Health Care Archives - Page 19 Of 22

Should some lung transplant programs shut down?

There are around 65 lung transplant programs in the United States, but 85 percent of the surgeries are performed by only about 20 programs. Regardless, even the smaller programs — some that do just a handful of transplants per year — require adequate staffing in order to stay open. As in so many areas of the world’s collective workforce, the supply of lung transplant doctors is dwindling, while at the same time the total number of lung transplants is expected to rise due to the ravages of COVID-19 on lung health.

Should some of the smaller transplant programs close?

Common sense would dictate so, but, as in many corners of our health care economy, the issue is more complicated, and the answer less obvious, than one would think. Here’s why.

Even if small, the hospitals want their transplant programs to stay open for two reasons: First, centers want availability of all solid organ transplants (heart, kidney, liver and lung) in order to facilitate “one stop shopping” for insurance companies who want to contract across all organ lines. Second, the existence of a transplant program of any organ type brings collateral business to the hospital in that particular disease group, creating up-and down-stream revenue that is hard to replace once it’s gone.

Black Friday and Cyber Monday deals from BestReviews:

Should some lung transplant programs shut down?

The 2022 International Society for Heart and Lung Transplantation (ISHLT) meeting in Boston last spring was enlightening in many ways — not just because it was the first in-person meeting of cardiothoracic transplant professionals since 2019, but also because it was an opportunity for the transplant community to celebrate an important milestone: more than 40,000 people are now being transplanted annually — a number that continues to rise — and patients are living longer. Despite these positives, I left the meeting feeling concerned, because the inadequate number of lung transplant physicians and surgeons to staff the existing transplant programs is getting worse. I could barely walk 50 feet in the convention center without someone stopping me to ask, “Do you know of any lung transplant doctors looking for a new position? We have a job opening.”

Physician shortages are not a new problem, nor confined to the transplant arena, but it is an issue that’s getting worse in lung transplantation, due to growth of the field generally and a workforce that is not being resupplied in order to keep up with demand. The acute and chronic effects of COVID-19 pneumonia have increased, and that will have a domino effect on the volume of lung transplants performed. As it pertains to the transplant workforce, lack of person-power is a pre-pandemic problem that will only worsen as we leave the acute phase of the pandemic.

So, why the lack of qualified people to staff these programs?

When I posed this very question to pulmonary medicine trainees when I was at Stanford — the group from whom we would expect to get our lung transplant fellowship candidates — the responses were both distressing and not completely unexpected. Patients dying regularly, lack of control of work hours, and the responsibility of carrying a waiting list filled with patients who could deteriorate at any time are characteristics of the job that are not exactly attractive to the current generation of physicians who are less swayed by the miracle of transplant, the euphoria when things went well, and the profound gratitude that this patient group regularly displays to transplant providers. These are all elements of the job that I loved — and missed when it was time for me to step away from the frontlines. In many ways, interacting with the field now in a consulting role, I can see the point of these younger physicians looking for a different career path. Perhaps they are right to protect themselves from the rigors of the field.

But how does the lack of transplant clinicians affect patients? In a word, adversely. Patients who are cared for by harried, stretched thin clinicians suffer poorer outcomes. These clinicians are always on the proverbial hamster wheel, being urged by hospital administrators to do more transplants and by regulatory bodies and insurance companies to produce better outcomes. When I evaluate a program with outcomes issues in my consulting practice, the number one problem is nearly always a simple one: lack of properly trained physicians, either younger ones to handle the growing number of recipients or, even more concerning, mid-career doctors who have the vision, expertise and commitment to lead programs in an ever more complex transplant environment. In fact, many of the more experienced doctors at some of the best programs in the country are looking for a way out, far earlier than what would be considered “normal” retirement.

What’s the solution?

First, we need to use technology to unburden the transplant teams, particularly around the organ procurement process which is physically exhausting (flying out in the middle of the night to retrieve organs from a distant hospital), costly and requires staffing that many transplant programs do not have.

