#2 - Vermont Woman Special Series: Green Mountain Care Board Profiles

Con Hogan - Seasoned Elder of Green Mountain Care Board

by Roberta Nubile

Con Hogan

Cornelius Hogan is a modern renaissance man. His experiences range from being a corrections officer to a musician, from published writer to corporate head, from farmer to government official. Widely known in Vermont by his nickname, Con Hogan is now the wise and seasoned elder of the Green Mountain Care Board, helping to turn Vermont's burgeoning health care reform into public reality.

When I drove up to Con and Jeannette Hogan's home on a dirt road in Plainfield, I looked for the horses I had read about on Con's website. Seeing none, I assumed he no longer had time for horses. In fact, the couple still runs East Hill Farm's boarding and training stable with the help of their daughter, Ruth Hogan-Poulsen and trainer Kathie Moulton. I got to see the horses after the interview, pastured just down the road.

I was there to ask Hogan to help SET ITAL Vermont Woman END ITAL readers more deeply understand the current health care crisis, and whether he could interpret new terminology. He perhaps knew how the board intended to fix the crisis and, frankly, whether it was really fixable. What immediately becomes apparent when talking to Hogan is the breadth of experience that informs his reflective wisdom.

Losing Flexibility

Hogan's version of the health care crisis goes like this: "The cost of health care has risen so fast," he told me, "it is on the edge of affecting the quality of health care. We haven't felt it yet, but it is coming. The other problem is that even though we have made some gains, there are still thousands of people in Vermont who have no coverage. Those who have coverage are being priced out of it. And they don't have 'comprehensive care' anymore. It is so big that it represents $5.2 billion dollars in Vermont. That's money out of our wallets—20 percent of Vermont's total economic activity.

photo byJan Doerler
Con Hogan pauses for a chat in his home office in Plainfield.

The cost of health care is now squeezing out wages, childcare, programs for the poor. Vermont is losing its flexibility to deal with problems it has."

Hogan knows Vermont's problems firsthand, as the longest-standing secretary of Vermont's Agency of Human Services, from 1991 to 1999 under two administrations, working first with Republican Gov. Richard Snelling and then with Democratic Gov. Howard Dean. "Due to heath care costs," Hogan said, "we are losing the ability to stay even, or make progress. Not just in human services, but all across government."

Looking at the scope of Hogan's work in human services and other areas, we see many examples of his leadership: his ability to think out of the box, and his courage to try new approaches to old problems. This is heartening, as this practiced leader takes on health care. One example of Hogan's leadership is in his passion: children's welfare.

"I was unexpectedly asked to head up Dick Snelling's transition team, and he asked me to take on human services," said Hogan. He didn't think he was qualified, or more accurately, he wasn't willing to simply slash items on the budget. So he asked himself, "Was there a way to broaden our focus? To have more of an impact with long term results?'"

Out of those questions came the program, "Success by Six," described in the 2004 Agency of Human Resources annual report as "a unified strategy to promote better outcomes for all Vermont children and their families." The program's measurable outcomes included the number of home visits after birth offered to every Vermont mother, increased numbers of Vermont children with health insurance, a decrease in child abuse and a decrease in children's lead levels. Lead is known to affect brain development in children, and lead paint is often found in Vermont's old houses.


It Takes a Village

One unique aspect of Success by Six was its goal to engage the larger community, including churches and schools, to help achieve the state's desired outcomes. Hogan said, "If you can break info down to local communities, so they can begin to grapple with the problems, so that problems are not all being dumped on the dumped-on front door of government agencies, then you have done something important."

Hogan said his longevity as secretary of Vermont Human Services accounts for the success of the Success by Six program. "I had a chance to really work with folks. It started as a theory, but I could follow it through."

Hogan eventually took this collaborative form of work into communities abroad. He travelled with Jeannette to Norway, Israel, Northern Ireland, Scotland, Chile and Australia, introducing this fresh perspective of shared responsibility in dealing with community issues.

The concept of shared responsibility permeates much of Hogan's work, and we can see it in his view of health care reform. Community is his bottom line.

Hogan said that three opportunities influenced him, combining to create his present work and perspective. First came his efforts during the Dean administration to help establish the Vermont Health Access Plan (VHAP). Next came the influential book, At the Crossroads: The Future of Healthcare in Vermont, that he co-authored with Deb Richter, M.D., of Montpelier, former president of Physicians for a National Health Program, and her advocate husband, Terry Doran. Hogan also began to spend time consulting in other countries.

