by Hamilton E. Davis

Arguably the single largest barrier to the full maturation of Vermont’s health care reform project is that it is so widely misunderstood. The press, such as it is, is basically clueless. The Scott administration supports the principle, but has provided no political leadership. The legislature is pretty much a health policy desert. There is simply no way, therefore, that the public can follow the twists and turns as reform moves ahead, or just sits there.

A few weeks ago, Eric Shell, a national class expert on hospital policy who runs a consultancy out of Portland, Maine, told the Green Mountain Care Board that the Vermont project is the most advanced such effort in the United States. Shell, who advises health policy experts in three dozen states along with the federal government, said no other state reform effort is even close to Vermont. Shell did not seem to grasp the extent to which reform is an orphan here. Shell doesn’t know David Yacovone.

Yacovone is a state representative from Morrisville and a member of the House Appropriations Committee, an influential post. He has had long experience in health-related fields. On Aug. 12, Yacovone published a commentary on VTDigger under the heading, “Who will protect the rest of Vermont’s health care system.” The piece cast the University of Vermont Medical Center’s plans to expand some of its services as a threat to the rest of the health care system.

The commentary was occasioned by the UVM Medical Center’s plans to build a new outpatient surgery center, at least part of which would replace the ORs that were lost at the Fanny Allen site. The UVM announcement did not include details; the specific action will be to seek state permission to plan the facility.

The UVM statement conflated changes contemplated at both its Medical Center in Burlington and at other sites in the UVM Health Network, which includes the Central Vermont Medical Center in Berlin and Porter Medical Center in Middlebury.

The network said that “over the next several years,” it will upgrade the Emergency Department at the Medical Center, expand its neonatal intensive care unit, and move its ophthalmology (eye care) and dermatology services to Tilley Drive in South Burlington. A critical piece of the long-range plan will be to build an inpatient psychiatric unit at the Central Vermont Medical Center in Berlin.

Yacavone attributed these projects not to necessary patient care, but to UVM’s desire to bolster its strength as a business. “The Green Mountain Care Board must put a moratorium on health care spending proposals intended to rebuild the hospital infrastructure, not because they may not be needed, but because we need to be sure what we do approve is most important.”

It is difficult to adequately describe just how preposterous that whole screed is. It is the sheerest demagoguery. The idea that you can just swap out treatment for heart disease, trauma, stroke, cancer and myriad other dangerous-to-life afflictions in order to treat diabetes and obesity is absurd on its face. Only in Vermont’s Alice-in-Wonderland health reform environment would something like that would appear in print, let alone be taken seriously. Given that Yacovone will get a hearing, however, let’s look closer at the string of absurdities that constitute his case. In no particular order:

Even if the Green Mountain Care Board decided to rein in UVM’s spending on acute care, that does not mean the care isn’t going to be delivered. Premature babies, heart attack and stroke patients, and car wreck victims are going to get care somewhere, and if it’s not available at UVM, they will go somewhere else at a minimum 10 percent cost increase, not to mention the huge inconvenience.
One of the fundamentals of contemporary medicine in Vermont as well the rest of the United States is that you can’t make any money on primary care. Primary care is the foundation for the whole medical edifice, but primary care docs get paid at the low end of the scale. A sustainable system essentially depends, therefore, on financial support from the hospital subspecialty community. One $800,000 a year orthopedic surgeon can keep several $200,000 primaries afloat.
An important example of this dynamic is the UVM commitment to build an inpatient psychiatric unit at the network’s Central Vermont Medical Center in Berlin. In September of 2011, floods generated by Tropical Storm Irene washed away the state mental hospital in Waterbury, and state government never got itself together to replace it. So, in 2017, when a spike in volume at the UVM Medical Center sent an extra $20 million to the hospital’s bottom line, the Green Mountain Care Board and the hospital agreed to use that overage to build the Central Vermont unit. The unit is still in the planning stage, but the UVM system remains committed to it. No UVM, no solution to the state’s mental health facility problems.
Yacovone claims that allowing UVM Medical Center to do a full schedule of subspecialty care means that there won’t be enough money to do the chronic stuff, like diabetes and asthma care. That is simply not true. The UVM system operates primary care clinics in Burlington, Colchester, Essex and Hinesburg. Moreover, UVM researchers contribute to medical knowledge on diabetes and obesity. And, not incidentally, the UVM College of Medicine trains new doctors in family medicine, internal medicine primary care, primary care pediatrics, and some primary care gynecology. Every dime that gets chiseled somehow out of the UVM spending will damage medicine not only in Chittenden County, but all over the state.
Even people who might concede the above points could be susceptible to the caveat that, whatever its merits, the UVM medical system is just too expensive, wicked costly in the vernacular. That claim is as bogus as the rest. The real cost of medicine consists in what the public pays in taxes for Medicare and Medicaid, and what employers and individuals pay in insurance premiums. The direct measurement of that is the per capita cost of care in the various hospital service areas.
As it happens, the federal government collects that information for the Medicare population across the country, and the numbers get published in the Dartmouth Atlas Project, an industry guidebook. The data for 2018 provides this quick look:

Hospital Service Area Cost of an individual Medicare Recipient

Chittenden County (UVMMC) $6,523.66

Bennington (Southwest Medical Center) $9,822.16

Randolph (Gifford Medical Center) $9,684.66

Rutland Regional Medical Center $9,631.90

The above is just a snapshot (I’ll do a full post soon on the DH Atlas findings for Vermont) but it is enough to disabuse the ordinary Vermonter of the bogus proposition that the UVM Medical Center is the big spender. In fact, in the latest data, it is the lowest, a full third below the high spenders and significantly below all the rest.

None of the above will have any impact on Yacovone and it will likewise have no effect on the dead-end opposition to reform that exists in the reform space. Yacovone is particularly interesting because his style is unusual. During the legislative sessions he speaks often, with a special kind of flair. Normally, when the representatives speak, they use a hand-held microphone. Yacovone pioneered a striking departure: instead of a hand-held mic, he arranged to use a tiny mic that attaches to a shirt collar, the way television celebrities do. That way, his arms are free to sweep wide as he offers his profundities to the multitudes in the high-ceilinged House chamber, the cathedral of Vermont’s political life. You could get a sense of that in the peroration of his commentary:

“Will the some (sic) 55,000 Vermonters with diabetes be better off with proposals like the one offered by UVM?”, he asked. “The short answer is no.

“Will obesity be combatted with more hospital construction projects? The short answer is no.

“Will Vermont’s rate of fatalities due to overdoses…change with more beds and operating rooms? The short answer is no.”

Then, ominous, pregnant pause:

“Vermont is watching.”

Okay, well, it’s a good thing Vermont is watching. But if what they’re seeing is a health care delivery system shaped under the twisted principles espoused, then they will experience a system badly debased, both medically and financially.