 Good afternoon. I'm Dr. Lewis Myers. Welcome to Health Care Today. I'm honored today to have as our guest Mr. Bill Schubert. And if you've lived in Vermont for any period of time, you've probably come across Mr. Schubert because he has been involved in a tremendous number of issues in the state and in a number of places. By birth he grew up in Morrisville, Vermont and has written about that in some of his writings and in some of his books. He attended Phillips Exeter Academy and Kenyon College where he majored in French. He went on to be an entrepreneur and started a number of businesses and has also been involved with, as chairman of the Fletcher Allen Health Care some years ago. He now writes for V.T. Digger commentaries on a very regular basis and he's written quite a bit about the health care system recently. I'm going to talk about some of those issues today and some of his own experiences. I should also tell you he's a published novelist and has written a number of books. One of my personal favorites I can recommend is this book Lila and Theron, which is a lovely portrait of a couple growing up in early 20th century Vermont in the countryside. So without further ado, Mr. Schubert, welcome. Thank you, Lewis. It's good to see you. I thought we would start with an article that you wrote recently. So you've made it sort of a public domain about a health issue that you had and a serious health issue and your experience with that. Can you tell us a little bit about that? Yeah, I was having difficulty. I do a lot of work in the woods and I would get out of breath as anybody would. But if I'd been lying down or sitting and I stood up, I was struggling to get air. And I went to the hospital and they wanted to check me out to see if it was a cardiology issue, which it turned out to be. And I went to the stent lab and they checked me thoroughly there and I did not need any stents. So I was only in the lab for, I don't know, 20 minutes or so. But they said I had a valve that was down to about 20% function. So they explained to me what a TAVR procedure was, relatively new, and that that's what I should have. And I did. And they were phenomenal. I mean, my cardiologist was terrific. I took the minimum anesthesia protocol, was awake for the whole operation, which was an hour and 15 minutes. They go up through the groin, up, and they move the old valve out. And they put a new artificial valve in and they make sure it's working. And as I said, I was on the operating table for an hour and 15 minutes in post-op for a couple hours and home the next day with a little list of things I shouldn't do right away, like chainsaw or split wood or run up and down stairs. And it was terrific. And I have to say the quality of care was terrific. And I made a point of sending a letter because I have been hard on the system. I sent a letter both to the board chair and Dr. Leffler, who's the president, and just let them know how grateful I was for the quality of care I got. This was at the University of Vermont Medical Center. University of Vermont Medical Center, yeah. In your article relating that, you also said that you happen to be very well insured in terms of your health care insurance. And you wondered if the average Vermonter or perhaps the Vermonters who are struggling would have gotten similar care. What were your thoughts about that? I don't think that people are triaged around their ability to pay. I don't believe that's the case at all. I know that a nonprofit by law is required to treat anybody who shows up. I think there are people who are afraid of hospital billing, afraid of what they don't know, that they avoid going in for treatment. To me the two biggest challenges, Louis, are frankly availability, the capacity to make an appointment in a reasonable amount of time, and second of all, the cost, the unknown cost, whether you're insured or not. And I talk to an awful lot of Vermonters who have just sort of given up on the system and say, well, I have to... Or they have a local federally qualified health center or clinic that they go to and can trust. The availability issue is important. I know seven days last year had written extensively about this, about the wait times for some of these procedures. But they got you in pretty quickly. Yeah, and that's a really complicating issue. Because did they get me in quickly because I'm writing about the health care center? Did they get me in quickly because I was a former chair of the hospital? And frankly privilege should have nothing to do with access. And that's not the way the world works, I understand that. But I think in an ideal health system or educational system, or criminal justice system, any of the complex systems, I'm not against privilege, but it shouldn't be a factor in something that we view as a basic right. You also wrote very recently in a long and thoughtful article in the VTD or commentary talking about non-profit versus profit hospitals, which is in the country, I don't know how the percentages break down, but here in Vermont we essentially think all of our hospitals are non-profit. And you wondered whether or not the University of Vermont Medical System, for example, which includes UVM, Porter, Central Vermont, and then three small hospitals in the New York side should retain their non-profit status. Can you talk to our viewers a little bit about what it means to be a non-profit hospital and how hospitals qualify? The way it's set up in Vermont is, and this goes back quite a ways, you cannot get what's called a certificate of need to start a hospital unless you