by Hamilton E. Davis
In the lengthening chronicle of Vermont’s health care reform project, one of the least remarked yet most important factors has been the performance of the press. It is a sad commentary that press coverage is one of the most difficult barriers that reform has had to surmount.
There are two basic thrusts to this indictment. The first is that press/media coverage has been not good, bad or mediocre, but, for the most part, simply missing. The underlying reason for that is the now years-long collapse of the newspaper business model; there simply aren’t reporters out there to get the job done. Even with that excuse, however, there has been real dereliction here.
There are some very solid reporters in the state: Paul Heintz and John Walters at Seven Days; Neal Goswami at the Rutland Herald and Barre Times Argus; Pete Hirschfeld at Vermont Public Radio; until recently, Kyle Midura at WCAX; and until a year or so ago, Dave Gram at the Associated Press. These writers and organizations do an occasional story on health care reform, but not one of them really understands the issue, and they completely ignore major movements in the reform saga, whose importance in both financial and social terms dwarfs most of what they do write about.
The only news organization that actually covers health care reform is VTDigger, the news web site founded in 2009 by Anne Galloway, a former reporter and editor for the Times Argus. That ought to ameliorate at least somewhat the lack of interest in the rest of the press corps, but it doesn’t. For the Digger coverage is badly skewed; it routinely reports material that supports a specific narrative, and ignores material that runs contrary to that narrative. Digger’s stories have regularly flouted journalism’s most basic rule—fairly reporting both or even multiple sides of a story. Unbalanced journalism like Digger’s is particularly damaging to public policy when there is no other coverage at all.
What is the evidence for such an indictment?
In my view, the evidence has been piling up for the last three years, but by happenstance an amazingly clear instance showed up just a few weeks ago, on Aug. 28. It’s worth starting this exercise by looking at the VTDigger story that ran that day under the headline “Regulators may tie pay parity to hospital budget process.” You can read it at this link, or Google it yourself.
The story was written by Erin Mansfield, and I want to make it clear that my opinion about the quality of Digger’s journalism applies only to Mansfield’s reporting on health care, not to the journalistic work on other topics by either Mansfield or other Digger reporters. I also want to make it clear, however, that the responsibility for egregiously bad reporting lies not just with the reporter, but with the top editor, Anne Galloway. Galloway has backed Mansfield’s health care reporting every step of the way.
The top of the pay parity story illuminates the way bad reporting can skew an issue to the point where it disconnects completely from reality. The story opens with a sketch of the narrative that Mansfield, along with several of the players in the health reform sandbox, have worked hard to establish over the last few years.
The principal villain in this narrative is the University of Vermont’s health care network, which is based on the UVM Medical Center in Burlington, and includes its partner, Central Vermont Medical Center in Berlin, and Porter Medical Center in Middlebury, which is in the process of joining the UVM network. The network also includes three hospitals across Lake Champlain in New York. (The New York issue will be the second count in the indictment). Lesser villains include OneCare Vermont, the Accountable Care Organization established by the UVM network and Dartmouth-Hitchcock, the academic medical center just over the New Hampshire boarder; Blue Cross, which has been complicit in steering too much money to UVM; and the Green Mountain Care Board itself, which has been supine in the face of UVM and OneCare’s power and has dragged its feet on legislative demands to cut UVM down to size.
The good guys in Digger’s narrative are HealthFirst, a small group of independent physicians, whose executive director Amy Cooper, has led the HealthFirst assault on UVM; Sen. Tim Ashe and some of his Senate colleagues, who have argued that the future of Vermont health care depends on independent physicians; BiState Primary Care; and its close partner, Community Health Accountable Care, which is comprised of most of the Federally Qualified Health Centers in the state—groups of primary care doctors that get financial government help to keep them in place, mostly in rural areas.
Those are the players and that is essentially the narrative that Digger has sought to establish. Look at the article on pay parity, which means paying academic medical providers less and other providers more.
The subject of the Board discussion was “how to reduce disparities, which independent doctors have been seeking to do for years,” Mansfield wrote. The majority of independent practices are in Chittenden County “where many are either closing or selling to the state’s largest hospital, the University of Vermont Medical Center.”
And: “HealthFirst has said doctors are often paid 250 to 350 percent more when they work for academic medical centers. The organization says the disparity is pushing doctors to sell or close their practices.” These numbers are completely bogus, because Blue Cross doesn’t report fees for professional services and overhead or facilities separately.
As for the Board, Mansfield writes: “The Legislature has been passing laws for about three years in hopes of narrowing the gap, but lawmakers complained in April that the board has not done enough to implement changes.” That’s the Digger narrative, and here’s where the specific count of journalistic malpractice occurs:
The August 28 Board meeting was held for the purpose of laying out the Board’s research project on pay parity, which showed that the entire narrative was simply rubbish. The grounds for that was not simply an array of contrary opinions by this authority or that, but was rather the findings of an unprecedented survey of doctors in Vermont.
The survey, which you can read at this link, was designed by Board member Jessica Holmes, an economist on the faculty of Middlebury College, and reported the views of 404 Vermont doctors. Those views were crystal clear. They don’t care very much at all about the disparity in payment rates.
What they really hate are the administrative burdens of independent practice. They also dislike the Medicaid reimbursement rates; and they worry about how reform models might affect their practices. They also worry about the certainty of their incomes, not the size of them. And so far from being pushed to sell out to UVM or giving up practice altogether, the great majority plan to continue practicing just the way they do now.
As the report said, after summarizing physicians’ dislikes about the medical practice landscape in Vermont: “Even with these frustrations, most clinicians plan to continue practicing in the coming years as they are today.”
