by Hamilton E. Davis
The Vermont health care reform landscape suffered a moderate earthquake last week. It is not clear what the final damage toll will come to, but the quake and the aftershocks laid bare the widespread failures of all the major players, which, summed over, constitute the formidable barrier standing in the way of full maturation of the reform project. And not just reform, the day-in-and-day-out operation of one of the most complex, expensive, and critical social institutions we have.
The precipitating event was a story in Seven Days, the weekly newspaper/magazine in Burlington, about the lengthy delays that Vermonters face getting medical care at the University of Vermont’s Medical Center Hospital, the flagship of the state’s delivery system. Those delays were not just surprising, they were not just shocking, they were horrific. As of this summer, the UVM Medical Center was scheduling important care out as far as the fall of 2022.
The response to these disclosures was at best dispiriting. The worst performance by far came from Mike Smith, the Agency of Human Services Secretary who steers the Scott Administration’s health care policy. Smith treated the crisis as a borderline criminal failure, which he, Smith, promised to get fixed. In fact, Smith has no clue how to fix anything in health care. The response of the hospital itself, in the person of its CEO Dr. Steve Leffler, was pathetic. In the face of a story he had known for weeks was coming, he offered Seven Days a 30-minute interview, which he cut off right at his deadline. A key job for a CEO is to manage his organization’s environment, and Leffler fell flat. On the other hand, the senior management team, including Leffler, is now closing in on a real plan; we should see the outlines of that within 10 days.
The most encouraging response came from Kevin Mullin, the chairman of the Green Mountain Care Board, who tried his best to turn policy and political chaos into a respectable process, like adding coaches and referees to a soccer game for seven-year-olds. Yet, the Green Mountain Care Board has been a major contributor to the buildup of financial pressures inside the UVM system for the last five years, and there is an excellent chance that the Board will do so again this year.
And despite the fact that Seven Days performed a signal journalistic service in cracking open the Medical Center’s internal mess, Seven Days has been missing-in-action for the last 10 years on the whole issue of health care reform, the single most important policy conundrum of our time. The magazine/newspaper would still be missing-in-action if Paula Routly, its editor, hadn’t failed to get a medical appointment she needed…
It may be a masochistic exercise to delve into these developments, but for policy mavens among my tiny corps of brilliant readers, I offer my best autopsy:
Mike Smith Redux
From the day they took office in 2017, the administration of Gov. Phil Scott has been clueless about health care reform, and indeed the nature of Vermont’s doctor and hospital system. They still are. And they are getting worse. Their latest depredation is Mike Smith’s “investigation” of the UVM Medical Center’s access problems. The hospital’s problems are very severe, and the performance of its leadership is a legitimate, even obligatory issue for public policy managers. But for Smith to treat it like a case of a town clerk running off with the tax money is simply irresponsible. Moreover, the idea that Smith himself might actually be able to facilitate a solution is a bad joke. This is not Mike Smith’s first rodeo, and he has botched things right from the beginning.
Smith took over AHS in late fall of 2019, when his predecessor Al Gobeille left to join the senior management team at the UVM network. At the time, reform opponents had been running a five-year campaign to denigrate the network, and they had concluded, accurately, that the best way to do that was to attack OneCare Vermont, the state’s lone Accountable Care Organization. That attack was based on a lie. OneCare was a for-profit corporation owing to a quirk in state law that involved the way that OneCare structured its Board of Trustees—OCV had to be for-profit to get the widest possible representation from the state’s providers.
In fact, OneCare had nothing to do with profit. In their 11-year existence, they never had a penny of profit or a penny of loss.
But Smith charged right in. He said that the profit designation was the source of the problems in the system and he demanded that OCV seek federal non-profit status. Which it did, and it sort of got it. The details of that don’t matter because the shift in status made no change whatsoever in the way that OneCare operated…what the Smith foray did was reinforce the public narrative hostile to UVM.
