High costs, few options in VT health care

Amy Cooper is executive director of HealthFirst and a partner in Green Mountain Surgery Center. Her last name was incorrect in a photo caption in this story.

The dearth of competition for health care in Vermont came as a particular shock to Annie Ode, who moved to Burlington from Boston two and a half years ago. Ode, 31, has been on an aggressive screening schedule for the past year because of her family's history of cancer. Family members have suffered from colon, brain, breast and liver cancer, along with Non-Hodgkin's lymphoma.

"I'm looking at a lifetime of screening, that's why (price) is important for us," Ode said.

UVM Medical Center recently billed Ode $4,321 for an MRI of both breasts, and $5,000 for a brain MRI. Ode said she and her husband are on a high-deductible insurance policy that required them to pay a portion of the procedures' cost out of pocket.

Ode decided to check the websites of two independent providers of MRIs in Massachusetts, Shields MRI and Merrimack Valley Health Services. She found that a brain MRI would cost her in the range of $700 to $1,000, while a breast MRI would cost in the range of $500 to $1000.

Related: Independent doctors say hospital thwarts competition

Related: Patients struggle with long waits at UVM Medical Center

"You have to let competition in to drive down costs, making health care more affordable and accessible," Ode said in an email.

Competition may sound like the answer to bring down Vermont's health care costs, but Amy Vaughan, director of revenue for UVM Medical Center, said the state is too small to support the diversity of health care businesses found in a state like Massachusetts. Vermont has 626,000 residents. Massachusetts has nearly 6.8 million.

But backers of the proposed Green Mountain Surgery Center disagree, saying the facility, if built, would lower prices and the center would also bring price transparency for other health care services now only available from UVM Medical Center.

Amy Cooper, executive director of HealthFirst and a partner in Green Mountain Surgery Center, said, for example, she anticipates a colonoscopy at the proposed Colchester surgery center will be priced in the range of $1,000 to $1,500. UVM Medical Center charges $3,500 for a colonoscopy while Porter Medical Center in Middlebury charges $2,500, according to Dr. Paul Reiss, of Evergreen Family Health, an independent practice in Williston.

Green Mountain Surgery Center has been opposed for nearly two years by the Vermont Association of Hospitals and Health Systems and Northwestern Medical Center in St. Albans. UVM Medical Center is a member of the hospital association.

Cooper said the surgery center has an April 13 hearing before the Green Mountain Care Board that could lead to a certificate of need being granted within 120 days.

The Vermont Association of Hospitals and Health Systems has said the proposed surgery center would hurt existing health care providers. UVM Medical Center has said a new surgery center is unnecessary for the number of patients in the area and that it would drive up costs.

Related: Jericho family sees medicine costs jump to $89k  

Tiny population, regulated market

In addition to Vermont being too small to support competition, Vaughan added that the health care market here is regulated by the Green Mountain Care Board, which grants certificates of need to new health care operations based on supply and demand, and other factors.

Todd Keating, chief financial officer of UVM Health Network, describes himself as an "open market person." But Keating said the Green Mountain Care Board has to consider whether adding "excess capacity" to the state health care system makes sense when Vermont is headed toward limited payments from Medicare and Medicaid.

Last month, Gov. Phil Scott rolled out a pilot program using this  "value-based payment," as opposed to fee-for-service for 30,000 of the state's Medicaid patients. The CEO of UVM Medical Center anticipates other insurers will embrace this type of program.

Vaughan said that UVM Medical Center's prices compare favorably to other academic medical centers in the region. She said in 2014, the charge for a brain MRI at Brigham and Women's Hospital and Massachusetts General Hospital in Boston was $4,803, compared to $3,451 at UVM Medical Center. Vaughan was unable to compare physician's fees among the hospitals, which make up a much smaller portion of the bill for a brain MRI. At UVM Medical Center that charge was $532 in 2014.

Some competition for brain scans

UVM Medical Center does have competition for MRI services from Vermont Open MRI in South Burlington. Patient Coordinator Carmelita Katon said Open MRI's contracted rate with MVP, Ode's insurer, for a brain MRI is $600. The facility does not do breast MRIs.