"I came out of that period with a great sense of frustration and foreboding—that this thing is out of control, and would get worse," he said about writing the book, which was published in 2006. "I spent ten years working overseas, mostly in Europe. Every country had some form of single payer universal health care system—all different, which is the interesting thing. But their per capita costs were about half of ours, and the quality of care was better.

"The work in health care reform during the Douglas administration by Peter Welch and others was influenced by At the Crossroads. Every committee member was carrying that book; it was underlined, and people tabbed it. People got it." (Legislator Peter Welch of White River Junction, first elected in 2006, now sits in Vermont's sole seat in the U.S. House of Representatives.) That experience, along with unique perspectives he gained, has shaped Hogan's present view of what is not working in Vermont health care, and how it can be improved.

Hogan's Road to Health Care

Catamount Health Care, which came out of that time, wasn't all that was hoped for by those in favor of affordable health care for all in Vermont, and a proposed single payer bill failed. But these early efforts, and rumblings and yearnings for reform, led the way for the controversial health care design study by Harvard economics professor and health policy expert Dr. William Hsiao. Hogan was instrumental in suggesting the Hsiao study, which provided three options for health care: no change, pure single-payer health care, and modified single payer.

"The general gist of the study," said Hogan, "is that if it were a pure single-payer system we would have $500,000 savings off the cost of $5.2 billion. And it would be comprehensive care. Hsiao's mistake," Hogan continued, "was that he promoted a particular way to pay for it. He proposed a 12 to14 percent payroll tax, and politically that didn't fly, and it got put aside. Act 48, the healthcare reform bill that passed in 2011, establishing a single payer system [in 2017], was then created with Anya Rader Wallack doing that work. It's a really powerful piece of legislation."

Wallack went on to become the chair of the Green Mountain Care Board (GMCB); she will step down in September, replaced by fellow GMCB member, Al Gobeille.

One of the tenets in Hogan's SET ITAL At the Crossroads END ITAL book is that health care is a shared service, that it is population-based, not individually based—more like police, emergency or roads than private enterprise. It is a huge concept and, according to Hogan, "A lot of people have trouble crossing that bridge. Health care is a public good. And if you can accept that we are all in this together—sometimes we are healthy, and sometimes we are unhealthy—then you are in a position to talk about really covering everyone with comprehensive care. It's a different ballgame than the way health care started in this country."

After World War II, when companies were having trouble hiring people, they started offering health care as a benefit to attract the workers they needed. That worked for a while, but in the last 20 years, as costs have increased, benefits start to slide, priced out of the market.

Hogan said, "Businesses began cutting their care benefits. The government is not paying its fair share. If we can get to the point where Vermont has a system that controls costs and keeps quality, you couldn't keep business out of Vermont. We would have the greatest economic renaissance the state has ever seen. Suddenly business won't have to pay the primary cost of health care for all their employees." Hogan believes businesses would then be freer to reward workers with pay raises.

"The multiple payment system we use today requires a horrendous amount of transactions, paperwork, and represents total administrative costs of 20 percent of health care; 10 percent is for transaction costs, alone. Just finding out how people pay [for health care], costs approximately over half-a-billion dollars." With annual healthcare costs of $5.2 billion, Vermont could find that extra money comes in handy.


Con, Jeanette, Rain
Con and his wife Jeannette stop to visit their favorite horse ,
Watermark (aka Rain), at their East Hill Farm stable.

The Dread Word

How is this going to be paid for? With taxes?

"We will be substituting tax money for [privately paid] premiums, and taking advantage of a generous federal bill," said Hogan, admitting, "All the numbers aren't laid out, but there will be substantial tax credits provided as you move down the economic scale. Add that to savings in administrative costs, and our belief is, as initial numbers are showing already, we can cover everyone with universal, comprehensive coverage with the same money we are spending now on an ineffective system."

How do we get from here to there, from theory to practice?

"It is a two-phase process," answers Hogan, whose horsemanship comes into play. "First is getting hold of the existing system. It's like riding a crazy bronco. It's regulating and controlling hospital budgets, insurance costs, certificate of need work—and that is for the existing system.

"Then it's beginning to do the planning and homework for the theoretical new system of 2017" when a single-payer system is projected to be in place in Vermont. "Most of our work up to this point has been, and still is, to bring the numbers down, to very close to or at the level of inflation, to really begin to put together a program for the future," Hogan says.

"A lot of it is not our job," he says on behalf of the five members of GMCB. "We have the Shumlin administration, we have task forces. Our job is virtually at every step, to approve, disapprove, re-adjust. I have been in an out of government, and have never seen a singularity of purpose across the whole horizon as I do now in the health care reform movement."

