A Cultural Change…

September 20, 2017

“Cultural change is what we need, a cultural shift in the way we look at medicine.” Words to this effect were echoed by many voices at yet another health care meeting I have attended since I last wrote here, yet another meeting about the “all-payer” model. This is the approach designed to focus not on fee-for-service, the current and long-standing model, but on quality of patient care while concurrently lowering the overall cost of health care. Why this new approach is called “all-payer” still eludes me.

So, to the “cultural change” being referenced at the meeting. The discussion was and is important, something that merits thought. It basically speaks to a change in what we “value” in the health care system. For example, currently it is specialists and surgeons who are at the top of the “value” ladder, in terms of both respect and dollars. Primary care physicians? Not so much. Nurses? Not so much. The result? They go elsewhere or they do something else, maybe specialize, and we wind up short on both primary care physicians and nurses.

With or without “all-payer,” it was stated that we need more of both. Increased primary care availability is directly linked to access to care. Having more support staff in primary care physicians’ offices is directly linked to increased educational interactions, more opportunities to help people see how they can and should take responsibility for their own health. Having more of both enables the system to refocus on the beginnings, the earlier stages of potential health problems, and hopefully contain problems, even avoid problems altogether, before they grow to needing the specialists and the surgeons and all those very costly tests that go with a health problem that has taken over a life.

So, whether you agree or not with the thinking, that is how the conversation went, with a lot of heads nodding in agreement… and, understanding that the conversation was slimmed down of many layers of complexity, I confess that it nonetheless made sense to me too.

I need to mention two additional components of the needed cultural change which were advocated. Both elicited that same positive head nodding, and also passion.

One is related to children and what are known as Adverse Childhood Experiences (ACES). These ACES are now recognized as multi-generational in nature and as overarching social factors having an impact on health. They are “experiences” such as abandonment, abuse of whatever description, endlessly angry households, divorce, repeatedly changing homes and schools, not having a home, incarceration of a household member, having not even one person to trust… as examples. They are experiences which previously have been given short shrift, located low on that “value” ladder… “just toughen up and get over it.” Research has now accumulated the evidence of peril in doing that. There is currently an ACES pediatric pilot in Berlin. Their findings can inform work across the state, and will be invaluable to specific individuals as well as to the system as a whole.

The other is related to senior citizens, particularly “long-term care” for seniors. It was pointed out that long-term care insurance is very, very expensive. As a result, for many, perhaps most, long-term care “insurance” ends up being Medicaid, once of course a person’s assets have been spent down to nearly nothing. This is not a good situation. For those not forced to spend themselves down and out of their homes, Vermont does have its Choices for Care program as well as SASH (Services and Support at Home). These programs have worked very well, so well that nursing homes have empty beds that they are looking to fill. At the same time, seniors, for whom it is a good and happy choice, have been able to stay in their homes… which was touted at this meeting as less than half as costly as being in a nursing home. Again, this is an issue much more complex than the surface suggests, but the situation which sparked this particular piece of the conversation should not be ignored, namely that Medicaid has become the de facto long-term care insurance. Not good.

As always, if you would like to talk about this or any other legislative issue, please do not be shy. Contact me by email at, by phone at 802-862-7404, at my home at 232 Patchen Road, on the street, or at Trader Duke’s from 8:30 to 9:30 on Saturday mornings.

If you would like further information about the state of our vital events records, or if you would like to discuss any other issue or concern, please let me know.  Please contact me on my email at or on the phone at 862-7404; or at Trader Duke’s on Saturday mornings, between 8:30 and 9:30; or on the street when I am out with my dog.


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