This is the third article in a series…
by Hamilton E. Davis
The wave of change that has engulfed the Green Mountain Care Board began to gather last spring when Kevin Mullin, who had chaired the Board since early in 2017, said he would retire in mid-summer. It was about the time that hospitals were preparing their FY2023 budgets, and the Green Mountain Care Board was preparing to issue its guidance for that process.
There was a palpable sense of movement in the air, but it was in the background; not very specific. With Mullin retiring, of course, there would have to be a new chairperson to take the Board through the late summer budget decisions, but there was no way to tell who that might be. A second factor was the consultants’ reports resting in the Board’s data vaults, the highlights of which we looked at yesterday. The material was explosive: it painted an unsettling picture of the high costs and poor quality in the state’s 11 non-UVM hospitals. But no one was assessing it or even paying attention. The press ignored it completely.
Yet another factor involved the budget of the UVM Health Network Medical Center’s hospital in Burlington. Starting in 2017, the Mullin-led Board routinely cut the UVMMC budget to damaging levels, despite the fact that data showed UVMMC to be, by a factor of as much as three, the highest quality facility in the state; and by as much as 50 percent, the least expensive. The UVMMC margins dropped steadily over the tenure of the Mullin Board, as did its Days Cash on Hand. The only thing that kept the bond rating agencies from cutting the Medical Centers debt quality was their forbearance in the face of Covid. Which won’t last.
The financial consequences for the state from the dynamics of reform were and still are simply enormous. The UVMMC budget alone is about $1.5 billion; its Network units in central Vermont and Middlebury run that number close to $2 billion. The 11 community hospitals in the state spend around $1 billion, for a total acute care tab of about $3 billion. Throw in the non-acute spending for things like nursing homes, home health care and various social programs and you get around $6 billion, which is 20 percent of the whole state domestic product of $30 billion. Screw that up and you could sink the Vermont economy. And that’s just the money. The damage to Vermonters from dodgy quality and lack of access is incalculable.
The System Begins to Move
The first stirring came in late winter when Robin Lunge mounted an effort to be named the new chairperson. A lawyer, Lunge was named to the Board in the mid-teens by then-Governor Peter Shumlin. Prior to that she served as Director of Health Care Reform, working out of a pod in the Governor’s Fifth Floor office in the Pavilion. She was placed there by Steve Kimbell, the Commissioner of the Department of Fiscal Regulation, who along with Anya Rader Wallack, was directing Shumlin reform effort. Whatever her title, her job was to liaise with the Governor himself and to give Wallack any legal help she might need.
As a member of the Board, Lunge was a secondary player. The intellectual leaders were Jessica Holmes, the Middlebury College economics professor, and Maureen Usifer, a private sector financial expert. The political direction and leadership came from Kevin Mullin, the chairman. The fifth member, Tom Pelham, had no discernable effect on the Board’s deliberations. In late 2021, Usifer retired and was replaced by Thom Walsh, a Dartmouth professor.
As the budget decisions loomed, however, Lunge stepped to the forefront. A major question was how to frame the overall spending level for each hospital. The details can be left to a later post. For now, it is sufficient to say that Holmes and Mullin favored beginning to move from a simple cap to a metric based on the per capita spending in a hospital service area, a metric that looked forward to a fully capitated system. Lunge disagreed and proposed a complicated, old style, two-year cap of around eight percent. Lunge won her point on a 3-2 vote. The policy impact of that was zero. The important point was that Mullin had lost control of his Board, and Holmes’ intellectual leadership had failed.
Fast forward now to early August of this year. Mullin is gone, and Jessica Holmes has been named interim chair of the Green Mountain Care Board. And that new Board was on a brand new track, although it wasn’t obvious to everyone. When Mullin was chair and a petitioner was finished with their presentation, Mullin would throw the issue to the other Board members for comment and discussion, starting now with one member, another meeting a different member. He would also regularly state his own views.
Holmes changed that from her first day. When discussion time came, she would call every time on Lunge first. Lunge would then launch into a fully prepared proposal as the right course for the Board. If Holmes had some views that would complement Lunge’s comments, she would articulate them. But the lead role was always Lunge. Holmes would then turn to Tom Pelham, and always last to Thom Walsh.
As the hearings proceeded, it became obvious the Holmes-Lunge posture had been worked out in advance, and that the Board had broken into two distinct blocs--Holmes and Lunge on the one hand and Walsh and Pelham on the other. For most of the hospitals, that divergence didn’t matter. Both Walsh and Pelham were inclined to support the small hospitals, and to be skeptical and tough about the UVM Network. The elephant in the room for all the Board members was the information from the consultants bearing on the problems of the small hospitals.
Running and Hiding from the Data
All four members avoided any mention of the data, even as they were spending hours talking to every hospital management team about their operations, their problems and their successes and challenges. Budgets for North Country, Springfield and Gifford hospitals, with not a word about the dangerously low Leapfrog volumes. Budgets for Springfield, Northeastern in St. Johnsbury, Northwest in St. Albans, Copley in Morrisville, Gifford in Randolph, North Country in Newport—all above 30 percent of their inpatient admissions and admissions from the ER that were not needed. Unneeded care is a huge quality red flag. Not so much as a whisper of discussion.
How do you rubber stamp budgets for Rutland, Gifford and Southwestern in Bennington when their PQI readings are far worse than national PQI standards…And how do you avoid a word about the findings by Mathematica that you have 140 too many beds in Brattleboro, Bennington, St. Albans, Middlebury, Newport, Morrisville, Randolph and St. Johnsbury?
I asked Jessica Holmes about those issues, and she emailed the following response:
She wrote first that Vermont is still in a Covid emergency, and that all the state’s hospitals are stressed by work force shortages, financial losses and problems with access and quality.
“So this year’s budget process was about short term stabilization as outlined in Act 167,” she wrote. (her emphasis) “As we emerge from the pandemic,” she continued, “the Board will be accelerating its work on long term sustainability…we will be doing a deeper dive into capacity, efficiencies, volumes, costs and quality…so the very important work started by the consultants in 2021will be accelerated in early 2023.” She added that the Board will hire a consultant to help with design work.
I responded to this by email, saying that there is nothing in Act 167 or any other Vermont statute that prohibits or discourages in any way the Green Mountain Care Board from taking action to protect Vermonters from dangerously incompetent medical care. I got no response to my second question.
The analysis by the various consultants is voluminous, and there be may well be a contrary case to be made about any element of it. I have asked for comment on that question from the Vermont Association of Hospitals and Health Systems, whose membership includes all the state’s hospitals, and received no response. In the future, I’ll seek comment from the individual hospitals, and I anticipate I will get some, or a lot.
The thing we can tell now is that the Green Mountain Care Board as constituted between early August and the end of September was a total failure. We don’t need a “deep dive” in early 2023. We’ve been living through a deep dive for at least the last five years. What we need is a Green Mountain Care Board with at least enough political courage to look at the facts we already know. Which is at least possible.
Because as of Oct. 1 we have a new Green Mountain Care Board, the third in our 10-year reform journey. In tomorrow’s post, we’ll look at the new Board’s maiden voyage.