VT Gov at FAHC Med Staff Mtg

VT Gov. Shumlin spoken Tues night at the Fletcher Allen Health Care Medical Staff meeting. The audience represented half of the medical care delivery system for the entire State of Vermont - physicians who have much at stake in this debate. For people who have dedicated 15 years to specialty training and decades of practice, changes are daunting.
Gov. Shumlin's poor selection of medical anecdotes aside, I believe that he is correct on two counts. First, the current trajectory of increasing healthcare spending will destroy this State if left unchecked. Second, Vermont is the best place for such reforms to succeed.
He focused his comments on three areas:
1) reducing overhead costs on the billing and reimbursement cycle
2) leveraging technology to reduce duplication of service
3) using preventative care and improved chronic disease management to bend the cost curve downward.

The first topic I'll leave aside - the billing and reimbursement - except to say that I would believe that our inefficient claims system with prior authorizations, variable drug formularies, and overburdening paperwork may well allow for 8% cost reduction with simplification and lean re-engineering.
On the second topic - healthcare information technology (HIT) - I am a big supporter of these systems in general. Vermont Information Technology Leaders (VITL), our State HIT Extension Center, is helping move practices toward electronic records, is negotiating the policy changes needed, and developing the infrastructure for healthcare information exchange (HIE). FAHC, since going live with its EHR two years ago, brings a huge portion of the State into the EHR age on a single, integrated platform. FAHC is bringing others along by discounting the EHR to local medical practices. Nevertheless, the State as a whole remains largely in paper records at many community hospitals and practices, and even as we implement EHRs at these locations, the creation of disparate systems across the State means that full integration of data across platforms is still well in the future. The goal, as described by Gov Shumlin, of having your entire medical record available and encoded in the insurance card, is still science fiction. It is possible, but it is futuristic. I'm the last one to say we should not attempt the effort because the tools don't yet exist. We have already demonstrated significant interoperability and connectivity (for medication lists, for example) in VT. We have a long road ahead before the HIE taps begin to flow. On an exciting note, I was at a meeting last week which demonstrated real-time transfer of CT scan images between hospitals. In the case of critically-ill patients being transferred to FAHC, this could significantly decrease duplicate images (since the original CT scan now usually is not available when the patient arrives at FAHC and thus gets redone). Soon, lab test done at CVMC will be visible seamlessly to FAHC physicians, again refucing waste and duplication. Bottom-line: incremental gains in the next few years are realistic, but how much this translates to significant savings in the short term is unclear. Still, we need to push HIT and HIE forward for the day when it does pay dividends.
On the third topic - prevention and disease management - we are already demonstrating cost reductions in VT with projects such as the Patient Centered Medical Home (PCMH). This system of comprehensive healthcare services, based in a primary care clinic, led to a significant decrease in ED and hospital admission rates at FAHC's Aesculapius clinic, comparing the 2 years prior to and 2 years after PCMH implementation. The graphs are impressive.
Vermont already has proven that we can deliver great care (best in the country by several measures); Vermont providers are dedicated, smart, hardworking; but the vestigial systems of care are strangling us. I do believe that using many of the tools employed by other sectors (Lean, Six Sigma, etc), we can make the system better without working longer hours.
It is going to be scary making this leap, but we have little choice. The status quo is not sustainable for Vermont or for Vermonters. Whether you agree with his approach or not, Gov. Shumlin has taken on a critical issue not likely to make him many friends. By one definition anyway, this is leadership. Fortunately, he has created a panel including two physicians. The coming months will be interesting here in Vermont. Time will tell if efficiency, technology, and prevention/disease management can pay off.
It is always my attitude that change is coming, and I'd rather direct the change the be caught at its mercy. Its messy either way, but I'd rather be the windshield than the bug!