The Board of Directors of the Mad River Valley Health Center, Inc. has reached out to the Green Mountain Care Board with the following statement and set of questions.
Our organization is the owner of the building wherein Central Vermont Medical Center (CVMC) currently operates the Mad River Family Practice (MRFP), its primary care clinic. We have had several meetings with representatives of both CVMC and the UVM Health Network to request additional specifics as to their decision to close the clinic here.
CVMC and UVM remain unwilling to provide us with any specific financial information, other than to tell us that the Waitsfield clinic is their biggest losing clinic and that is part of why they are closing it down. They would only tell us that their costs of running this practice are 46% higher than any other primary care location but declined to tell us what their actual claimed loss is.
The clinic here in the Valley has a unique background. In 1981 when the only doctor in the Valley announced that he was leaving, residents raised over $150,000 to purchase his practice and the building it was located in, forming the Mad River Valley Health Center, Inc. as the entity to run it. Eventually, the doctor hired by the Health Center bought the practice, but the building remained owned by the Health Center. When the original building became too small to accommodate the practice, Valley residents again stepped up and raised over $1,000,000 in 2004 to build a new building to accommodate the practice. For so many here in the Valley, the clinic here is one they feel that they have paid for and to have the clinic closed by CVMC without any apparent consideration of the consequences is incredible upsetting and frustrating.
While we understand that some of the other proposed cuts CVMC and UVM are planning to take have significant impacts on other Vermonters, for those of us in the Mad River Valley, closing the clinic is devastating. On behalf of the residents of the Valley we have a number of specific questions:
1. In response to the Green Mountain Care Board (the Board) order (the order), CVMC proposes (among others cuts) closing the Mad River Family Practice (MRFP) in Waitsfield. This is the only local family practice serving a 4-town community of 6,000 full-time residents. The MRFP has approximately 3,000 patients and approximately 500 (or more) patients on a waiting list.
CVMC has announced through meetings, press releases and community updates that closing the MRFP and transferring 3000 patients to other primary care facilities will not impact these patients’ access to primary care. This closure will have minimal impact on net patient revenue (NPR) and will reduce access to primary care for these patients.
Assuming all providers from MRFP are transferred to other primary care facilities, and there remains primary care capacity to continue the same level of care for these 3000 patients, there will be no net reduction in NPR, although there will likely be expense reductions.
Assuming all providers are transferred, not all patients will be able to drive the 60-90 minute (in good weather) round trip for primary care (working families, those who work in the Mad River Valley, seniors, the disabled, those who don’t drive/have a car (there is no public transportation in the Mad River Valley)). This is a reduction in access to primary care.
If not all providers are transferred, there will be a reduction in access to primary care.
What is the goal of closing the MRFP? What is the benefit to UVMHC/CVMC?
How does that compare to the loss of primary care access to the 3000 patients in their community?
What are the implications for the GMCB work in “improving access, affordability, and quality of health care to improve the health of Vermonters?”
How does this impact other Vermont State initiatives working to improve primary care access – AHEAD, Blueprint, etc.?
How does this impact the Oliver Wyman (OW) consultant recommendations that “Community-based care, primary care, mental health care, and housing capacity should be increased to divert care to lower cost settings?”
2. The order states UVMMC has opportunities for improvement in mental health and primary care and notes that these improvements reduce costs ‘by reducing avoidable and unnecessary utilization and shifting care to more appropriate and less expensive settings.’ Said another way, it is common knowledge in the healthcare industry (multiple references are available) that a reduction in primary care results in higher medical costs as patients will use urgent care and emergency departments for primary care. Patients will also wait until they are sicker to seek care which increases preventable hospital admissions. This increased utilization in higher cost settings will increase NPR.
What analysis has been done to determine the net increase in NPR resulting from the closure of the MRFP?
3. CVMC has responded that for patients unable to drive to other primary care facilities, telehealth will be available. Telehealth visits are currently charged at the same payment rate as office visits. Assuming the same utilization rate by patients, only split between telehealth and office visits, there will be no impact on NPR. Furthermore, many patients in the Mad River Valley have limited access to the internet and many also have limited cell service.
How has this been factored into net NPR change or cost/benefit analysis of closing the MRFP?
4. The Order states the ‘Board must execute its duties consistent with the principles of [Vermont] health care reform…’ including: ‘Primary care must be preserved and enhanced so that Vermonters have care available to them, preferably within their own communities.’
How does the Board achieve this principle despite UVMHN proposed cuts to the MRFP?
5. The order and (OW) report offer compelling evidence that UMMMC is not efficiently operated.
Improving administrative efficiency would reduce expenses and theoretically increase margins. Improving clinical productivity and efficiency would reduce expenses and increase margins if staff are reduced to eliminate the resultant excess capacity. Considering clinical shortages in Vermont and lengthy wait times, the improved productivity and efficiency creating excess capacity could instead be used to treat more patients with the same number of clinical staff. However, this would increase NPR.
Does the board assume the NPR increase due to this resultant excess capacity would be within the 3.5% limit on NPR in the order? If not, how does the benefit of reducing wait times compare with the additional NPR?
6. Reducing wait times and reducing the number of potential patients on a family practice (or any practice) wait list would likely result in an increase in the insured patient population. These additional patients would account for an increase in the overall NPR. However, they would not impact the age-adjusted per capita NPR.
What analysis has been done to determine the net increase in new patient population from those waiting for care and/or on wait lists? How is per capita cost/NPR factored into the 3.5% cap? Does the Board believe the increase in NPR due to the increase in patient population can be included within the 3.5% cap?
7. The Oliver Wyman report (August 2024) includes many short-, medium- and long-term recommendations for hospital transformation in support of improvement of Vermont’s healthcare system.
How have the recommendations for improvement and their timeline for implementation been factored into the 3.5% cap on NPR?
8. The current lease that CVMC has with the Mad River Valley Health Center, Inc. runs through September 2026. CVMC has acknowledged that they remain liable for that lease obligation and have stated that they will honor the terms of that lease. The Board’s September 2024 order states that UVM “has unacceptable cost management and operational expense growth.”
How does paying for a lease on a building that will be vacated reduce CVMC’s ‘unacceptable cost management’?
9. There is a long involved process for any new health care project to obtain a Certificate of Need from the GMCB prior to implementing that project.
Why is there not a similar process when health care services are eliminated as is being done here in Waitsfield?
Without specific numbers it is impossible to determine the real savings that CVMC might generate from closing the MRFP. Extrapolating some of the estimates from CVMC’s figures surrounding its inpatient psychiatric unit, it seems likely that closing the MRFP will result in less than a 1% reduction in their NPR yet it will eliminate 100% of community based primary care access for 3000 people.
The Board of Directors looks forward to answers to these questions so that we can provide the residents of the Mad River Valley a clear understanding of the implications of closing the MRFP.
Note that in response to the above, the Chairman of the GMCB did respond thanking us for our email and our advocacy for the community and its patients. He did indicate that he has been speaking with UVM leadership about this and related issues and has sent them a series of questions similar to many of those noted above. He indicated that he would reach out to us when they hear back.
Return to Clinic Closing.