by Hamilton E. Davis
The single most important document that has been published over the five-decade life of Vermont’s healthcare reform movement is the 144-page report delivered to the Green Mountain Care Board a few weeks ago by Bruce Hamory, a consultant to the Board. Hamory, a medical doctor, learned his trade running a very large hospital system in rural Pennsylvania called Geisinger; he left Geisinger to become a principal in the Oliver Wyman consulting firm, which advises clients on how to navigate the modern doctor-hospital environment.
Oliver Wyman was one of seven national consulting firms that did an extensive analysis of the Vermont hospital system under the umbrella of a Sustainability project launched by the Board in 2019. Yet, Hamory’s report ignored the Sustainability findings, including his own, and offered instead a breathtakingly broad set of recommendations that would completely remake not just Vermont’s healthcare system, but the state’s infrastructure, including housing, transportation, and the operations of government itself.
Of course, Hamory’s study never mentions what it would cost to implement even a portion of this scheme because that would make it clear that the whole contraption is a utopian fantasy. That should be reason enough to write the whole thing off—hey, it’s just a study. What’s truly alarming, however, is that the Hamory effort describes what the Green Mountain Care Board is trying to do to the hospital system itself. In fact, I will argue in a later post that the report was written, not out of Hamory’s real expertise, but to underpin the Board’s wishes. Successful consultants after all read their clients before they do anything else.
It is unfortunate that Vermont’s health care system, and indeed its whole economy is being held hostage to the Scott administration’s cack-handed management of the regulatory system and the obvious inability of most ordinary folks, our part-time legislators or even policy professionals to dredge through a 144-page miasma of graphs, tables, charts and wonderous speculation about stuff that’s never going to happen. I hate to impose it on my brilliant readers, but I don’t know any way to move the reform needle without just wading in. So, I’ll break an analysis into 1,000-word posts to make it more palatable.
Hamory Lays Out His Changes
You can skip the first 10 pages of the report, they’re just throat-clearing. The meat starts on page 11, where we are told how we need to rebuild the state machinery itself, how to configure the hospital system as a whole, and what needs to happen to each individual hospital. I was particularly interested in Hamory’s instructions on how to remake the state itself. The Vermont legislators would certainly appreciate that.
Anyway, lightly edited, here we go:
Vermont must support development of infrastructure and legislation to enable a robust workforce, greater access to transportation and an affordable housing supply all tightly linked to hospitals. The Agency of Human Services’ community care models will require reconfiguration to better coordinate health and social service needs at the community and individual level.
That all sounds sort of reasonable, but it has no connection to financial or political reality. There is no such thing as a “robust” medical workforce anywhere in the United States. There are shortages of doctors and nurses across the country and it’s getting worse—provider burnout is endemic. Moreover, the idea that the Vermont government can simply order up “affordable housing” either in Chittenden County or our rural counties is just silly. The only people who can actually build new housing are private developers and their carpenters. And affordable? By whom? Housing developers get their money banks or other lenders whose focus is unlikely to be on recasting the health care system.
And rejigger the transportation system? What does that even mean? The Vermont transportation system has been just fine since the 1960s, when the Feds financed the Interstate system: I-91 in the east from Brattleboro to the Canadian border, and I-89 from White River northwest to Burlington, then north to St. Albans and the western crossing into Canada. Route 7 from Burlington through Rutland to Bennington is not an interstate, but it’s pretty easy driving. The key reality is that 12 of the state’s 14 hospitals lie along the fast road network, as does Dartmouth Hitchcock Medical Center, which provides tertiary care all of eastern Vermont.
Hamory Rewires the Hospital System
New regional specialized centers of care should be identified…Community-based care, primary care, mental health care, and housing capacity should be increased to divert care to lower cost settings…Healthcare workforce affected by system changes could be redistributed or retrained to perform services needed by the community…
Several hospitals are at risk of closing their inpatient beds and should consider repurposing their facilities to options like Rural Emergency Hospital, Community Ambulatory Care Center, or Care at Home support program…UVM needs to examine current overhead and administrative costs, especially the proportion of providers supporting non-patient care activities.
This grab bag of ideas has been floating around the health policy space for the last 30 years or so, and they sound sort of reasonable; but are in fact totally impractical. Once you get beyond the 500-bed Medical Center Hospital in Burlington, and possibly Rutland with 144, the rest of Vermont’s hospitals are just too small to be “centers of excellence.” Eight of the 14 are 25 beds or fewer, and the rest are under 100. One, Copley in Morrisville, is already a specialist in orthopedics, but Copley is clearly a black swan, as I’ve described in the past, and then only for orthopedics. Centers of excellence are possible in cities like Rochester, N.Y., Boston, or Portland, Ore. But not in the boondocks.
Moreover, the idea of getting a few very expensive subspecialists to move around to hospitals where they might be needed is never going to work. It does work in the Vermont legal system where circuit-riding judges move from courthouse to courthouse, but all judges need is a good car and a briefcase. Doctors by contrast need lots of expensive infrastructure: labs, imaging, operating rooms packed with complex equipment, skilled nursing teams. The idea that you can take a cardiothoracic surgeon, a gastroenterologist, or a national-class urologist and bounce them around from Bennington to Newport to Springfield and back is just plain dumb.
And who would manage such a system? The Green Mountain Care Board? Oh, please. Neither the members nor the staff of the Green Mountain Care Board have any experience or expertise in running a 21st-century healthcare delivery system. The only credible source of the expertise necessary to run a large, vertically integrated medical delivery system lies in the UVM Network, and if you want to get a sense of how that appeals to the 11 non-UVM facilities, wear earmuffs. Not happening.
Okay, so much for page for 11 in the Hamory report.
In my next post, we will go deeper to see what kind of evidence Hamory can bring forward to support his plan.