Smith was new at the time, of course, and he might be forgiven for being low on the learning curve; but fast forward a year and Smith was right back at it. Someone had attacked OneCare for some damn thing or other, and Smith jumped right in and said he would “reboot” the whole OCV operation. He then produced a 19-point plan that had no substance whatever. The fact is that OneCare does one vital, but essentially simple job: they function as a device to transmit money from payers to groups of providers, multiple doctors, and hospitals to care for big blocks of Vermont residents for a fixed price. That’s it. Full stop. OneCare has done that without a flaw for Medicaid financing since 2017…but Smith got what he wanted when OneCare applied to the federal government for a sort of work-around non-profit status. The net effects—big political win for Smith; OCV looked bad, as did its owner, UVM; the change on the ground was zero. No change at all.
Fast forward again to last week. The situation with UVM is obviously very serious; and its senior management is desperate to solve the problem. It is important to understand the roots of the problem, however. The Medical Center suffered three powerful blows in a short time. The first was a computer attack that disabled the UVM system and cut heavily into their revenue stream; the second was the loss of six operating rooms at the Fanny Allan site, which further drove financial losses; the third was the increased costs that flowed from the installation phase of a system-wide computer system. Of course, the Covid crisis didn’t help either.
One should sympathize with UVM’s misfortune, but everyone in Vermont has a stake in a flourishing UVM Medical Center and the state administration has an obligation to pay attention to that. What to do?
In the early 1970s, for example, there were significant management failures at Green Mountain Power, and the prospect of Chittenden County toasters going dark became a serious threat. The public utility commission at the time quietly informed the company’s board of their concern, and within a month or so the Board replaced the management. State government, in other words, has a potent level of suasion over the private sector, but it takes a high level of skill to bring it to bear. Some sort of intervention would be theoretically possible in the UVM case if it became clear that current management can’t solve its problem. No such skill level exists in the Scott administration.
When Smith put himself to the test, he fell flat. Earlier this summer, it became obvious that a major factor in the access problem was the wave of people with mental health and substance abuse problems pouring into the Medical Center’s emergency department. Smith at that point pledged that he would open nine more beds at Vermont’s Psychiatric Hospital in Berlin and 16 beds at the Brattleboro Retreat, all beds that lacked staff to service. His self-imposed deadline was Sept. 1. My sources have said that Smith got none of these promised additions. Of course, that has to be checked and I tried for three days. A week ago, the Department of Health could answer no questions about that badly needed staffing. That kind of failure by one of Smith’s AHS units seems very suspicious; some kind of investigation or probe is clearly warranted…
My conclusion is that Smith is a second-rate political hack, and anyone who thinks he is capable of making any judgment at all about UVM is kidding themselves. Smith’s record to date supports that judgment, in my view.
Inside the Hospital Itself
What’s going on inside the Medical Center isn’t fully clear at this point. Reread the Seven Days article and you will see all sorts of unanswered questions. The essence of the problem is that the Medical Center hasn’t disclosed enough information to render even rough assessments possible. For example, the public relations apparatus published some early statements to the effect that UVM is trying to recruit as many as 94 doctors; a second datum was that they have developed a system to rapidly get appointments for people who particularly need them. Neither of those initiatives are described clearly.
What’s missing? What we need to see are first, the standards of care—how long should a patient have to wait for an appointment, depending on the service line. Primary care would be one metric, shoulder rebuild another. Example: In mid-August, I checked when a patient can get a routine dermatology appointment. Answer: early February. Clearly not good enough. Example Two: Recently a new Vermont resident of my acquaintance called the UVM network’s phone and asked to be referred to a primary care physician. The answer: Mid November—of 2022. Ridiculous. It might be possible to somehow improve the throughput rate, but shifting six months to a week or, let alone 15 months to so will take adding new doctors. That presents multiple problems in the current environment. One is that nationally doctors are scarce, and getting scarcer. Keep in mind also that each new doc will require 3.5 support staff. And all that new capability will be expensive, at a time when regulatory pressure on spending is heavier in Vermont than anywhere in the country.