There is definitely a move to consolidate practices, and the claim by players like Ashe and HealthFirst is that the trend is driven by a combination of rapacious acquisitiveness on the part of UVM, along with the pay differential. However, what the survey showed is that the consolidation movement has little or nothing to do with differential reimbursements to UVM but is simply a local manifestation of the same trend that is going on all over the United States. I wrote a lengthy report on the survey on my blog, A Vermont Journal, under the heading “GMCB Survey Blows up Ashe Argument.”
The survey was a striking departure from normal regulatory practice. It was designed, as I said, by Jessica Holmes, a Yale-trained economist; it was carried out very rapidly by the GMCB staff; and it had a very high response rate for such endeavors—400 of the roughly 2000 doctors in the state. It seemed to me to be close to peer-reviewed technical journal quality. And it absolutely zinged the whole Ashe, HealthFirst, et. al. campaign.
Anyone who seriously cares about what happens to the Vermont health care system would benefit by looking at the whole thing. You can read the survey itself on the GMCB web site. You can also read my report on my web site at this link. See whether you think I got it.
My point here, however, is about press performance. And the key takeaway there is simply this:
The Digger story never mentioned the survey.
There is no journalism theory on this planet to justify a performance like that. Mansfield often goes in and out of meetings, and an apologist for Digger might suggest that she simply missed it. The fact is, however, that following the staff description of the survey, the Board members spent a goodly length of time discussing how to react to it. And Mansfield’s story carefully picked its way through the discussion, working hard at reconciling their comments with her narrative, and ignoring the striking difficulty the Board members had in trying to figure out what to do in light of the survey findings.
The situation was laid out clearly by Holmes herself. The survey was meant to try to comply with the legislature’s insistence that the board deal with disparities in pay. Holmes said there was no question the claims about damage to the system from them was disproved by the survey itself. The problem, she said, is that while the sentiment of the Legislature is clear, trying to drive changes in the way insurance companies reimburse doctors and hospitals is very complex, and potentially very expensive.
Moreover, the Board needs to keep in mind that the whole thrust of Vermont reform is to shift from fee-for-service reimbursement to block financing, or capitation. The first contracts in that effort have been in place since February, and the project is on track to expand in 2018, and the whole point of the Vermont reform is to render fees for specific services moot.
It’s a house of cards, she said. It might be better not to monkey around with it.
Con Hogan, who retired from the Board a week or so ago, said he agreed with Holmes on that point. He said he wouldn’t want do anything that would interfere with the movement of independent doctors into OneCare Vermont, the Accountable Care Organization that is the vehicle shifting from fee-for-service financing to capitation.
Board member Robin Lunge also sounded amenable to such a strategy.
But then the chair, Kevin Mullin, stepped in. “That’s just not going to cut it,” he said of the idea of bypassing the problem of trying to tell commercial insurance carriers how they should pay providers still operating under fee-for-service. That was the quote Mansfield needed to drive her narrative, which supports the Senate’s effort to support independent physicians.
There is nothing basically wrong with that—Mullin’s view is critical and needed to be reported. The problem was that in the Digger story no one could know about the survey that so severely undermined the argument made by Ashe and the Senate. That’s biased journalism. It could go straight into a journalism textbook.
In an issue that arose out of this summer’s hospital budget hearing, Digger jumped at the chance to take an easy shot at UVM for its management of the New York State segment of its network. UVM owns three hospitals in New York; the largest is in Plattsburgh; the others are in Malone and Elizabethtown. A fourth, a small hospital in Ticonderoga, will down-size to a clinic and be managed as part of the hospital in E-Town.
Two of the hospitals have lost money in the last couple of years, and Digger began to pursue the question of whether UVM had bailed them out, and in the process sent Vermont money to New York. Is UVM using our money to subsidize New York, was the question. Digger ran three stories on the issue, with the theme that UVM is apparently using Vermont money to bail out the basket cases to the west. A subtheme was the proposition that UVM was hiding the facts from the public and the Green Mountain Care Board. They got a boost from Kevin Mullin, the chair of the Board, who bought right in to the narrative.
The first story was straightforward enough, laying out the financial problems that had plagued the Plattsburgh and Malone facilities since before UVM got involved; and reporting Todd Keating, the network’s financial officer, comments on how UVM would help the New York units to improve, but would not “subsidize” them.
A week later, however, Digger ran a second story to the effect that UVM was transferring money to New York hospitals. Keating was “backtracking on recent statements about whether the network’s flagship hospital transfers money to hospitals in New York,” the story said. UVM had sent $7.5 million to Plattsburgh to cover a budget shortfall.
In the wake of all this back and forth, Marc Stanislas, member of the UVM network’s finance team, provided the Board with a detailed analysis of all the money transactions between the Vermont and New York elements of the UVM network. It was the only hard data that exists on this tempest in a teapot and it fully illuminates the issue.
The spreadsheet showed that by any measure, it is New York that is supporting Vermont financially, rather than the other way around.
By far the most important datum is the $180 million that New York patients send to the UVM network for treatment at the UVM Medical Center and associated network units. That money pays for a significant piece of the UVM network’s fixed costs; it also enables UVM to provide a wider array of specialty services than they might otherwise be able to afford.
The Digger stories, however, focused more on the much smaller internal financial transfers. That analysis is instructive, too. The Stanislas analysis covers the actual spending for fiscal years 2015 and 2016, the projected spending for 2017 (the current year), and the budgeted spending for FY 2018, which starts Oct. 1. It looks like this:
So, there you have it. Over the four year period of the inclusion of New York’s three hospitals in the UVM network, a flow of more than $100 million to UVM, a huge plus in itself. And then there is the $180 million that will flow into UVM coffers in the coming fiscal year.
Pretty much disposes of the whole “Vermont is subsidizing failing New York hospitals” issue.
You won’t read anything about that in Digger, however. Doesn’t fit the narrative.