• Getting it together
    October 20,2013

    People signing up for health care coverage on Vermont Health Connect and similar exchanges around the country have had to contend with balky, unresponsive computers. Meanwhile, however, work is progressing rapidly in the effort to reform the way health care is delivered.

    That was the message of the Green Mountain Care Board, which held a public meeting in Rutland last week. Previous public meetings have occurred in Bennington and St. Albans.

    The Affordable Care Act — or Obamacare — has initiated a campaign of reform that is proceeding on many fronts. In Vermont the new exchange has begun to sign up Vermonters, with work continuing to make the process smoother. Meanwhile, the Green Mountain Care Board is overseeing a host of innovative efforts to transform the way that providers manage the care of their patients. A $45 million federal grant is funding the development of three new models for how to organize the system so that the care patients receive is less fragmented, more patient-centered and less costly.

    On the way out is the old fee-for-service method of paying for health care and a fragmented system in which patients bounce from one doctor to another with little centralized oversight about the care they are receiving.

    Anyone who has reviewed a hospital bill after even a modest procedure knows that the fee-for-service method is irrational and wasteful. Each device, procedure and bit of material used is priced at an exorbitant rate that has little to do with its actual cost. Each test or scan, each bit of dressing or medication — it all adds up. Under the old system there is little incentive to exercise restraint because each procedure brings in more money.

    There have been numerous reports about the exorbitant costs that Americans pay for devices, such as artificial knees or asthma inhalers. The same devices are many times more expensive in the United States than they are in Europe. That’s because medical device manufacturers maintain what amounts to a cartel, and the federal government has refused to negotiate price restraints.

    The imposition of price restraints is beyond the power of Vermont regulators, but they are moving to create other incentives for restraint. For example, under a new system a knee replacement would come with a fixed price tag; there would be no extra spending for extra procedures or readmission to fix mistakes. A fixed price could force institutions to demand lower prices from manufacturers.

    The delivery of care would also be improved through the creation of accountable care organizations and other systems that build in incentives for managing care more effectively. The Green Mountain Care Board used recent gains at Rutland Regional Medical Center as an example.

    At RRMC readmission within 30 days has been reduced for patients with congestive heart failure from about 25 percent of patients to below 15 percent. They achieve this improvement by coordinating the delivery of care among primary care doctors, cardiologists, home care specialists and others involved in the care of individual patients. Patients are not booted out of the door of the hospital clutching a sheet of instructions. They receive well-coordinated follow-up and attention to the needs of each individual.

    If this sort of care were spread across the spectrum of health care, it could achieve enormous gains in the quality of care and in cost savings. Depending on how reimbursements are organized, providers work within a fixed amount per patient or per condition. They have an incentive to keep people healthy.

    Al Gobeille, chairman of the Green Mountain Care Board, said Vermont’s health care community is making huge strides in adopting these new organizational and financial strategies. The pace of change is beyond anything the board had envisioned, helped in no small part by the infusion of federal money.

    These broad organizational changes are hard for policymakers to describe and for the public fully to grasp. But the health care professionals of Vermont are invested in carrying them out, Gobeille said.

    These changes may become evident to individual Vermonters when they arrive at their doctor’s office and see that the primary care doctor and the specialist treating their conditions are well coordinated and that tests are undertaken as needed, but not without reason, with results available quickly. Further, there will be a seamless transition from primary care to specialist to inpatient to at-home care.

    These changes are one of the major gains achieved by Obamacare. Without incentives for improvement the system could well lapse back into its fragmented, profit-driven state, with patients’ interests low on the priority list.

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