Hogan admits that no one knows what the collection process for revenue will look like, or how exactly Vermont's health care will be paid for. But he counts this progress: "The thing that has changed in the minds of Vermonters, based on our polling, is that they now understand we cannot keep going the way we are going. There are people who currently have great insurance. Change is hard for everybody. My thinking has not changed, but I am willing to chase this thing—as other board members are—to the best possible situation we Vermonters can get together."

Immediate & Long-Term

While looking at cost containment is the present task of the GMCB, it is already phasing into payment reform studies (see sidebar 2) that will provide the infrastructure or system under which to operate most efficiently. "There has never been an infrastructure to do this before," said Hogan. "That is the value of having an independent board. We can chase these things, and see what they mean, and make them bigger.

"One of my passions is the idea of community assessments (see sidebar 1). Why is this important? Because this is a move toward 'population health' in a region. That is the connection we want to make with our hospital budgets."

Under the terms of the federal Affordable Care Act, or Obamacare, Vermont had to make a choice for creating a state exchange for the existing prevalent private insurance programs, rather than immediately installing the single-payer system that Vermont's Act H202 created.

Vermont did not have the option to change its benefits (many of which are funded by the federal programs Medicaid and Medicare,) and won't have the option until 2017. So Vermont's short-term goal is to get the Exchange going for 2014. Then as 2015 comes along, when we really start planning for 2017, we will have to option to reconstruct the benefit package to work for as many people as it can.

Said Hogan, "For example, right now, we don't have much of a dental program. Each of us board members has a listing of people whom we've talked to, and made requests. In a year or so from now, we will begin to fashion what the information-gathering efforts look like. Some Vermonters are asking for alternative medicine approaches. Our criteria are: Is it scientific? Is there evidence?" Hogan's experience, as Human Services director, looking at measureable outcomes, will count here.

Real Benefits, Not Lip Service

Karen Hein, M.D., another of the five Green Mountain Care Board members, explained "community benefit" and why that term matters to hospitals. In order to be granted non-profit status by the IRS, which exempts an organization from paying taxes, a hospital must say how its work provides "a community benefit." Until recently, this term was vague and unenforceable at the federal level; the line between a non-profit and a for-profit hospital became increasingly blurred.

While a "community health needs assessment (CHNA)" has been required for years, prior to Obamacare in 2010 the form the CHNA took has been highly variable: everything from a quick and dirty survey at the admissions desk to extensive online community surveys.

The way a hospital applied its CHNA research to specific community goals also varied from hospital to hospital. It got administered less than uniformly; how accountable the hospital was to some measure of specific "community benefits" also was spotty.

Now, there is increased scrutiny and focus on non-profit hospitals and the CHNA must demonstrate itself in a more standardized way on the federal tax form. All 14 hospitals in Vermont are non-profits, said Hein, adding that Vermont has enlisted help from Sara Rosenbaum, a George Washington University health policy lawyer and expert in CHNAs, to form a more standardized and measurable approach in Vermont. GMCB recently approved the wording for providing guidance for hospital reporting around CHNAs.

Hein said she is "excited by the potential for improved patient care. This is a great opportunity for a hospital not to just say you are for the public good, but you have to demonstrate it. That's what is new and different." Hospitals will be charged with finding a way to tap into their communities, give an indication that they have thought about what they learned, find a way to implement a strategy to address the identified needs, and show in their hospital budget going forward where they are doing this.

Hein said the healthcare reform board provides guidance to the hospitals in all of these steps. She reports the Vt. Health Department has stepped in to provide seed money to hospitals to get teams together to think about the new CHNA process.

Keeping It Real

One and a half years into the process of reform, I was curious what has surprised Hogan. "I shouldn't be surprised," he said, "but it is how nervous people in the field are. When you start talking about how people get paid, what they get paid, what they get paid for, there are a remarkable number of people that want to see change, but are scared, and afraid of it.

"That's where Anya [Rader Wallack] has done such an amazing job," he said. "I mean that we've been able to conduct this business as close to a collaborative basis as you can. Notice there haven't been any major wars at this stage of the game. Her requirement was that people trust each other as individuals. They may be a little distrustful as to where all this is going to take us, but they know the state is not out to kill them. Change is hard; it's slow, it's difficult. And this is a complex process." But Hogan has been there before. He has faith in that process Vermonters call democracy.

"When we took office, the GMCB was told it was covered by an act that requires 'open meetings,' where if there are more than two people in the room, it is considered a public meeting. I worried we wouldn't have the deliberative opportunities to think things through, if all our discussion is public. We disagree, argue! It has lent a sense of genuineness to the process."

