By Hamilton E. Davis
In a momentous structural initiative, the five affiliates of the University of Vermont Health Network in Vermont and northeastern New York have voted to transfer their entire operational and strategic powers to the Network headquarters in Burlington. For the smaller hospitals in Berlin and Middlebury, Vermont, and Plattsburgh, Malone and Elizabethtown in N.Y., decisions such as hiring and firing of hospital presidents and other major employees, hiring and setting pay for doctors, establishing budgets, selecting service lines, and setting quality targets will be made at Network headquarters.
This shift will create a fully integrated academic medical care delivery system with more than double the throw-weight of the University of Vermont’s current Medical Center Hospital; and open a path for the UVM Network to take a seat at the table with the most important health care players in the United States—Mass General and Brigham in Boston, for example, or Yale New Haven, or Intermountain in Utah. The geomedical (sic) position of the Mayo Clinic in rural Minnesota, for example, is strikingly similar to that of the UVM Network.
Of course, such a trajectory will be very challenging, and it will not happen soon, but the UVM organization will have the infrastructure to get there. Moreover, to the extent that effort succeeds, significant benefits will flow to the UVM College of Medicine, and to the Vermont economy generally. For medical students, doubling the patient base will enhance their training opportunities. And for the economy generally, the same doubling should increase the potential for spinning off private sector biomedical initiatives. Finally, the availability of national class health care should appeal strongly to private companies looking to relocate.
The effective date of the new local hospital bylaws will be Oct. 1 of this year, although considerable progress has already been made in some areas. And the “unified” medical staff will be created over time, rather than at the effective date of the agreement.
The local boards will retain ownership of the assets, such as buildings, land and equipment and will continue to have responsibility for fund raising and for monitoring the local application of Network quality standards. The affiliates also gain by the shift of fiduciary responsibility from their community hospital to the Network. And representatives of the local hospitals will have seats on the various standing committees within the Network management structure.
The full integration of the Network community could trigger criticism by the array of UVM and health reform opponents in Vermont, who charge that the Network is too dominant and too greedy and is therefore a threat to the smaller hospitals in the state. The reality, however, is that the move is a done deal. The common bylaws that govern the integrated company have been legally adopted by all six companies, which include UVMMC itself, and by the Network Board.
Beyond that, there is simply no credible underpinning for the anti-UVM narrative. The Dartmouth-Health Atlas, as reliable a source as we have in the reform space, shows that the UVM Medical Center delivers not only the least expensive care in Vermont, but some of the most cost effective care in the U.S. And the consultants utilized by the Green Mountain Care Board have reported that UVMMC’s quality and, in fact, the quality of its Network colleagues in Vermont, is far higher than the non-network providers in the state.
Health Care Reform in Action
So, how after 10 years of intense reform activity, how did we reach this point? And how will it change things on the ground?
The recast system is the fulfillment of the vision of Dr. John Brumsted, the President and CEO of the Network, who conceived of it early in his career as a gynecological surgeon and who has pursued it for decades, in each post he held as he ascended the medical management ladder. After acting as a second to former UVM Medical Center chief Dr. Melinda Estes during much of the aughts, Brumsted was named interim CEO of the Medical Center in 2011 and assumed the permanent post in 2012.
Brumsted sums up his goal as “the right patient, at the right time, and at the right place.” All sorts of people salute the same flag, but Brumsted is one of a tiny number who are trying to bring it to fruition. And as far as I know, literally the only one who is doing so without owning an insurance company, and while coping with the most draconian state regulation in the U.S.
Not only is the agreement a done deal, it is steady forward. The Network, now effectively one company, deploys 927 full time doctors east to west from Central Vermont Medical Center in Berlin, Vermont, to Alice Hyde Hospital in Malone, N.Y. The support staff numbers 2300. For comparison’s sake, the listed roster at MassGen Brigham, the Boston behemoth, shows 1022 docs. The integrated Network will serve a million patients a year.
The map above shows the Network units, and the road—ferry transportation system that ties them together. On the east (Vermont) side, patients in the Barre-Montpelier area use Central Vermont Medical Center in Berlin as their local hospital; if they need more specialized care, they travel on I-89 to the Medical Center hospital in Burlington. Porter Medical Center in Middlebury serves patients in Addison County. If they need more extensive care they travel to Burlington on Route 7.
