by Hamilton E. Davis
The Legislature broke new policy ground in 2011 when it established the Green Mountain Care Board with a mandate to both regulate and recast the Vermont hospital system. The state has long regulated entities like electric utilities, and it has performed planning functions through agencies such as the Health Department and the Department of Financial Regulation. Combining the two, however, has been something new.
In an earlier post, I described the Board’s performance in that role as “atrocious.” I want to be clear at the outset that I am referring here to the third iteration of the GMCB, the one constructed by the Scott Administration in 2017, and modified, much for the worse, in 2022. The two biggest responsibilities the Board has to discharge are, first, ensuring the financial viability of the UVM Health Network, which delivers 60 percent of all the care in the state, and all of the most complex care, and second rationalizing the non-UVM network of 11 small hospitals that now waste $300 to $500 million per year. On the basis of the record so far, the Board is failing to ensure the survival of the UVM Network as a national class academic medical center.
The question for today, however, is the Board’s performance on the small network. The Board’s failure there is equally as bad as in the UVM Network, with the added malpractice on the Board’s part of hiding the questionable quality in the small network. I’ve written all of this before, but today I want to just remind my readers about the devasting indictment sleeping away in the Board’s archives over the last two years.
The indictment consists of the findings of half a dozen national consultants, delivered to the Board on Oct. 27, 2021. The consultants were Mathematica, Berkeley Research Group, Dartmouth Health Institute, Burns and Associates, and Oliver Wyman.
The following is a selection of graphics that set out their findings:
The above chart shows the 2018 quality performance of the Vermont hospitals by Service Areas against a national benchmark. (Note that the lower numbers are highest quality) The results are striking. The most dramatic is the huge quality advantage that UVM’s Medical Center Hospital shows against the national figures, and more important, against the smaller hospitals in Vermont—5.96 against the benchmark of 13.06; and the two smaller units in the Network, Porter in Middlebury and Central Vermont in Berlin, are just a little higher.
Then look at the top group, Southwest in Bennington, Gifford in Randolph, and Rutland, whose quality is just plain bad, all with unacceptable national rankings. In the budget hearings, the Green Mountain Care Board never even mentioned these findings. Of the rest, hospitals in Newport, Springfield, St. Albans, St. Johnsbury and Brattleboro need work, although they won’t hear that from the Board.
A major problem in the small Vermont Hospitals is that many of them deliver big-money procedures that are too complex for their capacity. A measure of that is called the Leapfrog readings, which determine for surgical procedures how many a doctor needs to do in a year to keep up his or her skills. An example: hip and knee replacements.
Pretty obvious here that Gifford in Randolph, North Country in Newport, Springfield and Northwestern in St. Albans are putting patients at risk with these lucrative surgeries.
A more broad-based metric considers patients that are admitted from a hospital’s Emergency Room and from its inpatient population. The buzzword is Potentially Avoidable Utilization. Those numbers, shown below, are quite high in the small network.
When the consultants summed over the findings, they recommended that the total number of beds be dramatically reduced. Eight of the 11 non-UVM hospitals need a total of 140 fewer beds in 2026 than they have now, the consultants found.
And some of those cuts were severe. Look at Southwestern in Bennington, for example. That hospital had 78 beds in 2020, and they only need 43 in 2026, a reduction of 35 beds. And in the broader perspective, Southwest has also been a real problem child. Its Medicare cost per capita in 2018 was $9,822, the highest in the state. UVMMC by contrast was $6,524. Plus, their quality performance in 2018 as shown in the chart above, was 16.4, the highest (lower is better) in the state, and well over the national benchmark of 13.06.
Yet in the recent budget deliberations, Southwestern’s spending got rubber-stamped: none of the above information even got mentioned. Which was also true of most of the small, non-UVM network hospitals in the state. There is simply no justification for that. It has been obvious for at least five years that the current makeup of the Vermont system makes no medical or financial sense.
After watching the reform project for 40 years, in 2020 I wrote the following Manifesto:
Vermont needs five fully elaborated hospitals—in Burlington, Lebanon, N.H., Rutland, Central Vermont, and Bennington. Smaller hospitals now operating in St. Albans, Newport, St. Johnsbury, Windsor, Springfield, Randolph, Middlebury, and Morrisville should be stepped down to some level of clinic, whose basis would be strong primary care, a strong emergency room, a few inpatient beds for patients transitioning from hospitals to home, and possibly maternity services, depending on travel times in their regions. The smallest hospital, Grace Cottage in Townshend, shouldn’t be a hospital at all, a fact known to everyone except the people of Townshend. A right-sized hospital system could save Vermonters hundreds of millions of dollars a year, and its quality would be better. Failure to do so will leave us with an unsustainable medical and financial mess.
I wrote at the time I didn’t have evidence to prove my contention. I didn’t know it then, but the Green Mountain Care Board’s consultants were working on that specific issue, and they reported their findings on Oct. 27 of 2021. My tiny corps can judge for themselves how close I was.
As of today, October 30, 2023, the Green Mountain Care Board is still hiding from the reality it is charged with reforming.