Legislative Update From Gary Gilbert

This weekend I had the unfortunate opportunity to see Vermont’s medical system up close and personal. In one 30-hour period I saw my family doctor, the emergency room, and several specialists before being admitted to the hospital. I was fortunate to have health insurance paid partly by my retirement plan and partly by myself.

The primary care physician did the initial screening, tests and diagnosis, and called the ER, which was prepared when I arrived with the test results. They contacted the specialists who performed other tests, identified the specific problem and began treatment. I was admitted to the hospital, had my progress monitored, taught how to use the new medications, and scheduled for follow-up care. It was a seamless system.

The reason I’m telling you this story is to make a point about how systems can function with greater efficiency and less overall costs if each of the parts are considered as part of the whole rather than judged on their own merits. There may be times when allowing advantages for one segment of the system will make the goals for that system more difficult to achieve. And there may be times when providing additional supports for a small segment of the system may make that system as a whole, more efficient and less expensive.

For example, quality hospitals must have the staff and equipment to deal with any issue 24 hours a day. They must maintain a capacity beyond what may be in use at any given time. They have the expense of being ready for anything. However, stand alone ambulatory services, like eye clinics or CAT scan facilities, can schedule staff time and patient visits to maximize the use of resources. This allows them to have less over- head and a greater profit margin and to draw potential clients from the higher cost hospital that serves everyone. This duplication weakens the comprehensive health care system and increases the overall cost of health services as it essentially shifts the total costs to all the remaining parts.

On the other hand, if Medicaid reimbursement rates were increased for those primary care physicians who practice in less affluent communities, it may help them to continue to provide the primary preventative care that will reduce the need for more expensive later care. In this case we are subsidizing doctors, patients, and those who are paying the bills through taxes or increases in their own health insurance costs. But we would also be reducing the need for more expensive services. Similarly, additional expenses to institute a comprehensive electronics medical records program and the use of the very high speed Internet would benefit primary care physicians, hospitals, and patients.

How do we want to address the educational system? Could there be instances when the goals of one school district will make the goals for many others difficult to achieve? Could there be times when additional supports for a given school make the system as a whole, more efficient and less expensive? Some of our school districts are like our hospitals, where multiple services are available. Some are like the primary care physicians operating with fewer resources trying to provide quality education for their students but who must be able to access highly qualified specialists when needed. How do we go about re-designing education to be as efficient as possible? Would the use of a common web-based software that included one common financial and budgeting and student records system enable schools and the department of education to share information and make choices based on consistent information? Could bulk purchasing, legal services, high cost learning specialists, food and transportation services be coordinated at a district level or larger? Should schools be considered as the primary care physician, given support to deliver care locally and having access to hospital level services as needed or should they be viewed as stand-alone operations that drain resources and increase costs? How does and should education relate to other public services like Human Services?

These are some of the issues that the House Education Committee is investigating and committed to addressing this year. In addition there is the ultimate question of where decision-making authority should be placed. Sharing information and services is only a concept unless it is clear who will decide how these services are produced, made accessible, and how they will be paid for. Every reform effort since the early 1900’s has failed because every community wanted to be able to make those decisions for themselves while accessing the common benefits designed for all. This needs to change.

What do you think? I can be reached during the week in Montpelier by calling toll free at the State House 1-800-322-5616, by E-mail at ggilbert@leg.state.vt.us, or at my home answering machine at 849-6333.

Gary Gilbert
State Representative
Fairfax/Georgia