post.
Which gets us to the Vermont Legislature. That body is undergoing historic levels of turnover heading into the 2023 session. There will be nine new committee chairs, including House Health Care; there will be a new President Pro Tem of the Senate, as well as a new Lieutenant Governor, who plays a role in choosing the chairs in the Senate. How the Legislature will react to health care reform is one of the most complex questions in the project.
A domino that doesn’t get enough attention is the Vermont Association of Hospitals and Health Systems (VAHHS), the trade group that includes all 14 full service hospitals in Vermont. The long-time VAHHS president, Jeff Tieman, left last spring, and his top deputy, Mike Del Trecco, is seeking to replace him; Del Trecco is now the interim CEO. Since 2019, Tieman focused his efforts in heading off the whole Sustainability project, which poses a huge threat to the finances and the complex medical procedures, especially orthopedics, in the states smaller hospitals.
Where Del Trecco will take VAHHS on the crucial issues of reform is not yet clear, but it will be important. Small and medium sized hospitals have enormous political support in their communities and if the people in those communities see Sustainability as a threat to those facilities they could lead an anti-reform revolt in the Legislature.
It will also be important to see whether and how the UVM Network, which pays 60 percent of the VAHHS salaries, utilizes that muscle to push the reform initiative into the community hospital group. Yet another critical point is who will quantify and then figure out how to supply the money it will take to transition the small hospitals to a 21st century structure.
That array of uncertainties is far from the end of the reform story for the autumn of 2022. No single one is as important as the unraveling and re-raveling (sic) of the Green Mountain Care Board. But the financial situation inside the UVM Network, especially inside the Medical Center Hospital in Burlington, is the key to the future of serious medicine in Vermont, and that issue will require its own cluster of stories.
Moreover, there are marginal players who bear on the future of reform—like the press performance in illuminating the complexities of the issues, the state Health Care Advocate, the Vermont Auditor, and Vermont Blue Cross and Blue Shield. We’ll catch up with them along the way.
And it won’t all take long. We’ll see some issues resolve by Thanksgiving, and many others by the end of the year. Plus, the action or lack of action by the Legislature in the 2023 session that begins in January will be more decisive than any since the 2011 session gave us Act 48, the policy tiger we’re still riding.
Tomorrow: What our system looks like now.