Kathleen McGraw: State's health care challenges need professional expertise

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On March 1, 2019 and March 28, 2019 I had the privilege of testifying in front of the Senate Health and Welfare Committee and the House Health Care Committee, respectively, on behalf of the Vermont Medical Society regarding Bill S.42 - an act relating to requiring at least one member of the Green Mountain Care Board to be a health care professional.

As a physician and the Chief Medical Officer at Brattleboro Memorial Hospital, my support of this bill is borne of the concern from the 2,000 physicians and physician assistants that the Vermont Medical Society represents, likely including your very own health care providers, that health care is being regulated without all the appropriate knowledge being intrinsic to the decision making process.

The Green Mountain Care Board (GMCB) was formed in 2011 as a way to regulate healthcare for the benefit of Vermonters. That means both controlling the cost and also the quality. Years ago you may remember we had a process that was called capitation, which aimed to control the cost of healthcare, but largely failed because of the neglect to also control for quality. Out of that was eventually born the goal of the triple aim which is a widely accepted concept for healthcare reform at this point. This concept is one which says that to improve health care we need to improve cost, we need to improve quality outcomes, and we need to improve the patient experience. It is like a three legged stool, and to truly move health care into the future we need to consider all of these measures, lest we fail as dramatically as capitation did several decades ago.

Currently the GMCB works with expertise on only some of these matters. Each of the members of the GMCB is a patient, and thus know the patient experience side of the equation, at least as it pertains to themselves and their family members. They are also adept at looking at the finances of health care, though they cannot see the granular effect of this effort. But they are missing one leg of the three legged stool, and cannot be truly successful without it.

They are missing the perspective of the practicing health care professional who routinely considers how to improve quality in the context of the other two variables. This is routinely what we all do every day. New ways of paying for care inevitably, and intentionally, will lead to new ways of providing that care. To make those decisions without the voice and perspective of a physician or other licensed clinician is misguided and a disservice to patients.

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Vermont is such a small state that being here is like being in a laboratory for the country. It is an opportunity to make change that could have an outsized impact on the nation. That is a tremendous opportunity for Vermonters, and a gift to those all over the country. But health care is exceedingly complex, and we can't do it in a vacuum. The changes that are being made are huge and impact the day-to-day lives of our patients. These changes need the line of sight that the licensed health care practitioner can give.

As a small state, we have scarce resources, and these funds must support an enormous amount of work. This is a big challenge and not just achievable by cost cutting. Medicine has never been static. We are not trying to hone a more efficient widget factory. We are seeing patients: you, your family, friends and neighbors. We are seeing those with unmet needs and are increasingly trying to figure out how to address our community's social determinants of health and our unmet psychiatric needs.

Healthcare has an impact on every Vermonter, no matter their age. Whether it is pediatric care for the baby, emergency care and surgery for the teenage snowboarder with a broken leg, diabetic care for the newly diagnosed snowplow driver, cardiac care for the retired teacher who just had a heart attack, or hospice care for the elderly farmer and their loved ones as they live that last phase of their life, there is little else that touches every single Vermonter in some way. To have the regulation of that chunk of life in Vermont be governed by those who cannot see all sides of that triple aim equation is to sell that expertise short.

A health care professional's expertise is not a conflict, but an asset, and it is missing on the Green Mountain Care Board. Take a moment to consider that the Green Mountain Care board already has conflicts of interest. Everyone is a consumer of the healthcare that is being regulated. Everyone is also a premium payer. It is a small state, we are robust people with interesting and complicated lives. The key is not how to eliminate the conflicts, it is in how we openly and clearly manage them. That is the actual challenge.

Kathleen McGraw, MD, FHM, is the chief medical officer for Brattleboro Memorial Hospital. The opinions expressed by columnists do not necessarily reflect the views of the Brattleboro Reformer.


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