register as a non-profit. It has to be non-profit. There are no for-profit hospitals in Vermont. Now, obviously the term non-profit and for-profit is open to some interpretation, although technically in statute it's not. They're very distinct, very carefully defined issues. And so by definition, any hospital operating in Vermont in order to maintain its certificate of need has to be non-profit. Non-profit carries some obligations. That means that you treat anybody who presents regardless of their ability to pay. It means although you can have retained earnings for future investment, they're not profit. You can't make profits. And the question that I raised, and I want to be really clear, I was not recommending that either UVM Medical Center or UVM Health Network lose their non-profit status. What I was saying is we have to be more assertive on the regulatory standpoint in understanding what non-profit means and what are the obligations of being a non-profit. In other words, bring that back into consideration at the regulatory stage. Can you talk a little bit about some of the areas that you would have some concern that the University of Vermont Medical Center, for example, has drifted away from its non-profit responsibilities? Well, there are a lot of things, and we don't have the time to go very granular, but pharmaceuticals, I mean, they get a government-enforced discount on pharmaceuticals. They mark them up very considerably. And when asked about that, they say, well, we need that revenue. Well, that was not the point. The point was is that very expensive pharmaceuticals would be made available so people could afford them. There's that. There's the whole issue of retained earnings. And to me, I think one of the most critical things, Louis, is the issue of when you do a deep dive on the expense analysis of any hospital. The question is, how much money in the budget is spent on administration and how much is spent on clinical care? And that ratio is really important in a non-profit. And I would argue that based on the figures that I've seen that are now in front of the Green Mountain Care Board as well, that there are real questions about how well that's maintained. We know that in websites like Charity Navigators, you can go on Charity Navigator and look up, if you're thinking about donating to a particular charity, how much they spend on administration, how much on direct care, where would University of Montt Medical Center fall on that at this point, do you think? If you can navigate the Green Mountain Care Board, you can see for yourself, it's not great. It's not great. Some deep dive analysis has been done on initially 200-odd academic medical centers around the country, and then it's been adjusted for bed count so that it's a fair peer group. And UVM doesn't do all that well. The compensation in the administrative level is extremely high. You mentioned that there, and this may be also part of one care, but that there were 17 administrators whose salaries averaged $480,000 a year. It's 19 who make a total of 16. And when you add that up, I mean these are people like chief legal officer, but it's not clinical. It's all oriented towards the business. And that's one of the major obligations of a governing board who cannot be paid by the way, is to impose on the administration a compensation philosophy. And UVM is very clear, both Medical Center and Network are very clear about their compensation philosophy. And that is they want to be at 50% of compensation for everyone in the country. So they're comparing themselves to Mayo, Kaiser Permanente, Mass General, Sloan Kettering. And I would argue very strongly that you have to adjust it for bed count, you know, how big a hospital is this, and also for the region. You know, so they use this to justify these extraordinarily high. So you mentioned regulatory boards need to look at this. Who is the regulatory board that would be looking at, for example, are they living up to their nonprofit responsibilities? Well, that's a really complicated question because since the Shumlin administration, when the Department of Health was sort of moved into the governor's office and not really clearly put back, and we now have four departments of health, and the Vermont Department of Health, which used to be responsible, sort of is not so much anymore, and then the Green Mountain Care Board came in and they were responsible for regulating. But the question is, who sets the vision and who regulates? And it's devolving to the Green Mountain Care Board to do both. And that's not a bad thing, but it's important to be really clear about it. So the Green Mountain Care Board's mission is evolving as well. Ultimately, you know, you can look at the legal system, which for for profit and not for profit is defined federally, but certificate of need is defined in Vermont statute. And then the Green Mountain Care Board has their own regulatory power, so it's complex. Speaking of complex, and you mentioned Governor Shumlin, of course the One Care program was negotiated and passed under the last part of his administration, and then Governor Scott has carried it forward. So we've had almost seven or eight years now of One Care, and you've written recently about that. Can you talk a little bit about what One Care is and where you think where it is right now? I mean, the philosophical tenet behind One Care, I agree with and a lot of people do, which is you don't charge people to repair them. You create a different incentive where you're paid to keep people healthy. It's, you know, the whole