Ode was surprised to learn she had an option, at least for her brain MRIs.

"I've never heard of them," Ode said of Open MRI. "That wasn’t offered. The hospital didn’t say, 'You can schedule with us or here.' I've never been told about them."

Ode points out that at Massachusetts General Hospital in Boston, her experience is that doctors let patients know they have options.

"They'll say, 'You can go through our MRI center or you can check out Shields,'" she said. "They don't hide it from you."

Dr. Stephen Leffler, UVM Medical Center’s chief medical officer, said the hospital has no policy against providers ordering tests from wherever they want to, as long as those tests are of the right quality to care for their patients.

He added however, that the safest and quickest way for providers to order images or lab work is through the hospital’s electronic medical records, which route all orders within UVM Medical Center’s system.

“It’s the most convenient way for providers to order imaging or labs,” Leffler said. “I would also argue it’s the safest way because we have mechanisms we put in place to make sure requests are acted on in a certain time frame and to make sure the provider sees the results as quickly as possible.”

The owner of Vermont Open MRI, Todd Kummer, acknowledged there is an image quality difference between the MRIs he produces and the MRIs produced by UVM Medical Center's state-of-the-art equipment. He says in most cases, however, his images are not "diagnostically different" from UVM's scans.

Dr. Kristen Destigter, interim chairwoman of radiology at UVM Medical Center, described a significant difference between the hospital's MRI images and those produced by Vermont Open MRI.

Destigter said the magnets used in UVM Medical Center's scanners are up to five times more powerful than the magnets used in Vermont Open MRI's scanner.

"A larger field strength magnet may perceive subtle differences in tissues that may allow you to determine if it's cancer or not," Destigter said.

Kummer says he regularly gets calls from patients whose UVM Medical Center doctors don't refer them to Vermont Open MRI. He said he also gets cancellations from patients who have appointments, but whose doctors don't want them to get their scans at Vermont Open MRI.

Vermont Attorney General T.J. Donovan said the issue of UVM Medical Center's dominance is "on my radar."

"This is a national issue," Donovan said. "At the two conferences of attorneys general I've attended, hospital mergers have been a topic. Locally, I'm aware of the concern and I'm working to better understand the issue."

Donovan said during his campaign to become attorney general he talked to a doctor who articulated some of the challenges independent doctors face trying to compete with UVM Medical Center.

"At the same time, I understand UVM Medical Center provides a vital service to our community," he said.

What's this going to cost me?

Ode is also frustrated by the fact that she couldn't find out in advance how much procedures at UVM Medical Center were going to cost — a common complaint about the American health care system. She praises her doctors at the hospital for providing her insurance company with the information and genetic testing necessary to make it clear some part of her screening should be covered.

"But it was the level to which it was totally unclear to me and my husband what this was going to cost us that was really difficult," Ode said.

Both UVM Medical Center and the proposed Green Mountain Surgery Center in Colchester have told the Green Mountain Care Board they are committed to cost transparency.

In an Oct. 16 letter to the Care Board, Dr. John Brumsted, CEO of the UVM Medical Center, called for the creation of a database, accessible to the public, showing costs for all "inpatient, outpatient and professional services provided to Vermonters."

In her testimony to the Care Board on Dec. 23, Cooper, from HealthFirst, said the Green Mountain Surgery Center "intends to offer price-transparency tools on its website."

More: Patients struggle with long waits at UVM Medical Center

Transparency for health care costs — along with a competitive marketplace — can't come soon enough for Annie Ode.

"Of everything that seems anti-American, monopolies are at the top of the list," she said. "You have 38,000 places to buy a mattress at this point. But when it comes to the most important purchase, you have no idea how much it will cost. That's the most shameful part of this. You get people at their most vulnerable."

More health care news:

Lawmakers: Vermont's new drug cost law is lacking

Welch meets with Trump to discuss skyrocketing drug prices

Independent doctors say hospital thwarts competition

Patients struggle with long waits at UVM Medical Center

Contact Dan D’Ambrosio at 660-1841 or ddambrosio@freepressmedia.com.