Plus, the surgeons who are flying around the country in the middle of the night to procure organs are often the same ones that have scheduled cases the next day, like complex cardiac surgeries. Would you like your heart surgery done by the surgeon that has retrieved organs the previous night or one that has been at home fast asleep? Easy answer.

Technologies to keep organs “alive” do exist, keeping organs viable until a daytime transplant operation can be scheduled but, currently, are not being fully adopted by transplant centers, largely due to lack of technical familiarity with these new systems, lack of understanding of reimbursement issues for these technologies, and, frankly, lack of willingness to embrace the transplant future.

Second, the transplant programs need to implement a different care model based less on using physician trainees for getting the work done and more on non-physicians team members who can follow treatment protocols for making routine therapy adjustments, tend to the electronic medical record and see transplant patients who are stable in the outpatient clinic. Using this model not only achieves a more rational life for trainees and more experienced physicians but also provides patients with continuity of care, a familiar face that will be around long after the trainees have left for other opportunities.

The responsibility of getting the infrastructure needed to make the transplant care environment more palatable will fall on the program directors who will need to make a convincing case to their hospital administrators that this route is the only way forward.

Third, hospitals need to continue to foster an environment where physician wellness is a priority. Many are starting to do so — an encouraging trend propelled forward by the pandemic, not only for the provider herself but also for the patient’s sake. Studies have shown unequivocally that health care providers that have achieved balance between their lives outside of the hospital, and their life within it, provide better care.

Finally, the most controversial solution. If there is an ever-expanding patient group that needs committed, specialized care, a classic supply and demand issue arises when the supply (in this case, lung transplant physicians and surgeons) seems very unlikely to increase any time soon. Therefore, we must cut the demand by reducing the number of lung transplant programs.

Having been in the transplant arena for decades, I am fully aware that hospitals won’t voluntarily close their transplant programs in order to serve some greater good. There are too many tempting financial and competitive incentives for a hospital to consider shutting down unilaterally. But some should, since not being able to adequately serve this very sick patient group in a manner that they deserve violates every tenet of our profession.

We don’t need our current number of transplant programs —we instead need only the number that best serves our patient population. And that means, fewer.

David Weill, M.D., is the former director of the heart and lung transplant program at Stanford University. He’s also the author of “Exhale: Hope, Healing, and a Life in Transplant.” He is also a board member of TransMedics.

What medical mysteries can teach us about getting better health care

Comment

You are reading our weekly Well+Being newsletter. Sign up here to get it delivered to your inbox every Thursday.

Who doesn’t love a good mystery?

For 15 years, medical reporter Sandra G. Boodman has chased down the most unusual, quirkiest and weirdest medical cases for her monthly Medical Mysteries series. Recent stories have focused on a teenager who couldn’t wake up, a woman wrongly diagnosed with ALS, and an entire family and guest felled by a strange flu-like illness.

I checked in with Sandra to find out more about how she writes the column and the lessons we can learn from it.

Here’s our edited conversation.

Q. How do you choose your ideas?

A: It has to be something I haven’t written about. It has to be a solved case. I need to know the ultimate diagnosis. Even though it’s a solved case, there has to be a mystery. And there has to be a human story.

Q. Once you pick a case, how do you report it?

A: I ask for a chronology of events and medical records that confirm the diagnosis. The medical records and chronology enable me to see whether, indeed, this is a mystery, whether it unfolded in an interesting way. Will this be an interesting case?

Then, I interview the patient, sometimes the parent, sometimes the spouse. The last step is to talk to the doctor who made the diagnosis or the current treating physicians. Any step along the way, the process can fail.

Q. Do you write about unsolved cases?

A. No, it has to be a solved case. A lot of people write to me and say, “I have this problem, can you help me?” Unfortunately, that’s not what I do. I did once write about a lawyer in Detroit who had gone to the undiagnosed-disease program at the National Institutes of Health. He’s seen more than 100 doctors and still doesn’t have an answer. But I thought his case was so unusual and interesting, I did make an exception that time.

Q. What are some of your most memorable medical mysteries?

A: I wrote about a family that kept getting recurrent strep throat. They couldn’t figure it out. An enterprising veterinarian got involved. It turned out their cat may have been the vector. When they finally treated the cat, nobody has had strep.

