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How is Vermont Doing - By Dr. Gene Lindsey

Vermont Physicians Voice Their Concerns

The doctors who had gathered at Stowe were well aware of the history of healthcare reform in their state. They did not seem to be resistant to the funding proposals of the Green Mountain Care Board. They seemed intrigued or at least interested in exploring what it might mean to have all of their services be delivered through an ACO and receive their compensation through the ACO. I dislike the old cliché, “The devil is in the details”, but that is where the discussion now seems to be. It is rapidly becoming an exercise of detail consideration. What I heard from many voices that included the citizen chair of the board and many of the physicians that spoke was a fear about the future of primary care, mental health services, and chronic and preventative care. Several physicians seemed worried about how to blend the culture of those services with the distinctly different worldview and culture of specialists and hospitals in a system where most of the assets were preordained to end up supporting hospitals and specialists. As one PCP said, “We are 5% of the total expense of care. How does the tail wag the dog?” To that question I said to myself, “By realizing that in a global payment environment you lead the transformation that leads to a more judicious use of the other 95%”.

One proposal that already seems baked into the plan is that as a first step the change in payment affect only primary care and that specialists continue to be paid fees for service (FFS). It was never explicitly expressed but it was my assumption that Primary Care practices will have a global budget and that their judicious management of those budgets will essentially make the specialists subcontractors to them. Controlling and integrating the care of their patients for better outcomes on a budget is the mechanism that grants PCPs the operational ability to impact specialty and hospital use. How they work with specialists will determine the way that 5% tail with an eye on what is efficient and effective will be able to wag the 95% body of expense.

As you might imagine, the discussions were full of questions and concerns from the floor that you might have asked if you, like them, were trying to understand a sweeping proposal and decide whether or not to accept an invitation to be a pioneer in an effort that will define a future that is quite different from anything anyone ever expected. There were concerns expressed about inadequate mechanisms of attribution and an inability to control leakage especially as older patients migrate to warmer climates to avoid the winter weather. Many were at a loss to understand how the program could tend to both the investment and financial needs of primary care and behavioral health when specialists and hospitals required so much of the healthcare dollar.  Specifically many just spoke to the spiraling negative effect on retention and recruitment of PCPs at the current balance of workload, regulatory burden and compensation. The loss of physicians in Franklin County was exhibit one in that argument.

Many spoke to their apprehension about the tensions in the working relationships between primary care and hospital based physicians and specialists. There is a tradition of independent practice in Vermont and those physicians  are not sure how they will fare in a more integrated environment. One compelling argument that was mentioned several times for Vermont’s continuing to search for solution was the new law that I have mentioned before, MACRA, the Medicare Access and CHIP Reauthorization Act of 2015. The link points to an article written by Patrick Conway, MD, the CMO of CMS, and others. The article notes that “the comment period” before final regulations on this legislation has been extended until November 17. It is important to remember that MACRA was passed with bipartisan support and replaces the SGR.  It is noteworthy that MACRA is connected in theme to the ACA but is not part of it and is likely to survive as a value based replacement for the SGR no matter which party wins the presidency in 2016.