EDITORIAL: Simplifying health care: A small step may help Vermont patients get better care while costing less

Sept. 20--Though he may have vastly underestimated the knowledge of pretty much all Americans, the president did get one thing right when he proclaimed, early in the GOP's 2017 Obamacare repeal effort, that "Nobody knew health care was so complicated." This much of the president's statement was completely accurate: health care is complicated indeed -- at least, in the factors that make it unreasonably expensive in the United States. They are many, complex and, in some cases, seemingly nonsensical.

Among the more Byzantine are the rules concerning Medicare and Medicaid coverage. The two so-called "entitlement" programs govern health-care access for millions of Americans -- Medicare providing coverage to seniors and Medicaid largely to lower-income Americans. In addition to the guidance one might expect of a huge federal bureaucracy such as the Centers for Medicaid and Medicare Services, these programs also fall victim regularly to the whims and political logic of Congress. All that results in some policies and guidelines that might have seemed like a good idea to someone at some point, but which, in real life, simply cause headaches and heartaches for program recipients.

One such regulation is Medicare's rule requiring patients stay at a hospital for at least three consecutive days before the program will pay for them to be treated at a skilled nursing facility. The rule dates back decades, from a time when the conventional medical wisdom was that if someone needed care, the best place for them was a hospital. But hospital care is expensive, and current trends call for hospitalization only in the direst of circumstances. Insurers don't want to pay for hospital care and because, especially for the elderly, longer stays can have as many downsides as positives, it often makes sense to allow a quicker transition to assisted-living or skilled-nursing facilities.

The rule is outdated and costly. Longer hospital stays are unduly expensive, and if insurers say they won't pay for the extra days, the patient is put on the hook to either pay for those days or not qualify for coverage of the needed care to follow.

But because of the Affordable Care Act, patients in some areas can bypass that rule and get the proper level of care when they need it. Remember, the point of the ACA was to fundamentally change the health-care system to reduce costs, largely by encouraging access and getting people preventive and routine care that will keep them from becoming sicker, requiring more-expensive treatment.

Thus, the ACA encourages the implementation of new health-care models, such as accountable-care organizations. Under that model, care providers get a set amount per patient per year. Instead of rewarding hospitals for pushing tests and procedures, it incentivizes them to provide care more efficiently, while keeping the patient healthy.

A year ago, 10 Vermont hospitals, along with other health providers, agreed to form such an organization: OneCare Vermont. All the state's Medicare and Medicaid patients are included in the arrangement. And one of the benefits is that OneCare Vermont can override Medicare's rule governing how long a patient must remain hospitalized.

Last month, OneCare granted Brattleboro Memorial Hospital and three other area facilities a waiver that decreases that requirement to one day, something a spokeswoman said could potentially affect 5,000 patients.

In the overall scheme of reducing health-care costs, it's still a very small step, one affecting only a tiny fraction of people. But every step counts, and the larger picture is that OneCare Vermont and other accountable-care organizations -- or other industry models not yet available -- may hold the key to effectively reducing costs industry-wide.

Health care may be complicated, but some simple notions, such as giving providers a reason to keep people healthy, can help.

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