argument I've made before about, you know, do we want to spend immense amounts of money in our emergency room, our prisons, you know, or do we want to move those investments upstream to education, primary care, you know, intervention, and early treatment? And One Care was designed to say to a hospital, okay, in your catchment area you have 70,000 people. We'll pay you this much per person on average to keep these people healthy. Don't send us bills for surgeries and all this other stuff. We're going to pay you a really good amount of money. You're not going to lose money on this, but your job is to keep people healthy. I think the term for this is population health. It is, and also, capitation. Capitation, yeah. And that was the idea, and not a lot of people oppose that. The problem is One Care, Vermont, you know, was set up to do this. And after, I can't remember whether it's six or eight years of operation, health care costs have continued to go up. So the reality is they couldn't deliver on mission. I should, I mean, as Vermonters know, we recently saw huge increases in the hospital insurance rates that the insurers who are still left in Vermont will be charging. And, of course, now they're going to make it very difficult. Yeah, and I have to say, I mean, I have a relative who was just laid off at a law firm, and he was offered COBRA. And for him and his wife and his 12-year-old daughter to have a gold policy is $4,000 a month. That's $48,000 a year. There are a lot of Vermonters who don't make that in a year. But, again, that's a different issue. I think what people often confuse is, they say, oh, MVP or, you know, Blue Cross Blue Shield, they're raising their rates again. If the Green Mountain Care Board is going to give the requested 23, 24, and 28% increase in one year to the three hospitals in the network, it's Blue Cross Blue Shield, which is a nonprofit request to pay those bills. So you can't give the hospitals a huge increase and then not give the insurers enough to cover the cost of those increases. Why do you think that, obviously, one care was going to improve overall health. It was going to control costs. The figures indicate that it's doing neither at this point. Why do you think it has, it is failing, so to speak? I think it's partially because the system itself is failing. I don't think the leadership was ideal. It's vastly complicated by the fact that a lot of the funding is federal. I mean, that's one of the things that we forget in Vermonters. We say, oh, let's just fix our health care system. Well, the reality is, our health care system is part of a national system. You know, what Medicare and what Medicaid are willing to dole out controls a lot of what we can do and what we can't do. So I think there are a lot of reasons why it failed. And as you know, Blue Cross Blue Shield just said, we're not going to be a part of it anymore because, frankly, as a nonprofit, it's not working and it doesn't work for us. And I have to say I respected that decision. You have written eloquently about, and you've mentioned here today about the need to look at the whole system in terms of education, in terms of child development, et cetera, as all part of the health care system. I think one question I would have is, is this putting too much on the health care system to try and fix all of these problems? Or should we be focusing on letting the health care system work on people's medical problems and letting the other responsible agencies take care of these other problems? That's a really, really good question. And one of the federally imposed mandates is that hospitals invest in community and, you know, they do these reports, these community benefit reports, which are pretty useless, frankly, at this point. But the question you raise is an important one to encourage viewers to just Google the term social determinants of health. It's a foundational document that basically says part of population health is access to education, equitable treatment, a social life, access to health care, nutrition, housing. They're all part of the same thing. And then they say, oh, we have a health care problem. Oh, my heavens. We have a public education problem. Oh, dear, we have a housing. They really all are integrated. Somebody living on the streets of Burlington is not going to have good health care, regardless of why they're living there. So we have to look strategically at how these things are interrelated. You're right, Lewis. It is not on the UVM Health Network to solve the issue of homelessness. Although I would say that from a mental health standpoint, we have failed miserably in understanding that there's a legal equity between physiological health and mental health. An awful lot of doctors I talk to when you mention mental health just go, uh, black hole. Well, federally, there's supposed to be parity, correct? Yes. But it's never really worked out that way. Well, let me ask you this. If you were the governor or the secretary of Health and Human Services or had a magic wand to begin to change our health care system, what are some of the things you would do? You've been looking at this now for decades. The first thing I would do would be to convene Vermonters. And I would bring them together from all socioeconomic and I would say, what do you think of the health care system? What's your experience? What could we do better? You know, and I would listen to that and I would evoke story, opinion, and data. And I would put those together and then I would essentially reverse engineer a new system. I would say, okay, what would