Last October 1st, the Green Mountain Care Board appointed by Governor Peter Shumlin began its work.  Its task?  Revolutionize the way health care is delivered in the state.
 
Last summer the VMS conducted a Q&A with the board’s chair Anya Rader Wallack, Ph.D.  Now, it’s asked the four other board members – Karen Hein, M.D., Al Gobeille, Con Hogan and Allan Ramsay, M.D. – to answer a few questions, including why they are interested in the delivery of health care, what they’d ultimately like to see happen in the state and how physicians can make their voices heard.  
 
Green Mountain Physician: The Green Mountain Care Board is made up of a fairly diverse group of people.  How will your background be valuable to the health care reform process?
 
Dr. Hein: I’ve worked in five sectors which all, I hope, are relevant to the deliberations of the (Green Mountain Care Board): (1) academia; (2) government (professional staff of the US Senate Finance Committee); (3) “think tank” as executive officer of The Institute of Medicine; (4) philanthropy (as president of The William T. Grant Foundation); and (5) global health and development (focusing on the professionalization of humanitarian assistance).  As a physician with additional experience in these five sectors, I am hoping to bring my extensive network of people and ideas to make Green Mountain Care effective for all Vermonters in improving health as well as making it the best system of care for all of us providing care and needing care.
 
Mr. Gobeille: I am a small business owner from Burlington.  I care deeply about the people of our State, our economy, and the quality of life we enjoy.  I have seen firsthand the challenges that our current insurance model has placed upon my business, my family, and my employees.  I hope to use my strategic business experience and my unique operational perspective to enhance our team’s vision.
 
Mr. Hogan: I’ve been active in health care issues in Vermont since 1991 when I became Secretary of Human Services where I served for most of the 90’s.  Over that 20-plus years I’ve seen several health care ‘reform’ cycles.  I’ve studied and co-written a couple of books on the subject.  At this point I believe I can be helpful to the process of bringing Act 48 to life.
 
Dr. Ramsay: I have been a family physician in Vermont and member of the Department of Family Medicine at the College of Medicine for thirty years.  Most recently I have also developed a specialty career in Palliative Care.  My experiences in both primary and specialty medicine will help me understand the uncertainties my colleagues feel about whether we can make the health care system work better for patients and themselves.  Both the people of Vermont and those that provide the health care want things to be better.  I saw that every day in my practice and in my teaching.

GMP: What spurred your interest in helping lead the state’s health care reform efforts?
 
Mr. Gobeille: I became interested when I joined the state’s payment reform advisory committee.  I also became increasingly engaged when I learned more about the affordable care act (ACA).  The more time I spent on the subject the more optimistic I became that Vermont would be able to do something better than Washington.
 
Mr. Hogan: The primary driver for me is seeing what the uncontrolled cost is doing to Vermonters, property owners, school systems, and government itself and even the effect that these costs are having on our economy.  We simply must bring these costs under control if we are to maintain the high quality of care in Vermont, and have a chance at making sure everyone in Vermont has access to care.
 
Dr. Ramsay: I saw this as an opportunity to change a system that is not working and one that is not sustainable for Vermont.  I would hear my colleagues tell stories about how difficult it has become to focus on caring for the patient.  The pressure to increase productivity continually is cutting into the precious time we have to spend with our patients.  Many of my physician friends just wanted to be able to have a meaningful relationship with their patients again.  They knew that is the most important thing to improve quality of care. 
 
Dr. Hein: I’ve lived in Vermont for the past decade and owned a home here for 41 years.  Ever since I was a medical student at Dartmouth from 1966 to 1968, Vermont has been the place where we felt most at home….and now I have a way to give back to the place and people in our community and state.  Hopefully, if we are successful, we will also show the nation a path forward to improving health and health care for everyone in the country.

GMP: Looking down the road, in your mind what does the ideal reform outcome look like?
 
Mr. Hogan: Health care costs would be rising in proportion to economic realities, the unnecessary cost and wastefulness of ‘chasing the money’ would have been greatly lessened and simplified, physicians could spend more time with their patients instead of paperwork, and every Vermonter would have access to high quality care.

Dr. Ramsay: All Vermonters will have access to a comprehensive and integrated health care system.  They will pay according to their ability.  The delivery system is designed by those that provide the health care.  Insurers and government are not the experts at this; we are.  Payment to all those that provide health care is fair.  There will be a primary care foundation that stresses health – both in the prevention of illness and in promoting healthy behaviors throughout the life cycle.  When people develop chronic diseases that lead to a limited life expectancy they will have appropriate discussions about their goals of care.  The goals will be determined by the patient and not the medical system.  If we can accomplish even a few of these goals the health care system in Vermont will be better.
 
Dr. Hein: Ideally the reform will mean improved health for Vermonters.  It will mean a simplified system of care in which three contributions to our health will work together: (1) Personal; (2) Public Health and (3) Health Care Delivery.  By considering all three, not just the contribution of the delivery system, we can help people become and stay healthy. This wider lens means considering all of the contributions to premature mortality since personal health (our behavior, genetics, choices in diet, exercise, smoking etc) contribute about 40 percent to premature mortality, public health (environmental considerations and population health measures) contribute about 30 percent and Healthcare Delivery System contributes only about 10 percent ….so considering all three would be ideal!  
 
Mr. Gobeille: Better access, better quality, lower cost is the simplified version.  My “complicated vision” is a Hospital and Provider lead reform of the current delivery system.  The improved system should lead to decreased costs and higher Provider satisfaction.  I realize this falls under the easy to say banner, and that it will take great energy and effort.
 