One of the weirder ones — there was a woman who had serious kidney and heart problems. It turned out she was eating too much licorice. That was really odd.

And I still vividly remember a State Department worker who had terrible itching on her head at night. She had even been worked up for a type of cancer. She had seen multiple dermatologists. It turned out she had head lice for an entire year. How did they miss that? That was really stunning.

Q. What have you learned about the medical system from writing about medical mysteries?

A. Medical care has become increasingly specialized. Doctors are familiar with a small slice of what’s going on, yet diagnosis is an inherently complex process. I also think time pressures are worsening. It’s like: “You’ve got 10 minutes. Go.” That’s not going to work with a complicated problem.

I also think sometimes patients are not good at describing the problems. The people who tend to do better are organized and can describe their symptoms in a way that is intelligible for a doctor.

Q. What’s your best advice to patients for getting better medical care?

A. Primary-care doctors can really help a patient. I often see people who go right to specialists. They may not have a primary-care doctor, or they use urgent care when they’re sick. That can be problematic. People really undervalue the role of a good primary-care doctor.

The 2022 Well+Being Gift Guide

Need a gift idea? The Well+Being team shared our favorite finds for cooking, exercising, spending time at home, improving our mental health, presents for your pets and more.

Some gifts are practical and affordable; others are definite splurges. I just bought air fryers for my family members because our Eating Lab columnist Anahad O’Connor recommended it. Runners will appreciate the perfect running shorts recommended by fitness writer Kelyn Soong. Amanda Morris, who writes about disability, suggested hearing-aid jewelry. Reporter Teddy Amenabar has found the perfect traveling coffee mug.

There are lots to choose from, and every item brought us closer to living healthy, fulfilled lives. We hope they do the same for you and your loved ones this year.

Please let us know how we are doing. Email me at wellbeing@washpost.com.

Ask Amy: Wonderful health care professional has patient wishing they could be friends

Dear Amy: I am a happily married, 54-year-old woman. I have a great primary medical provider.

“Rebecca” is a nurse practitioner in a large practice. I’ve been going to her for about four years.

Rebecca is personable, interesting, authentic, and has an easy and fun sense of humor. She asks about my family, vacations, etc., and seems to just be a good person.

From day one, I leave every medical appointment wanting to be friends with her. We just seem to have a compatible energy and sort of “click.”

At my most recent pre-op appointment, she greeted me with a huge smile and a very enthusiastic, “I’m SO glad you’re finally able to have this surgery! I’m SO happy for you!”

I have no idea if this is just her typical “bedside manner,” but I was quite touched.

I have a good group of girlfriends, and I deeply value friendship as one of life’s great joys.

If Rebecca were not my doctor, I would invite her to coffee, and be open to either making a new friend – or not.

But given the boundaries of this relationship, is there any way to figure out if we could be friends, or if this is just how she is with all her patients?

And ethically, CAN a doctor and patient become friends?

If so, it would be worth switching to a different provider in the practice, but I don’t want to make that switch for nothing.

– What’s Appropriate?

Wellness Checked

Dear Checked: The most “appropriate” and ethical stance is for everyone to stay in their boxes; “Rebecca” remaining your excellent and humane health care provider, and you remaining her grateful patient.

The warm personal rapport you two share enhances your medical care: you feel comfortable and communicate well – she obviously listens, remembers details about your life, and cares about you.

Despite the standard of maintaining boundaries, practitioners and patients do step out of these boxes because they are human beings and sometimes human beings just click. The OB who delivers the premature baby becomes a family friend; the oncology nurse administering chemo connects with a survivor.

Making a bid for friendship with your health care provider is somewhat risky because doing so might shift the dynamic between you.

If you want to take a stab at friendship outside the office, do not ask her for coffee (that’s a little too intimate).

Contact her via email (not through the patient portal), and invite her to a group event along with other friends – a fundraiser, hike, or performance.

She can then accept or demur based on her own comfort-level, and your professional rapport will be preserved.

