Ken Thorpe, a consultant who helped Vermont design its Catamount Health program, urged lawmakers to fully implement health care reforms already on the books, as they continue to reshape its health care landscape.

Thorpe is back in Montpelier for the 2014 session as a consultant hired by the Joint Fiscal Office to be a resource for lawmakers. VPR reported lawmakers will pay him a $20,000 a month fee.

Regardless of where lawmakers take reforms in the future, Vermont needs to make sure the efforts underway are having the intended effect and living up to expectations, he said.

"A lot of the infrastructure is in place, I think the challenge has been the pace of adopting it statewide," he said.

Thorpe said he's happy to be back in the Green Mountain State.

"Working in Vermont is a lot more fun than working in Washington, D.C., because you guys get things done," he told lawmakers, during a whirlwind tour of legislative committees Tuesday.

Thorpe helped Vermont design its Blueprint for Health and the Catamount insurance program for low-income people nearly a decade ago. In his absence Vermont's goals for health care reform have remained largely the same: improving quality, reducing costs and expanding access - ultimately to everyone.

The Emory University professor has been working in Washington to change the debate in Congress about entitlement reform from a budget discussion to one centered on health policy, he said.


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He's started an organization called the Partnership to Fight Chronic Disease, an umbrella group of stakeholders advocating policies to reduce the prevalence of chronic disease, which he said are driving the long-term growth in U.S. health care costs - and Vermont isn't immune.

In Vermont, 65 percent of the increased growth in health care spending is due to the greater prevalence of chronic conditions such as diabetes, hypertension and depression, Thorpe said.

Additionally, 85 percent of health care spending in the state is associated with patients who have multiple chronic conditions, he said.

"So if you want to sort of picture where the money is, whether it's in the commercial market or the Medicare market, it's tied up into an overweight, hypertensive diabetic with bad cholesterol, asthma, back problems, pulmonary disease and is depressed," Thorpe told lawmakers. "He's on multiple medications and really needs an interdisciplinary care team to work with and engage that patient."

The state needs an integrated approach to manage and prevent the growth of chronic disease in order to reduce overall costs. The alternative is to slash provider reimbursement rates, and that's a budgetary fix that doesn't remove actual costs from the health care system, he said.

He urged lawmakers to consider broader public health goals when designing the benefit package that will accompany Green Mountain Care, the state's universal coverage plan.

There are clinical guidelines that spell out routine primary care visits and examinations for patients with chronic diseases, Thorpe said. Those should carry no out-of-pocket cost to patients, he said.

"To me, none of that should be subject to any type of cost-sharing," he said, "because it has nothing to do with excess utilization."

"You might want to pay them (the patients) for that," suggested Mike Fisher, D-Lincoln, chair of the House Health Care Committee.

If we reduce the rate of readmission, unnecessary hospitalizations and clinic visits as well as trips to the emergency room, and build that into the health care infrastructure, costs will drop, he said.

"The long-term approach for slowing the growth in health care is virtually all utilization driven," Thorpe said.

Vermont's Community Health Teams, often called the patient-centered medical home model, is an example of how the state is already doing that, Thorpe said. The health teams are nurses, social workers, dietitians and health educators who work collaboratively to manage, and ideally prevent, chronic conditions.

It's also an example of a program that's taking too long to roll out statewide, Thorpe said.

Accountable Care Organizations (ACOs), essentially partnerships between providers, are another initiative that has the potential to improve delivery and reduce costs, Thorpe said, but they need to be more than a legal framework agreed to by multiple providers.

"The only way they work is if the collective providers change the way they deliver services," he said.

The bulk of Thorpe's prescriptions for bending the cost curve aren't short-term solutions, said Deborah Richter, director of Vermont Health Care for All, a universal health care advocacy group.

She described his focus on preventing and managing chronic disease as demand-side solutions, which could reduce costs but would take many years. That's because much of hospital costs are fixed at a level that meets the needs of the current system, Richter said.

If a hospital has a certain number of emergency room doctors, that cost is fixed and won't go down with the number of emergency room visits. Over time, a hospital could rescale to meet reduced demand, but those aren't cost savings that Vermont could realize quickly, Richter said.

"If you put two gas stations on the same street, costs go down. If you put two hospitals on the same street, costs go up, because we're already paying for the work they do," she said.

Vermont needs a focus on supply-side solutions to lower costs in the tight timeframe it has set for the move to a universal system, Richter said.

Supply-side solutions call for a reallocation of existing resources. For example, hospitals could convert underutilized acute care beds to less expensive and more widely used purposes such as inpatient drug or physical rehabilitation beds.

Thorpe said tackling chronic disease might lead to long-term solutions, but doesn't necessarily require a long time to implement.

Diabetes prevention programs, which allow primary care doctors to refer a pre-diabetic patient into a community health team setting, can produce savings within six months, he said.

National data collected through 10 years of randomized trials show the programs can reduce the number of new diabetics by 58 percent within a year.

If there were the money and political will, Vermont could have a diabetes prevention program up and running in 18 months, Thorpe said.

"It saves money, it's inexpensive to run," he said, "That's the type of program that should be built into whatever we do with Green Mountain Care or health insurance."

Editor's note: This article was updated at 6:09 p.m.