I am now involved in a small way with the Vermont Healthcare Innovation Project that is the latest of several efforts in Vermont to move away from healthcare that is fragmented, inefficient and expensive. Despite efforts to move toward value-based reimbursement and the presence of three ACOs in the state (the largest, OneCare Vermont, sees about one hundred thousand Medicare, Medicaid, and commercial patients), the current system of care in Vermont continues to be predominantly constructed on a fee-for-service economic infrastructure.
As is true everywhere, a fee-for-service infrastructure and the associated volume-based approach to finance does not provide all citizens equity of quality and access to care. Over the last twenty or more years a growing number of Vermonters have dreamed of a system that delivers better care to individuals, creates a healthier community, improves the work life and professional satisfaction of healthcare professionals, and operates as an economically sustainable expense for individuals, taxpayers, employers, and governmental agencies.
Vermont may be a smaller stage, but as is true everywhere, the scale of change required to actualize this dream can only be described as transformational and this latest effort at transformation with a focus on innovation is yet another attempt within Vermont to pursue what has been understood for more than fifty years, which is a need to move healthcare from a cottage industry to a more organized community effort or enterprise. Vermont has understood the vision of the Triple Aim for some time yet it has also been another example that vision is necessary but insufficient for large-scale change. Vermont has been and will continue to be on a difficult journey from the status quo of volume driven fee-for-service medicine to the dream of the Triple Aim. Dr. Robert Ebert had it so right when he said in 1965,
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Perhaps as much as any other state including Massachusetts, Vermont has been vigorously searching for that elusive “conceptual framework and operating system that will provide optimally for the health needs of its population”. There has been significant and measurable success in the effort to broadly introduce the principles of team based care and population health. As noted earlier, there are now three new ACOs in Vermont. Across the state leaders are exploring the practical application of the new economic and clinical organization of care to the urban and rural practice environments that exist in Vermont, but the majority of practices are still early in their transformation.