Dear Amy: My mother-in-law and I have not always seen eye-to-eye on everything, but we are cordial and appreciate one another.

As the grandkids have gotten older and there is less of a reason to communicate, I find I am unsure when or if to call her.

When I have called in the past to chat, she seems happy to talk to me, but she never calls me.

I feel like I should assume if she never calls me, she must not want to talk to me. In fact, once when she was going through a tough time, she actually told me that I didn’t “need” to call her.

However, she lives alone and is getting older, and I occasionally wonder how she is doing.

I do remind my husband to call from time to time, and he does.

We see her in-person once every month or two, and she has other family members and friends who live closer and see her more frequently.

– Unreturned Caller

Dear Caller: I think these calls you make are important – even if you always initiate. As she gets older, they will be vital ways to check in.

Your mother-in-law may be shy, or a little intimidated. Some people have an actual aversion to making telephone calls – it’s a sort of inertia that can be hard to overcome. From what you write, it seems that she also doesn’t call her son. Keep it up; it’s the right thing to do.

Dear Amy: “Concerned in Suburban Chicagoland” wrote that her 13-year-old daughter burst out laughing and left the room when these parents told her that they were divorcing.

I thought I was the only teen who laughed at the worst possible moment. When my folks dramatically told me my grandmother died, I burst out laughing.

A short time later I realized that this weird response was mainly because I was overwhelmed. I still miss Nana.

— Missing Her

Dear Missing: Laughing in response to loss seems strange, but it does happen.

You can email Amy Dickinson at askamy@amydickinson.com or send a letter to Ask Amy, P.O. Box 194, Freeville, NY 13068.

Amazon makes a new push into health care

AS BIG tech companies face a brutal slow-down the hunt is on for new areas of expansion. Amazon, which is now America’s second-biggest business by revenue, is a case in point. In the final quarter of 2022 its sales are expected to expand by just 6.7{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} year on year. On November 17th Andy Jassy, Amazon’s chief executive, confirmed that the firm had begun laying off employees and would fire more next year. Mr Jassy said it was the most difficult decision he had made since becoming boss. But he also noted that “big opportunities” lay ahead. One that he highlighted is the largest, most lucrative and hellishly difficult businesses in America: health care.

Many tech firms have health-care ambitions. Apple tracks wellbeing through the iPhone; Microsoft offers cloud-computing services to health firms and Alphabet sells wearable devices and is pumping money into biotech research. But Amazon is now creating the most ambitious offering of all. Two days before Mr Jassy’s statement, on November 15th, it launched “Amazon Clinic”, an online service operating in 32 states that offers virtual health care for over 20 conditions, from acne to allergies. Amazon describes the new service as a virtual storefront that connects users with third-party health providers.

Amazon makes a new push into health care

The Amazon Clinic launch follows the $3.9bn takeover, announced in July, of One Medical, a primary-care provider that offers telehealth services and runs bricks-and-mortar clinics (the deal has yet to close). It has 790,000 members. The deal was led by Neil Lindsay, formerly responsible for Prime, Amazon’s subscription service, who has said health care “is high on the list of experiences that need reinvention”.

These latest moves complement Amazon’s existing assets. Its Halo band, a wearable device that went on sale in 2020, monitors the health status of users. In 2018 it bought PillPack, a digital pharmacy that is now part of Amazon Pharmacy, for $753m. Amazon Web Services launched specific cloud services for health care and life science companies in 2021.

The move into primary care, jargon for the role of the traditional family doctor, is a big step but has an obvious logic. Walgreens, a pharmacy chain, reckons the industry is worth $1trn a year. Around half of Generation Z and millennial Americans do not have a primary-care doctor and One Medical’s membership has almost doubled since 2019. Amazon Clinic will accept cash for its services, rather than relying on America’s nightmare insurance system to recoup costs.

The company is betting that primary care will become more digital. And it is likely that it will seek to integrate these services with other parts of Amazon’s health-care offering. Amazon Clinic’s new users can buy drugs from Amazon Pharmacy. Over time the firm could add a feature to the Halo band reminding users to take medicine. It might also set up clinics in branches of Whole Foods, the supermarket chain it acquired in 2017. And it may wrap health care into Prime, which now has some 200m members worldwide. “The low-hanging fruit is offering discounts on membership to Prime members,” says Daniel Grosslight of Citigroup, a bank.

