Vermont hospital executives say there’s nothing new in an 80-page report released by the state last week confirming patients face months-long waits to see specialists, a problem that has long plagued hospitals here.
Hospitals face a range of challenges in reducing wait times, according to executives, including a burdensome regulatory scheme from the state that slows new building projects to a crawl, and an inability to attract new doctors and nurses to the state because of relatively low pay, a poor job market for spouses and scarce housing.
“This is not news,” said Claudio Fort, president and chief executive officer of Rutland Regional Medical Center. “Many of my colleagues and I have spoken about this for years. If Vermont’s nonprofit hospitals had not stepped up to the plate, over and over, there literally would be no access to specialists, but we do recognize more needs to be done.”
The Burlington Free Press reported on long wait times to see specialists as far back as 2017, and has written about the subject repeatedly.
The state makes a series of recommendations in its report to improve the wait time situation, including:
- Reviewing improvements to the regulatory framework.
- Addressing workforce problems by establishing a physician assistant program and expanding telehealth coverage.
- Promoting referral “best practices” between primary and specialty care to streamline appointments.
Secret shopper effort rubs hospitals the wrong way
Michael Pieciak, commissioner of the Department of Financial Regulation, responded that the state’s analysis did show wait times averaging about 100 days to see a specialist as far back as 2017.
“The report confirms what (hospital administrators) have known for a long time,” Pieciak said. “We need to do something about it. That’s the key here, giving our department authority to track (wait times) and provide consumers some transparency.”
The state report is the result of an investigation launched in September by the Agency of Human Services, which was joined by the Green Mountain Care Board and Vermont Department of Financial Regulation. It included information gathered from public forums, by soliciting written accounts from patients, and by talking to medical providers from around the state.
In addition, the report includes data from 1,000 so-called “secret shopper” calls, with state employees asking for appointments in 21 different specialties without revealing their true identities in order to mimic the experience of an average patient.
Hospital executives were critical of the secret shopper effort, saying it took place during the Delta/Omicron surge and at the peak of staff shortages, consuming “precious staff time” while hospitals were inundated with patients.
Pieciak responded that 92% of the calls were made in December, “before the Omnicron wave hit,” and that the program was wrapped up in the first week of January. He added that most calls took less than two minutes and that half of that time was typically taken up by being on hold.
“We did think it was worth getting a snapshot, how is it if you’re a Vermonter trying to call and get an appointment?” Pieciak said. “Vermonters were obviously trying to access care during the pandemic, including in December 2021.”
Average wait times
The state investigation calculated wait times in a variety of ways:
- A consultant found that the average wait between receiving a referral from a primary care doctor and seeing a specialist took approximately 100 days for 2017 through 2019.
- The secret shopper calls revealed the average wait times for all specialists in Vermont averaged 61 days, but varied widely by specialty, from 29 days for general surgery to 140 days for dermatology.
- The secret shopper calls also revealed that average wait times for a specialists averaged 65 days across different hospitals in the state, but varied widely by specific hospitals, from 26 days at Springfield Hospital to 101 days at the University of Vermont Medical Center.
The report also concluded that Vermont fared relatively poorly compared to surrounding states on wait times, finding, for example, that half of Vermont specialist appointments were not scheduled within two months, compared to about one-third not scheduled within two months for “peer states.”
No news here say hospital execs
The hospitals responded to the report within hours of its release last Wednesday, Feb. 16, arranging an online press conference with a group of chief executive officers as well as a chief medical officer. One of the first criticisms made of the report is that it did not reveal anything that hasn’t long been known.
“These problems are extremely complex and have no easy or simple solution,” Fort said. “Doctors and patients have been aware of and have been addressing the challenges for many years. The (state) study begins to identify challenges, but does little to diagnose root causes or solutions.”
The state report does identify “potential factors” influencing wait times, including:
- Workforce availability & composition — Demand may exceed supply for certain specialties.
- Distribution of care — Care that should be housed in primary care delivered in specialty offices, and specialists caring for patients who could be managed in primary care.
- COVID-19 — Wait times were long before the pandemic, but grew longer because of staffing shortages and deferred care caused by the pandemic.
- Technology — Slow rate of adoption of telemedicine, e-consults and office hours, plus problems with availability of electronic health records across sites of care.