an ideal health care system look like for Vermonters? What would be the spectrum from a community doc to a small clinic to a federally qualified health center to a community clinic to a secondary hospital to a tertiary care hospital? What would the ideal deployment be? Can I ask you one question? Sure. Because I know that you have written historically about Vermont and have a great sense of the history of the state in recent decades. Was Vermont's health care system broken when you were growing up? You had family doctors in every town. You had a central hospital, I guess, in Burlington. People were able to see their doctor for probably far less than it costs now. Was it broken? To me, it wasn't. I remember going skiing with some friends of mine in the gravel pit behind our house and I broke my arm and I knew I was pretty sure I'd broken it and I went home and mom wasn't there so I walked down to the hospital and I said, my arm hurts really badly. I was skiing and they x-rated and they put plaster on it and sent me home and my parents came home and said, what happened to you? And I said, I broke my arm. And, you know, Dr. Phil or Dr. Calcanny would come any time day or night to your home if you had an emergency. They had office hours. People paid what they could afford and they knew, you know, they might charge our family ten dollars for a visit and someone else too. Now they wouldn't even be permitted to do that. They'd probably have to charge everyone exactly the same amount. And when I was eight years old I was diagnosed with a slipped upper femoral apithesis which I worked really hard to pronounce and I got it wrong and I kept saying slipped upper female apithesis and people would say what? But, you know, and I came to the de Gauss-Brun hospital and I was there for two days and they put a pin in my hip and then I went back to Morrisville. Well, we haven't really even talked about primary care which is sort of the foundation in many ways of healthcare and which is certainly struggling now but, you know, we haven't talked about private equity companies which are swooping in and buying up nursing homes and increasing doctors' offices practices but I think it gets back to this idea of how do we get sort of back to the future to quote the old movie. If we knew that there were certain parts of the healthcare system that were working well and are now we've sort of broken it how do we get back to that and use the best of what used to be and with some of the new developments that we can use now? I think the real sort of existential question we have to ask ourselves unlike 130 other countries in the world many of which are poor we don't recognize healthcare as a human right it's a business and until we ask ourselves and answer that fundamental question we're not going to fix it I don't expect to have a national healthcare system in my life I will be grateful if we have one in my children's life In the meantime going back to my in our last couple of minutes we have going back if you had your magic wand you mentioned convening Vermonters to actually get opinion stories and data where do we go from there what would you do next? I would as quickly as possible develop a primary care deployment system so that people entering the system did not enter an emergency rooms which is the most expensive way in to the healthcare system they enter through a community health clinic or a community doc everybody would have a primary care doc and then based on the acuity or the seriousness of what the primary care doc finds they would be escalated up the system to the appropriate level of care and it may be a regional hospital we don't need to do everything in Burlington it feels sometimes like they want to do it all including primary care so we try and build back the primary care system definitely that to me is the highest priority and how do you attract what would you do about the University of Vermont medical system has it gotten too big or is it about the right size or how would you redirect its energies I don't like oppositional stuff you know I would say look we're in a regulatory position to insist on change let's co-engineer it let's talk honestly about what population health is it's quality, access and cost so let's agree on what that is let's re-engineer the system you will always be a critically important part of it but you may not do everything it seems to me that they do some things very well we have a fine medical school residency programs they've got some great specialists at the University of Vermont certainly I know for my own patients that they have been a huge help when we have very sick, very injured patients I wouldn't argue any of that but the question is as you said can they do everything and still manage to do anything well the other thing I would finish with Lewis is nonprofits don't compete they collaborate so does every hospital have to do joint replacements does every hospital have to do dialysis is every hospital going to have to do cart T-cell technology the first pill of which cost $420,000 or do we leave that to Sloan and Mass General and refer people there and refer people to places that are doing the best work centers of excellence well this has been a wide-ranging discussion we will have to have you back on this show and I would encourage listeners and viewers to read Mr. Schubert's articles in the VT Digger and wherever else he's publishing because there are some of the best articles being written right now in Vermont about health care thank you so much for being here really appreciate it nice to see you