Amazon’s health push comes with several risks. One is that its own record is far from flawless. It is closing Amazon Care, which it launched to provide health services for its own employees and which expanded to offer some services to outside customers. Haven—a collaboration with Berkshire Hathaway, Warren Buffett’s investment firm, and JPMorgan Chase, a bank—was set up in 2018 to procure lower cost health care for employees, but died less than three years later.

Another danger is competition. cvs, an American retail pharmacy, reportedly outbid Amazon for Signify Health, a large primary-care provider in September. In October, Walgreens increased its stake in Villagemd with a $5.2bn investment. JPMorgan recently opened primary-care centres of its own. Amazon’s new venture will also compete with the likes of Ro and Hims & Hers, tech startups dedicated to providing virtual health care.

Finally, Amazon will have to grapple with regulators. The Federal Trade Commission, a trust-busting agency, is examining the One Medical deal. The takeover, and the launch of Amazon Clinic, will raise questions about who should be allowed to hold sensitive health-care data. Amazon has said “we remain focused on the important mission of protecting customers’ health information”. The firm may need to set up hefty firewalls to separate customer information held by clinics from that gathered through other products and services. But satisfying data-privacy concerns could wipe out many of the data-sharing opportunities that Amazon deftly deploys across the rest of its business.

Amazon’s attempts at disrupting health care will be subject to intense scrutiny. Nonetheless it should have a positive effect on health care in America. Its experience at keeping customers happy while generating razor-thin margins could improve primary care and force other providers to up their game. It may also prompt other tech giants to do more to disrupt health care themselves. All this may be just the medicine that America’s heath-care system—and Mr Jassy’s tenure as Amazon’s boss—badly need.■

Hospitals hitting capacity from RSV, flu, covid and staffing shortages

Comment

When Christina Anderson’s mom started off owning upper body pains in October, they rushed to the nearest emergency space in their hometown of Ottumwa, Iowa. Because of her mother’s ovarian most cancers diagnosis, Anderson assumed they would be witnessed within just a sensible time. Instead, their excursion became a nine-hour odyssey.

“When we very first walked in, it was packed and compared with just about anything I have ever noticed,” Anderson explained. “I saw men and women laying throughout the chairs some slumped around who experienced been there for hrs in advance of we arrived, and some even received annoyed and remaining simply because they could not hold out any longer.”

Anderson’s tale is not an isolated episode. Patients nationwide are experiencing comparable ordeals.

Hospitals throughout the United States are overwhelmed. The mixture of a swarm of respiratory health problems (RSV, coronavirus, flu), staffing shortages and nursing property closures has sparked the condition of distress frequented upon the by now overburdened wellness-treatment technique. And professionals believe that the difficulty will deteriorate even more in coming months.

“This is not just an situation. This is a crisis,” stated Anne Klibanski, president and CEO of Mass Standard Brigham in Boston. “We are caring for patients in the hallways of our emergency departments. There is a enormous ability crisis, and it’s getting to be additional and a lot more difficult to acquire care of clients correctly and offer the greatest treatment that we all require to be furnishing.”

Along with a scarcity of beds, Klibanski reported her healthcare facility system is extremely small-staffed. The fast-paced and anxiousness-inducing atmosphere of an crisis space is a deterrent for many wellbeing-treatment workers.

“Many persons really don’t want to operate in hospitals,” Klibanski mentioned. “There are other [less stressful] settings where by they can function.”

The staffing shortages lengthen beyond medical professionals and nurses, and involve professionals, respiratory therapists and other tricky-to-fill employment, Klibanski said.

Much more than 50 percent a million persons in the health and fitness treatment and social providers sectors quit their positions in September — evidence, in component, of burnout related with the coronavirus pandemic — and the American Health care Affiliation says 1 in 5 medical doctors prepare on leaving the subject in two years.

