This is the second article in a series
by Hamilton E. Davis
The single most difficult barrier facing the Vermont health care reform project is right-sizing the state’s 14-hospital system. It is not the most difficult because it’s technically complex, but because it’s so wrenching politically. We now operate 14 full-service hospitals, when we actually need four, with the remainder stepped down to clinics of various sizes. Our current system was built for the Vermont of 100 years ago: a tiny, cold rural state with more cows than people, and a fretwork of goat tracks for roads, many of which weren’t even passable in mud season.
The key reform task now is to recast the hospital system so that it can deliver high-quality, cost-effective care in the 21st century. You can’t even broach that concept, however, without understanding first that it isn’t what we have now. The Green Mountain Care Board figured that out in the late teens, and in response initiated what it described as a “Sustainability” program. In each hospital service area, it is critical to determine what medical services can be delivered safely and at a reasonable cost.
To set the stage, the Board engaged an array of national-class consultants to study the Vermont hospital system and recommend changes. They included Mathematica, which studies the forces driving rural hospitals in the U.S.; the Berkeley Research Group (BRG) that advises government and corporate clients across a broad front; Burns and Associates, which advises states on health policy, financial modeling and program design; the Dartmouth Health Institute, publisher of the Dartmouth Health Atlas, the single most credible national authority on health care cost patterns; and Oliver Wyman, an adviser to payers and providers on system analysis and strategy planning.
On Oct. 27 of last year, these worthies spent a full day laying out their findings before the Board. Which were absolutely stunning. The full burden was that the Vermont hospital delivery system, outside of the UVM Network, is a total mess, cost wise, quality wise, pretty much however wise you want to look at it. Too extreme? Take a look and decide for yourself: In the current hospital budget season, this is a sample of the data the Green Mountain Care Board ran away and hid from.
An instructive view of the quality of surgical quality in was a metric developed by a corporate body called the Leapfrog Group. Formed in 2000 by a group of major national corporations that were unhappy about outrageous health care costs and based on the medical literature, the Leapfrog Group asserted that surgeons should do a minimum number of cases to maintain their competence. For hip and knee replacements that number was 50 per year. Below is what Berkeley Research Group reported for the Vermont hospitals.
For Copley Hospital, the 42 annual number of hips is below but close to the Leapfrog minimum, as is Porter’s 48 knees per year. But look at the figures for Gifford in Randolph—eight hips and 14 knees…and North Country in Newport—22 hips and fewer than 6 knees. And Springfield Hospital, 10 hips, 19 knees. These are huge red flags for patient safety. The Green Mountain Care Board, the most powerful health care regulatory body in the United States, should have shut those down the day the data appeared. What did the Board do with that information in the budget process? Zip, nada. Never was mentioned.
The graph above shows the finding by Mathematica that 21 to 37 percent of the care delivered across the community hospital network is potentially avoidable, which means that care probably should not have been provided. The metric is Potentially Avoidable Utilization (PAU). The consultant did not provide a figure for either UVMMC or Dartmouth Hitchcock, the first because UVMMC is urban, not rural; and DH because it is in New Hampshire. But the quantity of apparent overuse raises a red flag because it throws both the cost and the quality into question. Look particularly at the high hospitals with 30 percent or more questionable care—Northeastern (St. Johnsbury), Springfield, Northwestern (St. Albans), Copley (Morrisville), Gifford (Randolph), and North Country (Newport). Attention paid by the Board. Zero.
A second perspective from Berkeley on quality in the whole Vermont system is illustrated above. Berkeley used a metric called Preventative Quality Indicators (PQI), which was developed for the federal Department of Health and Health Services; it estimates the volume of care that could have been avoided and care that could be avoided is by definition low quality. Note that the shorter the bar, the higher the quality.
These data show a stunning disparity between the high quality (PQI 5.96) at the UVM Medical Center in Burlington, and hospitals like Southwestern in Bennington (PQI 16.41), Gifford Medical Center in Randolph (PQI 15.01), and Rutland Regional Medical Center (PQI 13.24). Those gaps are huge, and the people of Vermont should know about them. They didn’t hear a word from the Board.
Of course, one of the major questions presented to the consultants was what might be done to address the kinds of problems illuminated above. One of the most provocative was the recommendation by Mathematica to reduce the capacity in the state by as many as 140 beds. The analysis left Rutland Hospital, Central Vermont Medical Center, Springfield Hospital and Mt. Ascutney in Windsor pretty much alone. But look carefully at the rest, which Mathematica would render unrecognizable—Brattleboro, now a middleweight at 66 staffed beds, down nearly two thirds to 25; Southwest in Bennington, a middle weight at 78 beds, down 45 percent to 43; Northwest in St. Albans, another middleweight, down from 53 to 31. Even more striking, ironically, is that recommended cuts for the flyweights, the Critical Access Hospitals (25 beds) - in Middlebury, Newport, Morrisville, Randolph, and St. Johnsbury—would leave them too small to be full-service hospitals at all. Systemwide, that would be offset by the recommended addition of 60 beds at UVMMC, two at Central Vermont and four at Windsor. Moving decisively on even a portion of this would be a huge step toward sustainability. It would also amount to political Armageddon, which is why nothing is likely to happen in the near term.
The material above is just a selection of the mass that has accrued in the Green Mountain Care Board’s data vaults over the past year or so. It is simply the ante in the biggest public policy poker game the state has ever seen. Health care involves a yearly expenditure of more than three billion dollars for acute care, and in the short run, messing it up will not only be catastrophically expensive for residents and businesses in Vermont, it could crash the Vermont economy itself. On a longer reach, however, rendering the whole thing sustainable could save Vermonters $300 to $500 million a year. The benefits of sustainability would dwarf any growth or economic development ever imagined for our state.
We’re closer to those sunlit uplands than any other state, but we are dead in the water because our players simply aren’t good enough. That is particularly true of the Green Mountain Care Board, the linchpin of the whole system.
We’ll look at that problem in tomorrow’s post.