- Complicated referral process — Numerous steps and requirements create multiple points for failure.
The state report also recommends some “new initiatives” to address the wait time problem:
- Tracking & Reporting — The Department of Financial Regulation will request statutory authority to track and publicly report wait time metrics for providers across Vermont on a regular basis, including both hospitals and independent providers.
- Hospital Review of Wait Times — Hospitals either establish a board-level committee or designate a board member responsible for participating in monitoring wait times at their facility and continues improvement in patient access.
- Coordination — Hospitals and independent providers should regularly collaborate to share information and successful strategies designed to improve wait times. They should also make “operational changes” to speed the referral process.
Dr. Kat McGraw, chief medical officer at Brattleboro Memorial Hospital, said Vermont’s hospitals already have been supporting each other’s efforts to combat long wait times, sharing best practices and avoiding duplicating efforts.
“I know as a physician that long wait times are not helpful for anyone, patients or providers,” McGraw said.
‘Inappropriate and confusing’ comparisons
Hospital executives also criticized the study for failing to address the constraints placed on hospitals by “the most rigorous regulatory framework in the country,” in the form of the Green Mountain Care Board, and made “inappropriate or confusing” comparisons to hospitals in other states with little regulation and countries with completely different health care systems.
Dr. John Brumsted, president and chief executive officer of the UVM Health Network, took particular aim at Vermont’s certificate of need process, which requires any significant health care project to be approved by the Green Mountain Care Board before it can move forward.
Noting that UVMMC had submitted a CON to build more capacity for dermatologists — one of the specialties with the longest wait times — Brumsted said it takes months to get regulatory approval. It took two years for the Green Mountain Surgery Center in Colchester, a multi-specialty practice, to get its CON from the Green Mountain Care Board.
“If we were in New York or New Hampshire or Maine, we would go out, do an internal review and go find the money and build that facility (for increased capacity for dermatology),” Brumsted said. “In Vermont, you have to add months for the CON process, in some occasions a year or two to get your regulatory approval. That’s part of what we live with in Vermont.”
Pieciak responded that “it’s always important to evaluate ourselves relative to peer states.”
“If we’re not doing as well we should be figuring out why that is and improve it,” Pieciak said. “If regulatory constraints need to be improved on, that’s valid, but it doesn’t mean we shouldn’t compare ourselves to other states.”
One neurologist. That’s it.
Shawn Tester, chief executive officer of Northeastern Vermont Regional Hospital in St. Johnsbury, said the report didn’t put enough emphasis on the challenges faced by rural hospitals in addressing wait times.
“We have one neurologist in this little corner of the state, we don’t have a second,” Tester said. “That’s just the way it is. We can’t support or afford a second neurologist.”
Tester said his hospital has only two general surgeons on a team that should have three surgeons.
“We have been recruiting for that position for over one year,” he said. “Just last month we made an offer. We were excited about the prospect until she called us a week later and said she accepted a position out of state for 30% more than we could offer.”
Tester pointed to a lack of housing as another big challenge for Vermont hospitals trying to hire staff. He said Northeastern had to rent a dormitory from a local high school to house its traveling nurses because there is “literally no place for them to live when they come to work at our hospital.”
Pieciak pointed out that the executive summary of the survey acknowledges that some of the wait times are likely driven by a lack of supply relative to demand.
“That’s an important point, corroborating what Shawn is saying,” Pieciak said. “If you can’t get enough physicians for a specialty that contributes to wait times. We found that to be the case for at least four different specialties.
Another of the state’s conclusions in its study is that Vermont needs to clearly define exactly how to measure wait times, as different criteria can lead to different results.
“There’s no universal metric for wait times,” Pieciak said. “We can’t pull something off the shelf and say, ‘How do we compare?'”
Hospital executives agreed that Vermont needs a better definition of wait times, with a caveat.
“The real issue I would say in all of that is what information would be useful and how can we get that information made available as efficiently as possible,” Brumsted said. “The last thing we can handle is more administrative burden. That is just the proverbial straw.”
Contact Dan D’Ambrosio at 660-1841 or firstname.lastname@example.org. Follow him on Twitter @DanDambrosioVT. This coverage is only possible with support from our readers.