Hogan cites as one of his proudest accomplishments becoming chair of the board of the Vermont College of Fine Arts in 2009, helping to facilitate the rebirth of this alternative higher educational program in the visual, writing and music arts. "It's been a wonderful opportunity to see that place land on its feet." The other is his work as a charter member of the Permanent Fund for the Well-being of Vermont's Children, which funds mentoring programs in Vermont. Of this work Hogan said, "It's good for the soul."

When I asked him if he found the work of the Green Mountain Care Board stressful, he said, "I am 71. You get to the point in your life [where] you can call it as you see it and not worry about it. I am in the office four days a week. Friday is my day to recoup and read. Would I rather be playing with the farm? Certainly. But no, I don't feel stress. My goal is to complete my six-year term. I want to be around when this thing happens!" -

Healthcare Payment Reform

Richard Slusky, former CEO of Mt. Ascutney Hospital in Windsor for 28 years, was retired for less than three weeks before he was recruited as director of Health Care Payment Reform for the state of Vermont. Via telephone, he told me about two examples of Vermont payment reform initiatives.

Payment reform is a means to lower health care costs without compromising quality of patient care. As Hogan had earlier pointed out, finding more efficient systems to deliver health care should both reduce costs and enhance patient care, as the administrative process becomes more streamlined.

Two current pilot studies are providing data to the Green Mountain Care Board for review. They will measure whether payment reform delivers the goods. They hope to find improved quality of care for the patient and reduction of health care costs.

Enhanced Payments

The first study, "Enhanced Payments to Specialists and Primary Care Physicians," focuses on the care of the approximately 200 patients in the St. Johnsbury region who are diagnosed with cancer.

"The intent," said Slusky, "is to improve the coordination of care between the patient's primary care physician and the oncologist to whom they may be referred." When a patient is diagnosed with cancer, Slusky explains, typically a team of providers, such as oncologists, surgeons, and a palliative care team are mobilized to develop a plan of care for that client. Additionally, the patient is assigned a care coordinator—essentially the point person who ensures good communication among all, and makes sure the plan of care is followed.
What is unique to this study is the addition of a communication loop between the team and the patient's primary care physician. Also being looked at is improvement of the state's electronic health care systems, since presently, not all of the providers' telecommunications interface with each other.

This study came about, said Slusky, as there were identified gaps in communication between the specialist and the primary care physicians. His team wanted to see if it could improve that communication. This would prevent unnecessary and duplicative procedures, such as x-rays or lab tests. The enhanced payments go to the providers who agree to adopt the communication procedures and protocols that are part of the study.

Bundle Payments

A second study will follow Medicare patients who were admitted to Rutland Regional Medical Center with congestive heart failure, and examine a "bundle payment system." Patients would be discharged to either home health care or to an assisted living facility. The problem, said Slusky, was that patients who had an acute episode of symptoms related to congestive heart failure (CHF) would then be readmitted to the hospital because caregivers weren't prepared to deal with the relapse.

A group of cardiologists, pulmonologists, primary care physicians and representatives from home health care and assisted living agencies were gathered to develop a standard of post-discharge care. They agreed to provide training and support in management of CHF symptoms to staff in agencies that care for the discharged CHF clients.

For example, training would help non-hospital staff deal with fluid weight gain, swelling of extremities, or respiratory difficulty. If these and other symptoms of worsening CHF could be identified and reported to the provider before they became acute, re-hospitalization could be avoided.

Why call this new payment a "bundle?" From the time of hospital admission to 90 days post-discharge, Medicare establishes a target cost of care, based on what it would expect to pay for services in that period of time. If the providers can both meet the standards of care and not exceed the target cost, they, as well as the hospital, would become eligible to share the cost-savings of that bundle payment with Medicare.

As one goal is to prevent re-admission, the bundle payments also help to offset the loss of revenue to the hospital. In other words, the bundle payment provides incentives for everyone to coordinate, to reduce tests and bolster preventive care.

Roberta Nubile is a registered nurse and
regular contributor to Vermont Woman.

Special Series: Vermont Health Care Reform

1. Vermont Healthcare Reform: Guiding One Big Elephant! by Roberta Nubile , April/May 2013

2. Con Hogan – Seasoned Elder of Green Mountain Care Board by Roberta Nubile, June/July/August 2013

3. GMCB’s Al Gobeille: The Voice of Business in “Health Connect” by Roberta Nubile, September/October 2013

More articles in this series will be forthcoming in the Nov/Dec 2013 and Feb/Mar 2014 of Vermont Woman