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Green Mountain Care: Rationing by Any Other Name
Robert S. Emmons, M.D.
Duxbury, Vermont
Vermont lawmakers will soon get to the task of deciding how much your taxes must go up to fund a 2.5 billion dollar health care budget. That’s bad enough, but to add to your misery, you will also pay in the form of medical care withheld, thanks to the Green Mountain Care Board. At the update on health care reform delivered to the legislature on November 19, GMCB Chair Al Gobeille boasted that Vermont has more authority to regulate the practice of medicine than any other state: “That gives us the tools to do good work.”Documents available online at the board’s website detail plans for a system that takes decision-making power out of the hands of patients and their doctors, all in the name of cost containment.
The state’s health information technology plan envisions a database that will link your electronic record to all state departments and a federal data hub, with no provision for you to opt out of this data collection. Under Vermont’s plan for “payment reform,”your doctor will be monitored electronically to see if she is complying with state-approved clinical practice guidelines—selected for cost-containment purposes—and she will be penalized financially if your individual medical circumstances require a different treatment approach (“pay for performance”). Even if your care has been tweaked to meet all guidelines, if you are simply so ill that the cost of your care busts a budget set by state or federal actuaries, your physician will be expected to share the economic pain with third-party payers (“shared savings”and “episodic”payment). Green Mountain Care is Managed Care 2.0, a complex system of third-party financial incentives that undermine the independent professional judgment of physicians. It matters not to the patient whether the unwelcome intruder is a commercial insurer or the state.
On top of all that, a key element of the state’s plan to “bend the medical cost curve”is to reduce pay to doctors: the GMCB has unlimited authority to set fees for all clinicians and hospitals, including doctors like me who do not bill third-party payers. The target is Medicaid-level fees for all. If Vermont pays medical professionals less than their real value in a national market, then we cannot recruit or retain them, and you will have to wait longer for appointments when you are sick.
Practice guidelines, global budgets (either for the entire state or for individual hospital systems), and wait lists are all methods of rationing care, without calling it by its real name. In his recent presentation, Chairman Gobeille stated several times that appropriation of funds is a function separate from payment and delivery of services. I beg to differ. Here is how medical care will be rationed in Vermont, step by step: (1) public outcry and lobbying will pressure legislators to (slightly) lower tax rates; (2) lower tax revenues will lead to a (slightly) smaller appropriation for health care; (3) a smaller global budget will compel the GMCB to increase the financial penalties for hospitals and doctors when the cost of care overruns the monies available; (4) many of the physicians who are paid less will leave practice in Vermont and the ones left behind will increasingly find themselves diminished from deciders of optimal treatment to messengers of curtailed care; (5) fewer doctors means longer waits for shorter visits; and (6) as treatment is delayed or withheld to meet budgets, patients will get sicker and sometimes die. Green Mountain Care is rebranded managed care funded by a Medicaid-style appropriation process and administered by the folks who brought us Vermont Health Connect, so we need not look too far back in history to foresee our future.
Let’s connect the dots: if Green Mountain Care is implemented as planned under Act 48, then the pressure to restrain taxes today is inexorably linked to bad clinical outcomes in years to come. As a Vermont citizen, you can protest against higher taxes today, and you might even hold back the floodwaters for a while, but as long as you are corralled in Green Mountain Care, the state will still get you on the back end by reducing your medical care. Central to the execution of this plan is the abridgment of your right to spend your own money to get treatment outside the system. The solution to this problem is to fix it at the patient level, by restoring your legal rights that have been taken away by Act 48. I refer here to your rights vis a vis the state:
1) Just in case Vermont Health Connect continues to malfunction, and just in case plans available on the exchange use managed care techniques that degrade quality of care, give Vermont citizens the legal right to make real choices by purchasing their own individual health insurance policies outside the exchange. As it stands now, Vermont citizens do not enjoy that right.
2) Just in case it turns out that that quality, cost, and wait times get worse under Green Mountain Care, protect the legal right of Vermont citizens to spend their own money to get timely, excellent medical care from independent physicians outside the system. Don’t let the state set fees for private physicians, as that would have the effect of putting them out of practice, thus taking away choices for patients.
3) Just in case it turns out that health data mining is used in a way that ends up harming patients, give Vermont citizens the unrestricted legal right to say “no,” without penalty, to participation in Vermont’s health database, a right currently denied.
Some readers might ask, if patients are allowed to escape oversight and rationing by Green Mountain Care, then what positive alternative can I offer for reducing medical costs and improving the quality of the patient experience? In my private psychiatric practice where patients pay cash at the time of each visit, I already offer treatment at half the fees charged by the state’s premier Accountable Care Organization. I do not have a waiting list for new appointments, in contrast to who-knows-how-long a wait to see an attending psychiatrist at the Burlington hospital’s outpatient clinic. My friend Keith Smith, M.D., operates a direct-pay outpatient surgery center in Oklahoma City with fees posted online that run 1/5 to 1/10 the average at hospitals nationally. Cutting out the third-party payer saves patients time and money.
As it stands now, the GMCB, through the Certificate of Need process, can deny applications for larger, free-standing outpatient facilities like Dr. Smith’s that can offer high quality care at lower cost than hospitals. Amend the law to prevent state officials from blocking competition in Vermont’s medical marketplace. We in Vermont cannot repeal ObamaCare, but when we can, let’s get the third-party payer out of the patient-physician relationship, and it will not be necessary for the state to ration medical treatment.
Some readers will wonder about the fate of patients left behind in Green Mountain Care because they cannot afford to pay for private medical care. These are the patients I treat at my free clinic. A robust private sector that provides higher quality care will put pressure on the publicly funded system to keep up. Competition is the most effective corrective to the worst excesses of a small group of activists who are willing to trade off your access to optimal medical care in order to achieve their vision of social justice.
In 2013, Vermont Democrats in the House, in a nearly party-line vote, rejected H.331, an amendment introduced by Cynthia Browning that was designed to protect the legal right of citizens to make private financial contracts with doctors of their choice. An unwillingness to accept limits on the state’s authority to intrude with its fee-setting into private medical relationships signals a larger unwillingness to accept any limits on state power in medicine. If the majority party has been genuinely humbled by the results of the last election, then its leaders might look differently at patient rights in the next session. We cannot expect legislators to be able to raise enough taxes to meet the clinical needs of all Vermont patients, and rationing is the primary tool available to the GMCB to deal with the shortfall. Patient rights is the remedy: let’s empower individual patients to protect themselves from the fallible humans in state government who have their moments of grandiosity, calculated opacity, and erring judgment.
Dr. Emmons has maintained a fee-for-service private psychiatric practice in Burlington, Vermont for 25 years, and he is the founder and staff psychiatrist for the Franciscan Free Psychiatric Clinic in Moretown, Vermont. For two decades, he has studied financial conflicts of interest in medicine.
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