Healthcare expert forecasts bumpy road in Vermont

MIDDLEBURY — Green Mountain Care Board member Dr. Allan Ramsay urged Addison County’s medical community to be patient as the state transitions to a new health care system that he acknowledged will be fraught with change and challenges.
“One of the things I’ve learned intensely over the past two years is that change is very hard,” Ramsay said at Porter Medical Center’s annual meeting last week. “It is very hard to change the system.”
Ramsay, of Essex Junction, is a primary care physician with more than three decades in the field. He is past medical director of Fletcher Allen Health Care’s Palliative Care Services and the founder of the Rural Palliative Care Network. He has also served as residency director and vice chairman in the Department of Family Medicine at the University of Vermont and is a past member of the board of the Visiting Nurse Association of Chittenden and Grand Isle Counties and the board of the Community Health Center of Burlington.
He now practices at the People’s Health and Wellness Clinic in Barre.
He joined the GMCB around two years ago. The GMCB is a five-member panel created by the Legislature in 2011 charged with ensuring that changes in the health care system both improve quality of care and stabilize costs.
The board regulates health insurance rates, hospital budgets and major hospital expenditures. It also tests new ways to pay for and deliver health care as part of its role in building a new single-payer system. It is also evaluating what benefits should be included in Vermont’s new health system, how the new system could be funded, and the effect the new system could have on Vermont’s economy.
Ramsay told attendees at Porter Medical Center’s annual meeting on March 26 that he enjoys his work and is pleased to tackle it as a physician.
“I never did a health care policy degree; I never went to public health school; I never worked in the Legislature,” Ramsay said. “Basically, I’m a family physician.”
And it was the family physician perspective that Ramsay sought to bring to the Green Mountain Care Board when he applied for one of the positions around two years ago.
“One of my mentors said to me … ‘Allan, as Vermont embarks on this path toward making its health care system work better, you can either be at the table, or be on the menu,’” Ramsay recalled. “I decided that even with my lack of policy experience, maybe it was time for a family physician to be at the table.”
He considered what kinds of contributions he could make and how he might represent the best interests of health care consumers in the reform effort.
“I remembered patients I had seen over 32 years, and the ones that stuck with me the longest were those that suffered because they didn’t have access to health care, or those who had access to it but couldn’t afford it,” Ramsay said.
He now almost exclusively sees uninsured patients at the Wellness Clinic in Barre and finds himself thinking in many cases, “Why didn’t you come in sooner?”
At the same time, Ramsay has noted that increases in health care premiums have eaten away at most Vermonters’ income gains during the past decade. He acknowledged some of the increased health care costs have been directed at “things that are good,” such as new technology and better medications that have helped patients live longer.
“I quickly learned on the Green Mountain Care Board that if we only reduce the growth of health care costs in the state of Vermont by two percentage points, we save the state of Vermont $1 billion from 2014 to 2017 on a $5 billion total budget,” Ramsay said.
The GMCB had two roles in setting up the Vermont Health Connect insurance exchange, Ramsay said. First, the board had to approve what he called “a benchmark benefits package” that all the qualifying health plans were required to provide in the products that they offered in the exchange. The board also had to OK the premium rate structure for the qualified health plans (Blue Cross-Blue Shield and MVP) in the exchange. The exchange features health insurance levels including bronze, silver, gold and platinum from which consumers can choose.
Not everyone has been pleased with the exchange and the premium rates, Ramsay conceded.
“The GMCB has felt some heat,” he said.
That heat, according to Ramsay, has come from many directions — including the Statehouse, special interest groups, the business sector and some individuals.
Ramsay read from a handful of e-mails he has received from people concerned about the new health exchange and the state’s transition toward single-payer. Those e-mails related concerns about health care affordability and the potential that providers might not want to settle in Vermont due to the ongoing reforms.
He quoted from an e-mail from a woman he called “Kathy,” a medical industry worker who reported her monthly health insurance premiums under the new exchange have gone from $408 to $750, with a $4,000 deductible and a $12,500 out-of-pocket cost.
“It will cost me no less than $7,500, out of pocket, for the birth of my first child, and could end up costing me more,” Ramsay quoted. “This is not affordable health care.”
Cornwall resident and retired Middlebury College political scientist Eric Davis, during a question-and-answer period, agreed that the financial numbers aren’t adding up for a lot of people entering the health exchange. He noted the $55,000 median income for Vermont households and argued such incomes could not withstand $8,000 to $10,000 out-of-pocket expenses each year for health care.
“There’s no way that can be called affordable,” Davis said.
Members of the GMCB have said the majority of people who have thus far enrolled in the exchange have seen some savings. But Ramsay conceded more work will need to be done to increase affordability.
“I’m not sure the Affordable Care Act has really helped Vermont, to tell the truth,” Ramsay said. “This exchange has made things complicated, but it doesn’t change the fact that we have to make things more affordable.”
He cited the example of a four-person family earning $60,000 annually purchasing a “silver level” insurance plan through the exchange. When one considers the tax credit and subsidy to which that family is entitled at that income, the cost of the plan would be roughly $6 of their $30 hourly wage.
And Ramsay said keys to further savings will be cutting waste within the current health care system.
“Let’s not do things that bring no value; let’s reduce the waste,” he said. Ramsay cited “Vital Connect,” a consent policy for health information exchange in Vermont, as having great potential in cutting waste.
“That will make health care information available to all of the clinicians, no matter where the patients was seen,” Ramsay said. “You won’t have duplication of CAT scans; you’ll have the medication lists available when you see your doctors.”
Ramsay believes that Vermont physicians need to be involved in changing the state’s health care system.
“What do I tell my colleagues? ‘You need to be in charge of changing the delivery system,’” Ramsay said. “It should not be done by the insurers and it should not be done by the payers or the government. That’s hard, but that’s what we as clinicians have to be willing to work on.”
He acknowledged compensation concerns being voiced by prospective physicians, many of whom begin their practices with a mountain of debt.
“Payment for what we do needs to be fair, it needs to be transparent, and it needs to be equalized,” Ramsay said. “We need to make sure we don’t have the kind of variation in payment between public payers — like Medicaid and Medicare — and private payers, but we also don’t have the kind of variation that now exists between those that are now providing primary care and those that are providing specialty care.”
The GMCB will have the authority to set provider compensation rates, Ramsay noted.
“When we do set that rate, we will focus on value,” he said. “Value is the quality of care that you receive, over the cost. And that quality is the patient experience of care and the outcome.”
Ramsay believes the state should be proud in that it is “not in denial” on two public health matters — drug addiction and health care reform. And Ramsay believes the state will succeed in making inroads on both issues, due in large part because of Vermonters’ collective intelligence and selflessness.
“Vermonters trust each other and they trust their leaders,” he said.
“This is not going to be just an economic argument; this is a societal issue for all Vermonters.”
Reporter John Flowers is at [email protected]

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