GMP: One of physicians’ biggest concerns today is the increasing amount of time they spend dealing with overbearing administrative burdens; time that could be used to treat patients.  What can be done to reduce these burdens?
 
Dr. Ramsay: Every doctor I speak to agrees that the best part of the day is when they are providing care to their patients.  It is the time before and after that has become an insurmountable burden.  The medical record has become less a way to communicate important patient information and stories, and more a tool to justify a billing code for an insurance provider.  The cost of claims re-submissions, prior authorizations, and denials is not only a financial one it has also become an emotional burden on physicians throughout the state.  We need to move away from this fee-for-service model and toward a reimbursement system that rewards us for quality and cost effectiveness.  This new model will be applied to all payers, both private and public. That is the only way to reduce the administrative burden; change the system.
 
Dr. Hein: Simplification is a major goal of our reform for physicians, other health professionals and everyone involved in our care, particularly our patients!  By having a simple, unified registration form and procedure, by helping support seamless connections between individuals, offices, hospital, pharmacy and community, by encouraging connections between practices and best practices, we can begin to transform the experience for all of us.
 
Mr. Gobeille: I was fortunate to be invited by Dr. Tim Bicknell to spend an afternoon shadowing himself and his staff.  The paperwork burden was abundantly clear.  Great solutions come from great process and I feel we need to empower the Provider community to work with us to figure this out.  Electronic Medical Records, Insurance payment reform, improving interagency communication are all pieces.  The Providers are in the best position to suffer in a bad system and help build a new system.
 
Mr. Hogan: Much of the time of physicians is spent, as I indicated before, ‘chasing the money’ in an amazingly complex environment of confusion and uncertainty.  As we move toward consolidating payment systems and toward proscriptive payment systems for providers this simplification will have a positive impact on the current condition of ‘overbearing administration’.
 
GMP: With an aging population Vermont is forecast to experience a physician shortage in the near future.  How does the Board plan to address physician recruitment and retention?
 
Dr. Hein: Aligning incentives will be a magnet to attract the best and brightest of the new graduates.  Salaries are only one piece of incentives to get the mix of primary care and specialists we want and need in Vermont.  The practice environment is as important as monetary rewards.  The Vermont Blueprint is setting the foundation for learning about the incentives, and we hope to be a ‘learning health system’ that modifies as we go along to make Vermont THE place to be for physicians and the people we serve.
 
Mr. Gobeille: I believe it is the job of our board to create/reform a system that Doctor’s want to work in.
 
Mr. Hogan: We obviously have a lot of homework on this piece of the problem, but based on several physician surveys that have been done here in Vermont and beyond, that making the conditions of practice more about the care and less about chasing the money would have a positive impact on the overall medical workforce, including physicians.  Simply put, Vermont could end up being a place where docs would want to practice medicine.
 
Dr. Ramsay: One of our foremost goals is to make Vermont the best place in the nation to practice medicine.  When the 200,000 Vermonters who are either uninsured or underinsured have access to a comprehensive health care system we will need more physicians and other health care professionals.  We must make every member of the health care team able to practice to their full capabilities.   Taking away administrative burdens in the system will help make this happen.  The Board will identify the types of physicians and other care givers most in need and focus on recruitment, training, and retention.  I have had colleagues say they would likely leave the state if health care reform caused significant sacrifices.  I try to reassure these physicians that our goal is to make a better system for everyone.  The doctors in Vermont already provide high quality, cost-effective care.  I believe the sacrifices we make for our patients will be minimal once the waste is taken out of the system. 
 
GMP: Many of the decisions made by the Board will have a tremendous affect on how physicians care for their patients and are compensated for their work.  How can physicians make sure their voices are heard?
 
Mr. Gobeille: I am available and our Board is committed to transparency.  My email address is al.gobeille@state.vt.us, our Board meets on Tuesday and Thursday afternoons in Montpelier at 1 p.m. and there is a portion of the meeting for public comment.  That being said, I realize the tremendous weight of the subject matter we have before us.
 
Mr. Hogan: This is going to be a process that spans years to get to where we need to be.  Knowing that most physicians are not in a position to attend multiple public hearings and legislative processes, the importance of the Vermont Medical Society in both keeping docs informed and engaged, and having an impact on the results that unfold over time, will be paramount.  This interview is but a small piece of the coming interaction.
 
Dr. Ramsay: Act 48 includes a requirement that the Green Mountain Care Board have advisory committees. Those interested will be able to self-nominate for these positions.  The process will be posted on our website in the next few weeks.  Our Board meetings are open to the public and the agenda is announced on our website, www.healthcare.vermont.gov. The Vermont Medical Society will be an active voice in the reform process by providing advice to the Green Mountain Care Board and the new ideas generated by its members.  Each Board member has made a priority of getting to as many areas of the state as possible to speak to hospitals, physician groups and community members. 
 
Most importantly, I strongly believe that we all can better understand complex issues by hearing a personal story.  I have accumulated hundreds of them over my 37-year practice career in family medicine, hospital care, teaching, nursing home directorship, hospice, and palliative care.  I welcome the stories of any of my colleagues around the state and can be reached at Allan.Ramsay@state.vt.us.
 
Dr. Hein: All of our policy deliberations are held in public meetings.  Already, in our first month, we have had one to two hearings each week with the deliberations and presentations all open to the public with resources and documents, and agendas easily available on our website.  We continue to meet with the Vermont Medical Society colleagues and other groups of health professionals to hear perspectives and build upon the work of the past two decades.  We hope that physicians will be central to the rollout and introduction of others as various components of reform are crafted.  We are your partners in improving health in Vermont.