Bill Schubart: Vermont needs a new model for its healthcare system

A nurse looks into the room of a Covid-19 patient before entering the emergency department at Southwestern Vermont Medical Center in Bennington on Monday, Dec. 13, 2021. Photo by Glenn Russell/VTDigger

This commentary is from Bill Schubart of Hinesburg, author of nine fiction books, former VPR radio commentator and regular columnist for VTDigger.

Vermont’s health care system, infrastructure, and vision are broken, and Vermonters of all economic strata are the losers.

The soul of the system is good if you can afford it or access it when you need it. That is, the quality of care provided by medical staff, from nurses and nurse practitioners to physician assistants and physicians, is generally good.

But a major legal principle of health care is the “standard of care,” which is early diagnosis and treatment. If a Vermonter cannot afford or get timely access to care, the existence of a health care system is meaningless to them.

I have several male friends who, between coming into the system asking for help and eventually being diagnosed with late-stage prostate cancer, waited eight to 13 months because appointments were so hard to get. obtain. What, if any, is the responsibility of the health care system?

Failure to address such a critical statewide issue falls from the top. Although he has proven himself as a strong crisis manager during the pandemic, Governor Scott is not by nature one to solve complex strategic problems and has not used his voice of leadership to address and correct system failures at policy and regulatory levels.

Instead, he has focused on his “affordability agenda” – a false economy, as he continues to generate inefficient healthcare spending. Our outsized investments in curing the sick and our willful resistance to adequately funding mental health and addictions treatment, prevention, education and regulation are filling our emergency rooms and our prisons. There is no more expensive way to fund population health.

Our failures elsewhere are part and parcel of our failures in health care. A world authority on health care, Don Berwick, MD,. states in his classic “moral determinants of health”“Circumstances outside of health care either nurture or alter health…(M)most hospitals and doctors’ offices are repair shops, trying to correct damage from causes collectively referred to as the ‘social determinants of health’ “. Shift a substantial portion of health spending from an oversized, costly, wasteful and downright confiscatory hospital and specialist care system to addressing social determinants.

Here in Vermont, poverty – expressed in lack of access to housing, adequate food, physical, dental and mental health care, addiction treatment, childcare and an unprotected environment toxic – contributes to the stressors that produce the illnesses that keep our activities hospitable.

We need to shift our investments upstream to education, prevention and serious regulation of the pharmaceutical and chemical and industrial food industries if we are to improve the health of the population. This is the only way to reduce the chronic diseases that currently drive so many health care costs.

The legislature is trying hard, but with little policy and research support and a two-year window for action and a one-year budget cycle, it can do little more than tinker around the edges of a floundering juggernaut. , making it more expansive and expensive.

In theory, a governor would bring together voices and knowledgeable stakeholders to build consensus and form a vision for people’s health in Vermont. This vision would inform and integrate all agency initiatives across the state government.

The Vermont Department of Health is a public health agency. Its obligation is not to ensure the “health of the people” or to set policy with respect to the design of a functioning health care system, but rather focuses on protecting and promoting the health of Vermonters. regarding air and water quality, environmental hazards, immunizations, smoking cessation and drug abuse initiatives, safe driving initiatives such as seat belts and safety seats baby car, and mortality data collection.

It is neither funded nor equipped to envision and deploy efficient and affordable health care infrastructure, from doctors’ offices to clinics, hospitals, and nursing and residential facilities.

So who owns the vision and policy for establishing health care infrastructure in Vermont? Today, it is a proliferation of legally non-profit free market enterprises.

The Green Mountain Care Board should regulate health care infrastructure based on health care policy. But that’s a vision we haven’t articulated yet. The lack of boundaries between policy and regulation and the need for them to come from different agencies blurs the board of care’s understanding of its role today.

Moreover, the “guild mentality” of the medical profession separates physical care from mental care, as well as dental care and treatment, even though established research and brain imaging have scientifically shown that they are physiologically integrated.

For exemple :

  • Periodontal disease causes congestive heart failure.
  • Inflammation tests of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) show us how psychological stress, anxiety, depression and other mental health conditions compromise the immune system and pave the way for chronic diseases.

We must finally end the self-serving lie that these are separate channels of health care and move to a fully integrated system that supports the health of the population.

A model for Vermont

Deploy a range of services, from independent practitioners to small group practices to community health centers (including federally qualified health centers) to critical access community hospitals to secondary care hospitals such as Rutland, Berlin, Copley and Southwest, and finally to our two tertiary care hospitals UVM and Dartmouth-Hitchcock.

Of the 14 hospitals in Vermont, eight of which are critical access hospitals, we probably only need six geographically dispersed hospitals and trauma departments with assigned specialty practices such as dialysis and joint replacement.

Others can be repositioned as expanded community health centers with a broad focus on access, emergency care, diagnosis, chronic disease management, nutrition and mental health counselling, dentistry, prevention and education.

The Plainfield Health Center is a fine example of rural health care delivery.

A patient’s point of entry would be based on symptom acuity, with the first and best choice in the event of a non-traumatic injury being a local primary care facility. Major trauma cases would be transported by air or ground ambulance to a tertiary care trauma center.

Truly cost-effective care and rapid access is achieved by referring patients to local services from where they can be referred to more sophisticated services, depending on the acuity of the diagnosis. Emergency rooms should only be used for true emergencies, not primary care.

Telemedicine for some presentation systems can increase system capacity.

There is also strong evidence on the the effectiveness of self-care interventions in the areas of communicable diseases, non-communicable diseases, mental health and sexual and reproductive health and rights. There are guidelines covering conditions such as depression, drug and alcohol use, stress management, migraine, hypertension, coronary heart disease, and HIV, among others.

And emerging artificial intelligence capabilities, combined with electronic health record systems, can help address the accuracy of data entry and the need for more doctor-patient time together.

In summary, I am increasingly convinced that investing in alleviating the stressors that we as a society continue to tolerate is our most cost-effective and long-term approach to health care.

We already know that there is enough money invested in dealing with the disastrous consequences of these stressors to fund most of these societal needs.

Upstream investments in health care education, prevention, regulation, primary care, mental health, chronic disease management, addictions prevention and recovery will reduce the staggering amounts of money we spend to care for the sick, often with poor results.

A national program of universal health care is ultimately the only way to reduce the $4.1 trillion – $12,530 per person – that we now spend each year on health care. Here in Vermont, we spend $6.5 billion – $10,442 per Vermonter – not much less than the $8 billion annual budget for the entire Vermont state government.

No other country in the world spends what we spend on a health care system that produces ranked results 28e in the world.

Don’t miss a thing. Sign up here to receive VTDigger’s weekly email about Vermont hospitals, health care trends, insurance, and state health policy.

Comments are closed.