On the west (New York) side, the anchor facility is Champlain Valley Physicians Hospital in Plattsburgh. CVPH is not a tertiary care facility, but it’s pretty close. Its 300 beds aren’t far off the Burlington capacity, and it delivers some pretty complex care, like cardiac catherization, for example. Virtually all the surgery carried out in the New York units takes place here. Alice Hyde Medical Center in Malone serves Franklin County, and refers its complex patients to Plattsburgh. Elizabethtown Community Hospital in the southern tier of the Network area does no surgery at all. It sends its complex care patients to Plattsburgh. So does the Medical Village (primary care and ER) in Ticonderoga. Some obstetrics patients in southern Essex County go to Porter Medical Center in Vermont for delivery. And if Elizabethtown needs to it can send patients directly to Burlington over the Essex-Charlotte ferry. Beyond the Network itself, the New York State Police helicopters out of Saranac Lake regularly to deliver critical patients to the Medical Center in Burlington.
The trickiest leg in the transport system is moving patients needing tertiary care at an academic center from Plattsburgh to Burlington. Ambulances and cars travel on local roads to the Cumberland Head ferry for the 14-minute ride to South Hero on the Vermont side. That ferry runs all day, year round; but it can occasionally be blocked by wind-driven ice.
The approximate travel times on the transport web are shown in the accompanying table.
Early Progress
I said earlier that there has been considerable progress toward integration. Which is true, but it’s been patchy. In Vermont, for example, top management in Burlington has been deeply involved for years in the operations of Central Vermont Medical Center, which serves the Barre-Montpelier area. The current hospital chief, Anna Noonan, came out of the Medical Center’s executive offices; and the former Network Chief Financial Officer Todd Keating spent at least half his time in the late teens trying wrestle Central Vermont’s annual budgets into submission. The current Network Chief Finance Officer, Rick Vincent, will manage those budgets out of Burlington.
Perhaps the clearest example of how the shift in corporate structure will work is the experience of Porter Medical Center in Middlebury. A 25-bed Critical Access Hospital, Porter ran aground in 2017, and the Porter Board decided to affiliate with the UVM Network. The Board recruited a new Chief Executive Officer with instructions to attack the Porter financial problems.
The new CEO did so, but the local doctors revolted and the new CEO was gone. The Porter Board recruited a replacement, against the advice of the UVM management. That recruit also failed to work out, and the Porter Board selected yet another CEO, and this one, Tom Thompson, had the support of Burlington and he is still in place. All that back-and-forthing ate up time and money, but under the newly integrated structure, it won’t happen again.
Thompson will be evaluated by the senior Network management and if he leaves or begins to fall short, the Network will select that replacement. The Network CEO will consult with the local board, but the Network chief will select the new replacement, and set his or her salary. And the new Middlebury chief will not be a CEO; that person will be a Chief Operating Officer, who will report to the CEO of the Network…as of today, the CEO of all six Network hospitals is John Brumsted.
The New York wing of the Network, meanwhile, presents yet another variation on the theme. John Brumsted has already completely rewired the three county, four hospital system that jumped into his lap between 2013 and 2015 He closed a small hospital in Ticonderoga and replaced it with a “medical village” consisting of an Emergency Room and primary care; recast the management and service lines at Champlain Valley Physicians Hospital In Plattsburgh; and stitched the whole into an integrated operation that also included Alice Hyde Hospital in Malone and the small community hospital in Elizabethtown. In effect, Brumsted made those decisions because the New York units asked him to.
Now the shift of power from local boards to the Network management has been formalized, and the operating and strategic decisions in New York will be made in Burlington. The doctors across the Network will work for a “unified” staff, which, over time, will be comprised entirely of academic medical center-level physicians paid according to an integrated template; the latter is an IRS requirement for non-profit institutions.
So, What do we Get Out of This?
There are enormous potential benefits from this newly integrated system:
Operating one organizational structure rather than six will save money and facilitate decision-making. There will be one CEO—of the whole Network. The smaller units will become, in effect, divisions of one company. They will be lead by a Chief Operating Officer, a COO. There will be one Chief Financial Officer, rather than six; one Human Resources chief, not six; one IT, computer manager, not six.
There will be a single Electronic Medical Record system, EPIC, which came fully online last spring. EPIC’s expense and firepower dwarfs that of the smaller IT systems available to individual community hospitals.
It will be much easier to recruit high quality personnel across the board. A high performing chief medical resident in training somewhere will be far more likely to move to Malone, or Berlin, or Elizabethtown, if he or she will be part of a national class academic medical center rather than a small, remote, stand-alone hospital.
Of course, these benefits are potential. Rendering them actual will be very difficult. John Brumsted’s new ship has been built for speed. Sailing her, however will be equally challenging. And it won’t be Brumsted at the helm. Brumsted will retire this fall, and it will be up to his successor to confront the very rough seas and heavy weather that lie just ahead.