The shortages have strike the health and fitness-treatment program like a tsunami, in accordance to Thomas Balcezak, main medical officer at Yale New Haven Health and fitness Medical center. He mentioned medical professionals, nurses and guidance team have experienced a change in how the public treats them as opposed with 2020.

“When covid to start with strike, there would be all of these parades earlier our medical center the place people would call wellness-treatment employees heroes,” Balcezak stated. “Now, we’re observing nurses who clearly show up in scrubs attempt to indicator up for residences remaining turned down because [management companies] really do not want individuals living there who do the job in health and fitness treatment.”

Considering that the get started of the pandemic, wellness-care staff have faced raising violence, reported Christopher S. Kang, president of the American School of Unexpected emergency Medical professionals.

In accordance to the American Healthcare facility Affiliation, 44 {bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of nurses noted actual physical violence, and 68 p.c stated they skilled verbal abuse due to the fact the pandemic commenced.

In October, two well being-care staff were shot lifeless at Methodist Dallas Health-related Centre. Teams this kind of as the Texas Nurses Affiliation say hospitals keep on being among the most hazardous area to get the job done.

“I’ve viewed nurses and doctors be the victims of the two physical and verbal violence,” Kang explained. “It should not be a shock when they depart a field in which they are no longer revered.”

And the workload is daunting: Kang has witnessed medical professionals acquiring to evaluate individuals in waiting around rooms in the unexpected emergency ward. Patients who will need to be admitted will in some cases be pressured to linger in the ER for the reason that of insufficient nursing workers to go them to the inpatient flooring.

“It’s regrettable due to the fact it is an unpleasant problem in conditions of privacy as properly as perception,” Kang reported.

Some hospitals have set up overflow tents and activated transfer agreements with nearby facilities to regulate the surge in patients.

In the Northeast, Boston Children’s Medical center introduced in November it would postpone elective surgical procedures.

In Oct, Johns Hopkins Children’s Heart, which was managing at ability, reopened covid triage tents that ended up in the beginning utilised to control the Baltimore hospital’s overflow at the peak of the pandemic.

In November, Colorado hospitals activated transfer protocols to assist control the overflow. The Colorado Medical center Affiliation claimed the activation was simply because of “flu, COVID-19, and respiratory syncytial virus (RSV) conditions, which are tough medical center potential, specifically for the pediatric inhabitants.”

Facts shows that overcrowding in hospitals prospects to worse well being results. An analysis revealed in the Journal of Affected individual Protection identified that lengthier waiting around moments in the unexpected emergency home ended up involved with a increased likelihood of medical errors.

But not like pediatric hospitals, wherever ability troubles stem from an explosion of RSV conditions and other childhood respiratory health problems, older patients and these requiring extensive-term care deal with a various problem: They do not have any put to go when they have been discharged.

“Many people will come into the healthcare facility from a nursing residence for treatment of some kind, and then when it is time to discharge them, they just cannot go again because there is not a bed out there,” claimed Kathleen Parrinello, main operating officer at Solid Memorial Hospital in Rochester, N.Y. “And then we just cannot get people into our emergency department for the reason that our beds are stuffed with additional nursing home people than we’ve at any time had.”

The medical center bottleneck is only likely to get worse. All through the pandemic, 327 nursing residences were shut down nationwide, leading to 12,775 inhabitants to be displaced, and extra were projected to close this yr.

Parrinello reported nursing residence mattress availability in her area has absent from 4,500 to 3,000 simply because of facility closures. But most of the ability challenges can be attributed to present nursing properties not staying equipped to regulate their ability. “They do not have the personnel to continue to keep the beds open and choose in all those patients,” Parrinello reported.

Out of the approximately 1 million hospital beds in the United States, additional than 700,000 are registered with the Centers for Medicare and Medicaid Solutions. Seventy-eight percent of healthcare facility beds registered with CMS are filled with sufferers, and 4 percent of individuals are crammed with covid people, according to information from the Section of Health and Human Expert services.

And the selection of occupied beds is expected to increase as the United States heads into the late tumble and winter as coronavirus time collides with an before onset of flu conditions.

