How will this help my doctor?

by Jeff Wennberg

Dr. Allan Ramsay’s commentary “How will this help my patient?” seeks to offer health care providers and patients reassurance that he and the four other members of the Green Mountain Care Board will respect the need for doctors and patients to make critical clinical decisions under Vermont’s future government monopoly single payer system.

I have no doubt that Dr. Ramsay and his peers sincerely intend to accomplish this; they are good people facing a very difficult challenge. But notwithstanding their best intentions and broad authority, the government’s control over clinical decisions is hard-wired into the global-payment single payer reform prescribed in Act 48. Even the executive director of the Green Mountain Care Board has acknowledged that when the state prescribes payment systems, treatment fees and doctor compensation the state is directly or indirectly making clinical decisions.

Dr. Ramsay also sought to reassure us that there will be no “doctor drain” in Vermont as physicians flee the Green Mountains to practice in less restrictive and higher compensation states. He correctly points out that reform is happening everywhere, but Vermont is the only state that now has the authority to directly set physician compensation and control where physicians may practice. There is powerful evidence that the uncertainty associated with Green Mountain Care has already suppressed recruitment of new physicians and is causing growing numbers of Vermont Doctors to quietly prepare for early retirement or exit.

If Vermont manages to keep compensation competitive doctor shortages will be minimized, but the principle means by which Act 48 contains costs is to limit compensation to providers. This leaves practitioners with the unpleasant option of reducing income or withholding services to patients. Or, of course, practicing medicine elsewhere.

Dr. Ramsay defended the Legislature’s decision to exclude malpractice reform from the suite of changes under Act 48. He cites a Congressional Budget Office analysis that minimizes the expected savings; a report that has been dismissed by most of his peers. But whatever the ‘real’ savings are is academic. As pointed out by Dr. Hsaio, whose recommendations served as the basis for Act 48, malpractice reform is a critical component of any government health care monopoly reform. If the financial incentives of Green Mountain Care cause a doctor to withhold treatment and that decision results in an unfortunate outcome, should the doctor be held legally liable? Or should the responsibility rest with the state, as is the case under Canadian single payer health care? The refusal of the state to assume this responsibility, or at least to limit the doctor’s exposure, will have a chilling effect on the willingness of physicians to practice here.

On Dr. Ramsay’s final point – that Vermont physicians remain principally concerned about the good of their patients – we are in full agreement. And it is largely due to that concern that we must all examine where Vermont is headed with open eyes and skepticism.

Jeff Wennberg is the Executive Director of Vermonters for Health Care Freedom