Watch out for higher costs, rationing, and loss of doctors
By Rob Roper
Asked what concerns he had about healthcare reform as it is playing out in Vermont, Joe Woodin, Administrator for Gifford Medical Center, replied, “Well, I have a lot of them.” Although Woodin and his colleague Dr. Bill Minsinger, who served as Gifford’s sole orthopedic surgeon for twenty-five years, are in favor of making improvements to the system both have deep reservations about the path the Vermont legislature is taking.
Woodin’s number one concern has to do with the complexity of the system in place. “There are a lot of details out there. There are a lot of systems in place, whether they’re federal systems or current local systems that work quite well, and I just think we’re being challenged to say how do we improve the system without actually causing harm to it.”
The uncertainty that now exists about many of the details of what Vermont’s universal, single payer system will look like is also a problem. “I think it creates a sort of a whole morass within the healthcare providers in all of the state and all of the hospitals…. I think when you go from a point A to a point B, and point B is the desirable new state, there is… stress. However, if you sit in that stress zone for any long period of time it really wears on you and is actually creates problems because you’re wondering where are we going? Give us the details so that we can actually measure/know the cost issues and… adjust our operations.”
One of the difficulties Woodin raises is the retention and recruitment of doctors. “We’ve had some cases where folks are looking at Vermont and we’re trying to recruit them. Quite intelligent and apt people say, well, tell me about healthcare reform, because I’m not going to move my family up to Vermont and find out within two or three years that your system is going to change dramatically and it’s going to affect my income or my ability to do services.”
Dr. Minsinger shares this concern. “For the last ten years of my practice, ending just two years ago at Gifford, I really wasn’t making money at Gifford. I was doing all the work but I wasn’t making money. They paid my salary and it all came out in the wash. But what my concern is going forward is, I saw proposals to change reimbursement schemes in the state of Vermont I was thinking my practice was going to make less and less money. So, that is an issue here.”
“It isn’t easy to attract physicians and it never has been to a facility like Gifford – a small hospital in a rural setting,” Minsinger explains. “If you’re one of only two OBGYNs, you’re going to have to do half the call. That just comes with the turf, and that’s just one of the issues. With that, though, if [the government decides] to cut down reimbursements to providers, and the reimbursement isn’t there so that the salary isn’t there that you can pay someone to take fifty percent call all the time, that is going to be a real detriment when you’re trying to recruit new doctors to the community. And, clearly more of a detriment when the person is young, just out of medical school and with big debt.”
And Vermont can’t afford to lose doctors. As Minsinger points out, “There really are a limited number of physicians in the state of Vermont. Only fifty-two general surgeons. Only twenty-four urologists. And as we go forward here we have to be very careful not to limit reimbursements to the point where people will retire as I did, people cut back on their practices, or the worst-case scenario, leave the state.”
One serious consequence of losing doctors Minsigner raises is the potential loss of Fletcher Allen’s status as a Level 1 Trauma Center. “I know in Burlington certainly there is concern that there is a small number of neurosurgeons in Burlington, and if one were to leave, then their setup as a Level 1 Trauma Center would then be called into question.” A Level 1 Trauma center requires a range of specialists and equipment on duty at the hospital 24 hours a day, including surgeons, emergency physicians and anesthesiologists. Being treated at a Level I Trauma Center has been shown to increase a seriously injured patient’s chances of survival by an estimated 20 to 25 percent.
“We don’t want to have a situation where the closest neurosurgeon is in Boston,” warns Dr. Minsinger. “The legislature has to be aware of that – that they can’t feel that they’re going to save money just by ratcheting back on reimbursements.”
Neither Woodin nor Minsinger see much hope for cost containment in the current reform plan either.
“If we want to get to this better place where we all sort of passionately believe that Vermont can make a stand and have a better, improved health system, that’s going to cost money to go from point A to point B,” says Woodin. “It’s not that we can just look at our current state of affairs and say there’s a bunch of cost savings on the table, let’s just take them out, use them, and that will help transform us. We’re going to have to spend money, and we don’t have the money currently, to actually do that.”
Dr. Minsinger echoes the sentiment, “The projections are not all that good. We could be two billon dollars in the hole by 2018, and that’s what really concerns physicians, I think, in the sense that the natural inclination would be then to say that we’ll reimburse at a much lower rate, we’ll reimburse hospitals at a lower rate and you [the doctor or hospital] need to find the savings that will allow that to happen. And I guess my point is that I’m not so sure that there are easy savings that can now be cut out of the system. A recent New England Journal of Medicine Article shows that Vermont physicians as a group do very well – are tops in the nation – at saving money. We’re spending the least amount of money to provide care in Vermont compared to any state in the nation. So, there isn’t a lot of fat here that is going to be easily cut out.”
“If we’re going to cover more people so that 100 percent of the population is covered, with no limitations on that coverage,” Dr. Minsinger continues, “that is going to cost more money. And, we suddenly aren’t going to find that we’ve cured diabetes or done other things that are suddenly going to save us a hundred billion dollars. We’ll be treating more patients with as much disease as they have now. Hopefully we can make some inroads on some of those disease status by seeing patients more frequently or as needed, etc. But I don’t think we can guarantee that.”
The way the numbers fit together leads to a logical place, and that is rationing. “We can’t promise all things to all people,” says Woodin. “But, it’s very hard to say no. I think any politician would find it very difficult to say no to any constituent as it relates to a particular therapy or type of professional who provides it or a particular disease state. So, we need to talk about that. You can’t afford to give everybody everything… At some point you’re going to run out of money.”
Woodin sums up our situation this way: “You’ve got to spend more to transition….. You’re going to have to spend a lot more money to get us over that hump, so to speak. And, hopefully that second stage is less expensive. That’s hard to estimate too. There aren’t enough budgetary numbers out there to say that that second stage is less expensive…. I think the business community would like to see less expense on their books for all their employees, but, again, I’m not sure exactly how we get there…. In the end if healthcare reform does not provide a more cost effective way for businesses to provide insurance, then we’ll lose them.”