In Brief:
Nearly 3 in 10 Americans lack access to primary medical care, which is essential to detecting chronic health problems in early, treatable stages, if not preventing them altogether. Caring for the millions who have chronic diseases already accounts for 90 percent of the nation's $4 trillion in annual health-care costs. Dramatic increases that lie ahead in the population past the age of 50 will bring new demands.
Since 2008, Vermont has been working on an approach to primary care that has unique elements, not the least of which is consistent support from state leadership and the legislative branch. Vermont’s Blueprint for Health model begins with an expanded concept of what “primary care” encompasses, one that in some ways anticipated recent calls to transform the field.
According to the Blueprint’s most recent report, which was presented to the Legislature in January, medical and pharmacy claims are 30 percent lower for individuals receiving care through its primary-care practices than for those treated elsewhere.
Pat Jones, an official with the state’s human services agency, worked for the Blueprint when it first began to reach across the state and now supervises its operations. “I don't think we have a corner on this work by any means,” Jones says. “But there are some factors at play that have made it more likely that we're able to implement something like this.”
An Elegant Design
The Blueprint for Health was first introduced in a 2003 executive order from Jim Douglas, then Vermont's Republican governor, as a plan to improve care for chronic diseases. The program has been in state law since 2006 and was expanded to include primary care in 2008.
Vermont law requires insurance providers that operate in Vermont — including private companies, Vermont Medicaid and Medicare — to pay additional monthly fees beyond reimbursing caregivers or services. The fees are based on the size of the population in Blueprint practices and are used to help caregivers incorporate services that address complex health needs.
The services are delivered by two types of entities operating in tandem. A Patient-Centered Medical Home (PCMH) is a primary-care practice that provides comprehensive, continuous care in partnership with a team that can help patients address physical and social impediments to their health. Vermont now has 135 PCMH practices that care for 70 percent of its population. They range from single-person practices to hospital-based teams. To receive Blueprint funds, a PCMH must be accredited each year by an independent quality assurance committee.
All physicians and their patients have access to a multidisciplinary Community Health Team (CHT) comprised of staff that includes social workers, nurses, registered dieticians, care coordinators, counselors and health coaches. CHTs are funded by supplemental payments from carriers and provide their services at no cost. A diabetes educator or dietician can meet with a patient with uncontrolled diabetes to help them get on track. Social workers and counselors can help with personal and family problems, or mental health.
There are 13 health services areas in the state, and each has a CHT. Team members may be embedded in practices or operate from outside then. The community in a service area is allowed to take the lead in the composition of its team, to ensure it meets local needs. There is a program manager in each service area, also funded by the Blueprint, to coordinate the work of the health teams and the care homes.
To some, the Blueprint is complicated, says John Saroyan, the physician who serves as its executive director. “To those of us who have grown to know it very well, it’s elegant,” he says.
Is It Working?
Health and economics are intertwined. The theory of the case, Jones says, is that coordinated care will reduce the need for the most expensive care, such as emergency room visits or hospital stays. There should be a return on investment for the monthly per-patient fees that keep the Blueprint functioning.
Chronic health problems such as diabetes, cancer and heart disease that affect 60 percent of the population have roots in factors ranging from diet and exercise habits to stress and social disparities. A standard visit with a doctor couldn’t be expected to encompass such things, but a patient-centered, “whole-person” approach might.
A 2016 study did find that expenditures were lower for persons who received primary care in PCMH and CHT, and that for every $1 million invested in the Blueprint initiative, medical expenditures decreased by nearly $6 million.
The ”ecosystem” that the Blueprint made possible creates opportunities for practitioners and health teams to bring challenges that are baffling them forward and tackle them together, Saroyan says. His tours of health service areas have brought him into contact with health team members who have been developing knowledge of their communities and each other’s capabilities for more than a decade.
There’s anecdotal evidence that the Blueprint could play a part in retaining and recruiting primary-care physicians. Hannah Ancel, program manager for the Morrisville Health Service Area, has had providers tell her that they can’t imagine going back to a situation where there’s no one to help their patients with issues like food insecurity.
Even with these resources, substance abuse and mental health issues are on the rise in Vermont, as they are throughout the country. The state's in the middle of the pack in regard to cancer mortality rates. The Blueprint isn’t a panacea, Saroyan says, but its achievements and durability continue to inspire participation by caregivers and support from the lawmakers.
Miles to Go
Vermont isn’t the only state to emphasize access and whole-person care, but the model is far from a national trend. In February, the Milbank Memorial Fund published a dashboard tracking state-by-state progress toward high-quality primary care. It was accompanied by a report warning that primary care in the U.S. is in crisis due to factors including workforce shortages, underinvestment and neglect of research regarding delivery, and payment models.
America’s health system is severely out of balance, says Christopher Koller, Milbank's president — more focused on specialty care and pharmaceuticals than any other system in the world.
“Primary care is the only health service where the more we have, the better our health and equity results are,” Koller says. “We can’t say that about anything else.”