Bleak as that outlook seems, there were indications in the last few days that the senior management team was beginning to right its ship. One positive note was in the Seven Days piece itself: While the access was terrible, most patients thought the care they finally got was terrific. A straw in the wind comprised the first hard numbers for the recruitment program—75 doctors and 250 nurses. Those are difficult numbers to achieve, but at least they are real. The most hopeful augury is that fact that network CEO John Brumsted recently added Anya Rader Wallack, a national class health policy expert, to his senior management team to manage strategic communications. External communications has been a black hole at the UVM Network for a decade—that’s changing rapidly.
The Green Mountain Care Board
With the hospital at bay, and the Scotties making their usual political mess, Kevin Mullin, the chair of the Green Care Board, made a gallant effort last week to turn chaos into something resembling a rational policy process. He announced that the Board would join Scott’s “investigation”, but he in effect took command when he said that Mike Pieciak, the Commisioner of Financial Regulation would also. That was an important step: Smith is ineffectual, but while Pieciak has been a quiet presence, he is one of the most competent players across the whole of state government. So, future government pronouncements on the access issue should be far less strident and considerably more centered on evidence-based decision making.
Mullin’s second move was equally shrewd. He said that he would appoint a two-woman ad hoc group to help seek out solutions to the access problems. The two would be Jessica Holmes, one of the five members of the Green Mountain Care Board, and Ena Backus, the Director of Health Care Reform for the state.
A professor of Economics at Middlebury College, Holmes is the most capable member of the Board. And Backus is one of the few fully credentialed health policy experts in state government. She works for Smith, however, and with Smith strutting around offering pronouncements, there is no oxygen left for anyone else. So, linking Backus to Holmes solves a very real problem. I have no idea whether Holmes/Backus will get anywhere, but if you had to pick two players to try, they were the right two.
In addition to these steps, Mullin made it clear that the basis for government action going forward would not be the prosecutorial edge so beloved by Smith, but a cooperative effort to find a way to higher ground on a problem that affects everybody.
The Deeper Issues
While the Mullin initiative was a positive step, there are very hard issues that lie beneath surface. It isn’t clear, for example, whether the best efforts of all the current players can find a solution to the access problem. If the Medical Center simply can’t get the through-put it needs without a huge infusion of new players, then it may not be possible to get those players. And even if Mullin can get all the current players pulling in harness, not one of those players has any experience, or credibility in the field of recruitment. Not one player on the Green Mountain Care or its staff, or in the top tier of the Scott administration has ever recruited a doctor, let alone a dozen, or two dozen, or 90, or 100. The likelihood that Jessica Holmes and Ena Backus can find a “solution” to the access problem at UVM hovers just above zero. Neither has ever been even close to the complexity of operating a billion dollars a year academic medical center, let alone one facing the enormous challenges UVM does. What we can do is credit Mullin with a good try to rationalize something has been looking like a barroom brawl.
The only one who has any chance of carrying something like that off is John Brumsted. And it is likely that Brumsted himself is the key to any solution. Brumsted’s role and his performance as the—by far—strongest health player now in Vermont deserves a full post on its own. For the time being I’ll revisit a post I put up in 2019, laying out the way that Brumsted rebuilt the medical delivery system in the upper reaches of the North Country of New York into one of the most effective ones in that state. Brumsted is more or less hated in Vermont. But in New York state, whose health care apparatus dwarfs that of Vermont, Brumsted is considered one of the best health care executives in the country.
There is no way to tell whether Brumsted can resolve the current mess; he could fail—anybody can fail. But on the record of the last 10 years, no player now on the field has demonstrated anything close to the kind of competence that Brumsted and some of his senior colleagues have. Not One. Single. One.
The Press
In her editor’s note on the access issue, Paula Routly lamented the difficulty of a weekly magaziny (sic) type publication trying to wrangle a journalistic nightmare like health care into a manageable framework. Her two reporters, Colin Flanders and Chelsea Edgar, did a terrific job. But the fact that Seven Days and its reporters ignored health for the last five years left them vulnerable to an important blotch right in the middle of the second most important story it ever published.
