A state the size of Vermont claiming savings of $120,000,000 through a patient-centered medical home (PCMH) program should raise eyebrows.
North Carolina made similar claims about its PCMH model, only to have the results so thoroughly debunked that consulting firm, Milliman, was forced to retract its key assertion.
I expect more from Vermont, if only because I’m a Democrat and Vermont has turned so “blue” that in 2008 John McCain received only 10,000 more votes than Calvin Coolidge garnered in 1924. However, it turns out red states don’t have a monopoly on invalid PCMH data.
A brief summary of the Vermont Blueprint for Health, as described in the enabling legislation, would be: “a program for integrating a system of healthcare for patients, improving the health of the overall population…by promotion health maintenance, prevention, and care coordination and management.”
This is to be achieved by emphasizing the usual suspects — patient-centered medical homes and various support mechanisms for them. The idea is to achieve “a reduction in avoidable acute care (emergency visits and inpatient admissions).”
Growth in participation has been phenomenal. In 2009, only a few practices and a dozen employees were involved, so we can call that the baseline year. The report’s findings take us through 2012, by the end of which two-thirds of the state’s primary care practices (104) and population (423,000) were involved, along with 114 full-time employees.
The State’s Analysis
Through the end of 2012, the state — by using the classic fallacy (also embraced by the wellness industry) of comparing participants to non-participants — was able to show savings of $120,000,000 and a double-digit ROI.
The governor of Vermont, Peter Shumlin, devoted all of his annual speech to the problem of drug addiction. On the national news, Shumlin points out the link between prescription painkillers and death, and he calls for treating opiate addiction as a medical problem no different than cancer. The White House praised the governor’s position.
Meanwhile in another part of Washington, I’m involved in the federal effort to link the law enforcement Prescription Drug Monitoring Program databases to the health records physicians use, and to link the databases across state lines.
The unintended consequences of criminalizing addiction and driving medical problems underground need to be considered here as well.
Physician-patient confidentiality is important to public health, and networked electronic health records have both individual privacy and public health consequences. Privacy is essential in infectious disease testing, domestic violence, mental health, adolescent, reproductive, and addiction medicine. Subjecting clinical encounters to law enforcement surveillance beyond the physician’s discretion is life-threatening.
Well-meaning people are now working to link PDMP databases to EHRs and across state lines. The evidence to justify the coerced crossing of the criminal – medical boundary is anecdotal findings in pilot studies that more physicians are in a position to uncover addiction and offer treatment.
The other goal is to reduce illegal diversion of prescription drugs by both physicians and patients. What could possibly go wrong?
I was delighted to see the lead article in Health Affairs describing Vermont’s new single payer health care financing system. Harvard Professor William Hsiao and his coauthors describe this as a “Bold Experiment” and I couldn’t agree more. It is also a very welcome experiment. For over thirty years I have heard the rhetoric that a single payer system would never work in the United States. For that matter, I have heard that a true market-based system (with vouchers) would never work either. Why not let the states experiment and find out what will and won’t work? Thankfully, the Vermont legislators and Governor Shumlin had the courage to take this leap of faith.
The biggest obstacle to implementation appears to be ERISA, which limits the extent to which states can regulate self-funded plans. Apparently, self-insured employers could object to having their tax payments used to support the plan. But Vermont can apply for an ERISA waiver under terms in the Affordable Care Act and the state hopes to begin its bold experiment in 2015.
As bold as the plan might be, Hsiao et al. might be even bolder in projecting the potential cost savings, which they peg at 25.3 percent. Academics rarely go out on a limb with projections like this that can easily be assessed in a few years time. And academics are rarely so optimistic. I wish I could share that optimism.Continue reading…
In just a few days, Vermont’s Governor Peter Shumlin will sign into law what the media is calling “single payer health care reform.” But is it?
Vermont has certainly demonstrated more enthusiasm for a single payer approach than any other state. The Governor and key Democratic legislators have supported the concept, the state has a well-organized lobbying group in Vermont for Single Payer, and a state-funded study earlier this year estimated that a single payer approach could dramatically reduce health care costs. The major result has been passage in the past month by both of the state’s legislative chambers of the bill that Governor Shumlin indicates that he will sign.
So does this mean that Vermont is ready to upend its existing health care financing system and replace it with a French or British-style system? Not exactly.
The versions of the bill passed by Vermont’s House and Senate are each far, far more tentative than committed single payer advocates would wish, and have already been subject to scathing criticism by national single payer advocates. The bill provides for the creation of the legal framework of a public insurance program, to be called Green Mountain Care, but includes no funding mechanism, defines no benefit standards, is vague on the future roles of private insurers, and is silent on exactly how existing federal programs are to be incorporated.
What the bill does do is to establish the state exchange required by the Accountable Care Act, encourage experimental capitated payment structures, and create a Board for Green Mountain Care with responsibility for examining funding, benefit, and other issues, with recommendations to be submitted to the state legislature in 2013.Continue reading…
This past Monday, the Vermont Senate passed a Single-Payer bill. The House had already passed a similar bill and the governor is friendly to the legislation, so all that stands between Vermont and a single-payer law are a few formalities. At the moment, though, Vermont is alone in taking advantage of the Affordable Care Act to achieve universal coverage without private insurers. In fact, it isn’t clear that any other states are taking serious steps even toward a public option.
Massachusetts isn’t going there: it is doubling-down on its eponymous model that relies on private health plans, and seems hell bent on showing the nation that this model can work. The state just boasted that capitation rates will actually go down in 2012, allowing the program to grow enrollment without additional funding. It’s not difficult to imagine the feeling of responsibility weighing on administrators and Democratic officials there as they work to pull the levers of payment reform to reign in Partners HealthCare and other misbehavers.Continue reading…