Influenza cases go on to rise, with the most up-to-date information from the CDC getting that there have been 23,000 hospitalizations and 1,300 deaths from flu so far this period.

Just about 146 million doses of flu vaccine have been administered. And 31 million men and women ages 5 and up have obtained the current coronavirus booster vaccine. But vaccines are not plenty of by yourself to deal with the crumbling crisis home infrastructure.

In November, the American Higher education of Emergency Medical professionals and 35 other wellbeing-care associations sent a letter to President Biden urging the administration to address ER staffing shortages and burnout. “Shift operate, scheduling, hazard of publicity to infectious-condition, and violence in the crisis section can all influence the psychological wellbeing and properly-staying of the medical professionals and nurses,” they wrote.

Quite a few of these very long-standing challenges ended up exacerbated by the pandemic, and the assumption was when the coronavirus surges subsided, factors would return to usual. But Klibanski, of Mass Common Brigham, stated “there is no additional standard.”

“Everything has modified, and now all these troubles at the forefront are only finding more exacerbated around time,” Klibanski explained.

New health care regulators ask OneCare executives for measurable results

OneCare, the nonprofit that distributes millions of public and private health care dollars to providers throughout Vermont, has asked state regulators to greenlight a $15 million operating budget — a slight decrease from this year — as part of an annual review process.

This is the first OneCare budget cycle for most members of the Green Mountain Care Board, the five-member body that regulates major players in Vermont’s health care sector, including hospitals. And the board’s new members seem keen to put OneCare executives in the hot seat.

During a five-hour marathon hearing last week, the board repeatedly pressed OneCare executives for quantitative results, whether that meant reducing Vermonters’ health care costs or improving their quality of care.

“Vermonters, either through taxpayer-funded health care groups, out-of-pocket expenses, copays or insurance, have borne the bulk of those staggering numbers,” said Owen Foster, the board’s new chair, at the start of the meeting. “And for that they deserve results.”

Owen Foster, chair of the Green Mountain Care Board, at the board’s office in Montpelier on Oct. 27. Photo by Riley Robinson/VTDigger

Thom Walsh, who was appointed to the board in December, asked OneCare CEO Vicki Loner to name the organization’s top three key performance indicators, or metrics of success. Loner declined to name any, saying, “They’re going to our board to be reviewed.”

OneCare is an accountable care organization, or ACO. It’s been described as a policy experiment because it’s intended to shift the state’s health care spending from a fee-for-service model to one in which providers get a flat fee per patient, with incentives to keep people well for the lowest cost. It funnels money from Medicare, Medicaid and private insurers to health care providers across the state, ranging from big hospitals to independent primary care doctors.

OneCare has a $15 million operating budget to manage these various contracts between payers and providers and to conduct data analysis of the health care system. Its operating costs are funded by Vermont hospitals, which pay millions in fees each year to be part of the ACO.

Tom Borys, OneCare’s vice president of finance, cited OneCare’s increased enrollment as one of his top indicators of success. He argued that increased participation in an ACO model is inherently good because it changes the incentive structure behind participants’ health care.

But Walsh quickly cut him off, seemingly unimpressed.

“What I’m struggling to find is an outcome that would be meaningful to Vermonters, and you may be able to say something like, ‘reduced (emergency department) visits,’” Walsh said. “Those are outcome measures that matter to patients, and I can’t find them.”

As part of this year’s budget process, OneCare submitted a study comparing it with a group of 20 similar ACOs nationwide. OneCare outperformed other ACOs on some cost metrics, including cost of inpatient and outpatient surgeries.

However, it found OneCare patients went to the emergency department at significantly greater rates, averaging 36{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} higher than patients in other ACOs. Vermonters in OneCare had 18{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} fewer visits to primary care providers and paid 30{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} more for prescription drugs.

In a June 2021 report, State Auditor Doug Hoffer recommended that the care board find a clear way to measure the ACO’s effectiveness, to determine whether OneCare saved Vermonters more money than it cost. The auditor said that assessment should be a prerequisite for any new all-payer agreement with the federal government, which is expected to be worked out in the next few years.