It was the part where the writers tried to show that the underlying fault in the access problem might have been greed on the part of John Brumsted, the CEO of the UVM Health Network. The writers quoted Jim Daily, the retired president of Porter Medical Center in Middlebury, as saying that Brumsted had “screamed” at him when he told him that he, Daily, wanted to fully employ the urologist then being shared between Porter and UVM.
“We employed specialists because we thought it served our patient population,” Daily is quoted as saying. “UVM thought we should concentrate on primary care.”
Okay, wow. That theme needs some unpacking. In the first place, Brumsted was absolutely right. The only sensible role for not just Porter, but also the other tiny hospitals in Vermont, is primary care, with an admixture of minor specialists when they make economic and medical sense. And at most of the small hospitals in Vermont, the numbers of people seeking complex specialty care are far too small to keep surgical teams sharp and even less likely to be accomplished at unit costs that are anywhere near reasonable. The small hospitals are squeezing in every possible bit of specialty care not mainly because they want to serve their patients—it’s because they are desperate to get the money, and sky-high unit cost and dodgy quality are the price we all pay.
That all became obvious when Daily, who bought up primary care and specialty practices with abandon, drove Porter Hospital onto the rocks and it had to be rescued from bankruptcy by UVM. It has taken four subsequent CEOs to get Porter back on track. And Porter still shares the urologist with UVM.
My tiny corps may be wondering why I describe the Seven Days article as the second most important the paper ever wrote on health care. In contrast to the current effort on the UVM access problem, the most important article was a blundering screed the newspaper published in January of 2015 excoriating the Medical Center as having “mushroomed” into a behemoth that was “gobbling up” all the other health care providers in the region. The writer of that piece never asked the most important question, which is how big the hospital needs to be. When you drive by the main facility on Colchester Avenue it looks huge. But it is important to understand that its main service area includes more than a quarter of the whole state population, and that it provides the only tertiary care in Vermont. The fact is that the Medical Center was too small in 2015, and it’s too small now, a major factor in the access crisis. When the Green Mountain Care Board approved the construction of the Renaissance Tower in the early teens, they refused to allow UVM to add a single additional bed. They could change double rooms to singles but were allowed zero new capacity. They were also not supposed to add new staff, which fortunately they ignored.
The consequences of that one 2015 piece were severe. Seven Days itself abandoned health care entirely until last week. But the “huge, greedy, gobbling up” theme that the article hung around the Medical Center’s neck spawned a five-year vendetta against UVM first by a clown car carrying key Chittenden County Progressives like former Senator Tim Ashe and current Sens. Chris Pearson and Michael Sirotkin; and then provided the foundation for an even more vicious, incompetent, and irresponsible anti-UVM campaign by Anne Galloway and her minions at VTDigger.
A few days ago, I called Routly to ask her whether her experience with the health care uproar would lead her to change her outlook on covering continuing issues like health care. She said she it had, without gainsaying the journalistic challenge of trying to bridge the gap between hard news coverage and the immensely more difficult task of producing magazine level stories that go far beyond piling up of facts for 600 words. The facts themselves can be difficult enough; setting scenes, constructing compelling narratives, finding and analyzing patterns in a mass of events, quickly and effectively sketching disparate characters—that is incomparably more difficult. Twenty-eight-year-old Chekovs are rarer than hen’s teeth (Routly would murder a cliché like that in a New York minute. Along with the New York minute)…anyway, one of the few shafts of light in the pervasive gloom is the possibility that Seven Days will step up somehow to fill the journalistic vacuum on health care.
The Vermont delivery system and the people it serves need all the help they can get.
N.B. The above post is obviously a beast that covers a huge amount of ground. The reason is that I think my tiny corps deserves a chance to see the way that various pieces of the health management machinery interact. Every element of the panorama deserves elaboration, and I will get to that as soon as possible.