Bill Schubart: Health care is a self-driving truck with no GPS

John Brumsted
Dr. John Brumsted, the CEO of the UVM Health Network. File photo by Mike Dougherty/VTDigger

The headline: “After major budget shortfall projection, UVM Health Network suspends adolescent mental health unit project.”The situation: “The ball’s in your court,” Brumsted told regulators on Wednesday. “That (money) either sits there and simmers until hopefully we can resurrect this project.”

I cannot pretend to know what the University of Vermont Health Network’s recent announcement about suspending motivated its future mental health plans. I can only hope that our region’s dominant tertiary-care hospital recovers its lost sense of mission and focus on “population health” and the well-being of Vermonters, rather than business expansion and asset-accretion.

So, please read the above headlined story carefully. What does it say to you about UVM Health Network’s much-touted commitment to “population health”?

  1. Does it tell you, as they wish, that, given the rejection by the Green Mountain Care Board of its midyear request to raise its fees another 10% on top of the 6% increase it just got for the current year, they cannot address one of the most serious health problems we face in Vermont: the mental health care and well-being of all Vermonters, especially children, adolescents and young adults?
  2. Is it a simple quid-pro-quo hostage tactic to ultimately get a double-digit increase in 2023?
  3. Or, given the need for reform focused on population health, is it actually a beneficial outcome that they won’t be expanding, given their present medical model of inpatient psychiatry? UVM Health Network has not had a stellar history in mental health services and may lack the creative vision that providing quality mental health services demands.

The fact that these questions are in play means that UVM Health Network is essentially failing Vermonters, as each question is inconsistent with any vision for patient-centered care.

Comparative costs

As to the first question, here are some important data regarding UVM Health Network’s comparative costs:

— Vermont’s academic medical center is one of the most expensive in the country.

—As of Sept. 1, 2020, UVM Health Network had $194,792,000 in cash reserves and $544,279,000 in “board-designated assets.”

—According to page 7-8 of UVM Medical Center’s 2020 990 tax form, it pays 26 administrators salaries that substantially exceed those of the key medical service providers — nurses, hospitalists and primary care docs. The three “total” columns on page 8 add up to $16.9 million a year for 26 UVM Medical Center administrators — an average annual salary of $650,000 each.

As to the second, is UVM Health Network holding Vermont’s mental health system hostage in its negotiations for hospital budget increases?

When the Green Mountain Care Board declined its request for 10% rate hikes, the UVM Health Network announced that these projects, so critical to Vermonters and especially young Vermonters, have slipped again in priority.

Is Vermont’s debilitated mental health system being used as leverage for the Green Mountain Care Board approving substantial budget increases in years when it projects losses, while allowing the network to keep revenue overages in years when the budgets produce significant positive fund balances?

Furthermore, UVM Health Network has just announced it will not renew its contract with a number of nursing homes for which it has supplied medical directors and on-site visits, both of which are mandated by state regulation. Nursing homes cannot admit patients without this physician component and will, as of June 30, be left out of the network while patients remain stuck in hospitals. Is this a pattern?

No other regulated entity in Vermont would be allowed these liberties with Vermont dollars, nor should they be. Holding the mental well-being of Vermonters hostage in defiance of mission is indefensible.

The third case is probably the best outcome of all, given UVM Health Network’s mixed history with mental health care provision, which ranges from evasion to inpatient care remote from family and community.

Especially with young people, hospital diversion to community-based resources, which are better-equipped to handle acute mental health issues, makes more sense than storing young people on gurneys in emergency rooms for lack of in-hospital mental health beds as is currently the Case.

It’s also important to hold the state accountable here. Since closing its flooded State Hospital in Waterbury in 2011, Vermont has never had an appropriate vision and policy for providing for people with chronic mental health issues. Off-ramping care to hospitals with no clear state vision or policy is equally unconscionable.

UVM Health Network’s proposed 25-bed psychiatric facility at Central Vermont Medical Center in Berlin was put on hold because estimates for the project, which included upgrades to the hospital, came in at $150 million. So, let’s take the $150 million and invest it in community-based mental health, where it would go a long way to producing tangible improvement in mental health care at the community level where it belongs.

Further points in question

UVM Health Network’s current strategy denies the necessary collaboration among independent primary care practices, federally qualified community health centers, critical-access community hospitals, tertiary-care hospitals, and health insurance providers.

Only an organic design that acknowledges the unique role and mission of each will ever deliver on the promise of “population health.”

Now that UVM Health Network has crossed an ethical Rubicon and become both a health care provider and a commercial insurer with its Medicare Advantage insurance business — businesses currently being snapped up by private equity Because of the immense profit potential at the expense of policyholders — how will it reconcile the inevitable conflict when it denies care to its policyholders through “claim denials”?

How much money did it spend on public relations and marketing to acquire a modest number of UVM Medicare Advantage policyholders, money that could have gone to patient care and caregiver salaries?

Does the UVM Health Network Board of Trustees have any sense of how the institution they manage is perceived by those who need it? Why is there no longer a public comment period at each board meeting? Why are there no community stakeholders on the search committee for the new CEO, Dr. John Brumsted’s ultimate replacement?

Does the board perform annual 360 performance reviews of its CEO with stakeholder input? Do the board members regularly review performance-against-mission for the institution they govern? How many on the board are also highly compensated employees of the UVM Health Network system, and is their intrinsic conflict managed? Do board members know and understand the network’s mission?

If UVM Medical Center’s costs are so high compared to other regional academic medical centers, how does this align with access and affordability, both intrinsic to its mission?

The state’s role

The final issue, and perhaps the most troubling, is the state leadership’s absence from this discussion.

When then-Gov. Peter Shumlin moved the functions and mission of the Department of Health, which oversaw the health of Vermonters, into the executive office, they never got clearly returned and there are now six freestanding departments of health within the Agency of Human Services:

Department of Mental Health

Department of Health Access

Department of Health

Disabilities, Aging and Independent Living

Department for Children and Families

Department of Corrections

Do these agencies not share a single mission supported by different aspects of their work? What is the coordinating and oversight role of the Agency of Human Services in articulating, ensuring and regulating the health care infrastructure to deliver population health to Vermonters?

What was or is the role of the Green Mountain Care Board? That depends on whom you ask and when you ask it. With Hogan’s answer it would have differed from Kevin Mullin’s. Is it the source and overseer of Vermont’s mission with regard to the well-being of Vermonters or is it simply a financial regulatory body whose role is to sustain the flagging hospital business models?

Gov. Phil Scott, whose crisis management of Covid has been by all measures excellent, must be asked what the state’s role is in overseeing the well-being of Vermonters and the access and affordability of its health care infrastructure. Until he answers that question, we’ll continue to stumble.

We Vermonters are aging and will need a cost-efficient and effective infrastructure for health care. Where will it come from? And how will we support young families considering a move to Vermont when it comes to housing, health care access, educational quality, child care, paid family leave — all elements of “population health?”

I have no desire to join the growing number of Chittenden County Vermonters and others in the Northwest who have chosen to bypass the University of Vermont Health Network and its flagship hospital to make the two-hour trip to Dartmouth to find accessible care.

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