Green Mountain Care, First of two articles: By Lisa McCormack
Fears that physicians will leave Vermont if the state enacts universal, single-payer health care may be unfounded.
Many local physicians say they favor single-payer because it would lower their administrative costs and reduce their current paperwork headaches.
Others support health-care reform because it would give their patients affordable access to care.
And at least 200 physicians from across the U.S. have said they would strongly consider moving to Vermont if it adopted a single-payer system.
Controversy has been swirling around Vermont’s comprehensive health-care law, Act 48, which took effect last May. Its goal is to provide care to all of the state’s residents through a Euro-pean-style single-payer system called Green Mountain Care. Now, the Green Mountain Care Board says, about 65,000 Vermonters — one of every 10 — have no health insurance.
Some doctors have questioned whether the plan financially sustainable. The state is still working out the details of how much universal coverage will cost and how it will be paid for.
But most physicians contacted for this report agree that the current system isn’t working when it comes to containing costs or providing health care to every Vermonter.
Peggy Carey, M.D., is president of the Vermont chapter of Physicians for a National Health Program, 18,000 doctors who want single-payer national health insurance. She’s a family practitioner in Cambridge and the Champlain Islands and is a former adjunct professor at the University of Vermont medical school.
“Physician attitudes are changing, and more and more doctors support single-payer reform,” Carey said. “I believe all the talk about physicians abandoning Vermont if it were to adopt a single-payer system is at best unproven, at worst a bit of a scare tactic by opponents of reform.
Deb Richter, M.D., a primary care and addictions medicine physician who practices in Burlington and central Vermont, founded Vermont Health Care for All, an organization that lobbies for universal health care. She has been arguing for years in favor of universal coverage.
“As far as the delivery of care is concerned, single-payer has no effect,” Richter said. “As far as financing care, it’s the most efficient way. We’re spending 31 cents of every health-care dollar on paperwork and related costs. With a single-payer system, we could funnel more money to health care rather than paperwork and bureaucracy.”
Vermont’s law
Act 48 would contain costs by setting reimbursement rates for health-care providers and streamlining administration into a single, state-managed system.
A five-member board was appointed last October to set up Green Mountain Care. Among other tasks, the board will design a payment system under which hospitals and other providers will be paid a set amount to provide health care to a set population. The current system is known as fee for service, which pays doctors on a per-visit basis.
The single-payer plan wouldn’t affect health benefits for Vermonters covered by Medicare; that’s a federal program, and the state plan wouldn’t change it.
The federal health-care reform law won’t allow Vermont to enact single-payer until 2017. In the meantime, the state is moving to set up a health-benefit exchange program in 2014, as required by federal law. At the exchange, individuals and small businesses could compare prices and benefits offered by a network of in-state and national private insurance companies.
Endless paperwork
Fred Rossman, M.D., a Morrisville-based gynecologist and obstetrician, believes single-payer would reduce paperwork, time and expense for him.
He said his administrative costs have risen sharply since he began practicing medicine 29 years ago, driven in large part by insurance-related paperwork.
“Hopefully, it would lower health-care costs in terms of insurance and general medical care, or at least contain the cost,” Rossman said.
Rossman has worked with as many as 18 different insurance companies, each with different benefits, rules and drug formularies.
He employs a full-time staff member to handle the paperwork and phone calls.
Carey points to a medical office in South Hero, staffed by a physician and several nurse practioners. It spends between $50,000 and $80,000 a year just on administrative costs.
“That can be absorbed by a larger practice, but we have a lot of smaller, cottage industries here in Vermont,” Carey said.
Richter has lost track of the number of insurance plans she works with. The list of addresses where her office staff must send claims is 190 pages long.
“It is totally ridiculous,” Richter said. “We could simplify the system tremendously by offering Medicare for everyone, with expanded coverage from birth through death. It’s the right thing to do. It’s the best way to contain costs. It makes no sense to spend millions on paperwork. That would provide more money for other areas of the economy — educating our kids, fixing our roads.”
When doctors finally receive payment for their services, it’s common for them to be paid varying amounts for the same procedures, depending on the patient’s insurance coverage.
“It’s as if everyone went to the store and paid a different amount for the same gallon of milk using different currency,” Richter said. “It doesn’t make sense.”
Hospitals are slammed just as hard by the endless paperwork. Last year, Copley Hospital in Morrisville dealt with more than 200 private insurance plans, as well as Medicare and Medicaid.
In addition to filing insurance claims, Copley staff must preauthorize medical services, send medical records to insurance companies upon request, document medical necessity for certain procedures, prepare Medicare and Medicaid cost reports, file appeals for denied claims, and provide financial counseling to uninsured and underinsured patients, among other administrative tasks.
Cost questions
State officials aren’t sure yet how Green Mountain Care would be financed. One idea is a combination of a payroll tax and a progressive income tax — that is, the more you earn, the higher your tax bill.
Richter says Vermonters already spend $5 million a year on health care; the challenge in setting up a statewide, universal system is how to capture that money.
The system will depend on money provided through the 2010 federal health-care law. Without federal funding, the state couldn’t cover its start-up costs.
Bill Minsinger, M.D., a semiretired orthopedic surgeon who sees patients at Gifford Hospital in Randolph and at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., worries that Green Mountain Care won’t be financially sustainable.
During his 26 years as a salaried physician at a Randolph clinic, he treated uninsured patients for free, or allowed them to work out a payment plan.
He predicts that, once universal health care is offered, patients who previously put off care will flood physicians’ offices and hospitals.
“If we cover everyone with insurance, people are going to take advantage of that,” Minsinger said. “People will spend money. That’s not a bad thing, but to think that that’s going to save us money is looking at things with rose-colored glasses.”
He also worries that single-payer reimbursement rates will be too low. Roughly 70 percent of the patients he treated at the clinic received Medicaid or Medicare benefits, which pay fees to doctors and hospitals that are far below market rates.
Because of the low Medicaid and Medicare reimbursement rates, the clinic didn’t make a profit in the last two decades he worked there.
“I’m not saying we shouldn’t look at changing things,” Minsinger said. “Twenty percent of the Medicaid population spends 80 percent of the resources. Can we look at how we care for these patients? Can we use a care manager?
“It’s an area we have to address, but it shouldn’t be addressed by a five-member board. We need to find a broader set of solutions. I’m just not sure that where we’re going is where we should be going.”
Choosing Vermont
Physicians choose to practice in Vermont because of the quality of life, and single-payer health care wouldn’t change that, Rossman said.
“There are other factors that motivate physicians to move to Vermont or not move,” Rossman said. “I think the benefits would offset any disadvantages.”
Carey points to surveys conducted by Physicians for a National Health Program, which show growing support for single-payer health care among physicians nationwide.
“We have to make sure we don’t blame health-care reform activity for the difficulty in recruiting physicians,” Carey said. “Across the country, fewer people are going into medicine and the number of physicians going into primary care has declined 20 to 30 percent.”
A single-payer system will likely give physicians more power than they have today when it comes to negotiating the payments they receive, Richter said.
“Doctors can bargain, as they do in Canada and France,” Richter said. “We have no bargaining power whatsoever because the system is so dissipated. Having a concentrated bargaining power would strengthen the system.”
Minsinger isn’t convinced. He believes many new doctors, especially those who practice specialized medicine, will bypass Vermont for greener pastures.
“I see medicine from being in the trenches,” he said. “The state of Vermont can’t pay physicians 10 percent of what everyone else gets and expect them to come here, or people to have access to care.”
Next week: Uninsured and underinsured Vermonters, how single-payer would affect patient care, and its impact on hospitals.