“On a high level … it’s important that any regulated entity, like OneCare going before the board, gets a good, careful review,” Mike Fisher, chief health care advocate at Vermont Legal Aid, said after the hearing. “And so I’m pleased to see the level of questioning from the board.”

OneCare executives pushed back on some of the board members’ demands for quantitative impact. They argued that changing the entire health care system takes a long time.

“How do you manage the one-year payer contract cycles and performance expectations with long-term outcomes that, our clinicians remind us all the time, it’s going to take years, decades, generations to address?” OneCare Chief Operating Officer Sara Barry said.

When governments or organizations invest in big, upstream factors that impact people’s health — things such housing, walkable communities and food security — those benefits don’t have an immediate, measurable impact on the health of a group, Loner said. OneCare executives also noted that about half of the ACO’s lifespan has been during the Covid-19 pandemic.

Walsh agreed with executives that systems change is a long game but countered that six years should be enough time to at least have some way of measuring results.

“If OneCare’s role was to support through data analytics, maybe trainings and other things over time, wouldn’t there be improvements that we could point to, right?” Walsh said. “If we look year over year, and it’s been going on for five or six years, wouldn’t there be improvements that we could point to, even if it’s just a little piece?”

About 296,000 Vermonters are “attributed” to OneCare — meaning they see a provider who participates in OneCare and is accountable to the ACO’s performance targets. These 296,000 patients are expected to generate $1.4 billion in health care spending in 2023, an expected $97 million increase from this year.

Overall, OneCare’s requested $15 million operating budget would reduce its expenses by about $248,000, or 1.6{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}, from 2022. The ACO cut costs by reducing its in-person workspace and by combining some operations, such as data analytics, with UVM Health Network, executives told the care board.

OneCare’s budget request includes a roughly 3{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} cost-of-living increase for employees. If the budget were approved, Loner, the CEO, would make more than $490,000 next year.

Aside from the organization’s operating expenses, OneCare would also be responsible for another $29.9 million, which it would distribute to health care providers throughout the state.

That money includes bonus payments for providers who reach certain population health goals. It would also fund targeted investment and programs in specific areas, such as about $212,000 for the state’s five nonprofit Area Agencies on Aging.

In response to questioning by Foster, Loner said OneCare had conducted no cost-benefit analysis on how it should allocate money to particular programs or types of providers.

The proposed budget would raise hospital participation fees by 1{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}, generating a total of $19.8 million. If approved, this budget also “escalates risk quite dramatically” for Vermont hospitals, Borys, OneCare’s vice president of finance, told the care board.

By participating in OneCare, hospitals join a risk pool. If hospitals meet certain cost targets and quality goals by the end of the year, hospitals can earn funds from the pool. If hospitals miss these targets, they could owe money — potentially millions. Theoretically, this payment model is meant to change financial incentives, to encourage coordinated care and reduce expensive or unnecessary services.

With the onset of the pandemic, OneCare had substantially reduced how much risk hospitals took on through their shared pool, from $42 million in the pre-pandemic portion of 2020, down to about $16 million for the past couple years. The proposed 2023 budget would raise the stakes for hospitals back to roughly pre-pandemic levels, at $36 million.

At last week’s meeting, Foster asked OneCare executives what the hospitals’ risk actually means: If a hospital fails to meet certain targets and owes money at the end of the year, who ultimately pays that penalty?

“Would any executives or individuals who are responsible for that loss have, actually, any skin in the game?” Foster said.

Hospital leaders are not individually responsible to OneCare’s goals, Borys said, but they are accountable to their boards.

“In the sense that if they had to make a large shared loss payment, the boards are going to consider that when evaluating management,” Borys said.

“So if the hospitals, ultimately as an organization, would foot the bill, is it fair to say that by and large, Vermonters are paying that?” Foster said. “Given that’s the source of the revenue streams?”

“I think through extension, there’s some truth to that,” Borys said. “But I will also add that the complexity of health care funding is huge. And if the general belief is that every dollar that funds health care comes from individual people, which is probably fair, then I’d say the answer is yes.”