Tom Huebner is the former president of Rutland Regional Medical Center, where he worked for 28 years. Huebner was on the BlueCross BlueShield of Vermont board of directors for 24 years, and is now on the boards of the Federally Qualified Health Center in Rutland, the Vermont Nurses Association in Rutland, and the Brattleboro Retreat. Returning to the OneCare board having first served in the organization’s early years, Huebner brings a deep knowledge of health systems and policy reform and is committed to working toward improved health and well-being of Vermonters and our communities.”
We sat down with Huebner and asked him some questions to get to know him better and hear his perspective on what’s next for health care reform in Vermont.
Tell us your story—where it all began and how it all led to your involvement in health care reform in Vermont.
I have worked in health care for about 45 years now. I started in the Boston area—I went to graduate school down there, and then worked for the Commonwealth of Massachusetts, the Massachusetts Hospital Association, and for the community hospital system in Boston for 15 years. I moved here to Vermont in 1990 for the position of vice president at Rutland Regional Medical Center. In that role I did strategic planning, some operations, some new business development—a variety of different tasks. And then in 1997, I became CEO at Rutland and I continued to do that work until 2018 when I retired. And all through that, I’ve been on quite a few boards—including an earlier stint on the OneCare board—I was on the Blue Cross Blue Shield board for 24 years, I am on our VNA [Visiting Nurses Association] board here in Rutland, the local FQHC [federally qualified health center] board here too, and I am on the board for the Brattleboro Retreat. So, since retiring from Rutland Regional Medical Center, I am working in a volunteer capacity to continue to be involved in health care.
How would you describe the state of the American health care system? And where do you see the greatest opportunities to transform the system here in Vermont?
In many ways the health care system does a wonderful job. We’re really, really good at taking care of sick people. And you know the advances we have made clinically and scientifically have been extraordinary—both physical techniques, pharmaceuticals, and every other technological advance you can think of led by some brilliant people. The problem is that they’re really focused on fixing people once they’re broken and not really focused enough on stopping the breaking from happening in the first place. And people will still get sick no matter what, but we have a great opportunity, from my point of view, to really do a spectacular job of coordinating the care so that it’s very efficient, very effective, creates the best possible outcomes at the lowest possible price, creating great value. So, both on coordinating care and really working upstream of illness is where I think the great opportunities lie.
When you say “upstream,” how far upstream do you think our health care system and/or OneCare should be investing in prevention of illness?
It depends on whether you want to take a long-term view or a short-term view. Community prevention, wellness activities of many varieties—it’s all very important. And they have a very long payback. It’s not something that creates a savings against the budget next year. It just isn’t that way. That doesn’t mean we shouldn’t do it. We should. We should get in front of it. Everything from immunization, to smoking cessation, to obesity, to exercise—all that are great and important. In the OneCare world, where we’re working from one year to the next, the lower hanging fruit is probably in the coordination of care and making sure that people are getting the care at the right moment as early in their disease process as possible. And as I already mentioned, the care coordination practice is superb. That’s where we can eliminate unnecessary demand and really improve outcomes for patients.
I have heard you talked about the collaborative environment built under your leadership at Rutland Regional, citing how the synergies among the staff are what made quality improvement and financial stability possible. Can you talk about that experience and draw any parallels you see in terms of what it might take for for OneCare to be successful in both improving quality and stabilizing health care costs?
When I came to Rutland in 1990, I used to refer to it as the Wild Wild West. Every doctor that was in private practice competing against each other, the VNA was an afterthought, there wasn’t an FQHC, nobody was thinking about mental health services, and there really wasn’t coordination of care at all. And we came a long way—I should say, we’ve come a long way since it has continued since I retired—because now the level of integration of care, even though they’re still separate entities, has come an enormous distance. There really aren’t private practices existing in the Rutland marketplace—there are in some other places, but very, very few. So, you now have care coordination going on across the spectrum: behavioral health services have been embedded in the primary care offices, and the level of communication between primary care, the hospital services, and the specialist has come such an enormous distance. It’s really quite remarkable and I think patients are well-served by it and the system is well-served by it too.
Having said that, there’s still room for improvement as I do not think incentives are not properly aligned across the system. Even with OneCare, most of the risk is still at the hospital level and you really need to have that risk aligned across the entire system. It’s still a work in progress—we have not yet arrived. We also then need to make sure that data is transparently and rapidly being shared across the system, so that we can make the best decision for patients. Again, there is an enormous improvement today in data sharing practices, but we have not perfected that for sure and there are many opportunities left to come. To me, the key really is in aligning incentives across the entire system and making sure that actually happens. Easily said, and really hard to do. For example, there’s a lot of disparity across the system, like primary care is underfunded historically and needs more resources. So, it’s very difficult to pull off, but to me, that’s what is fascinating—it’s what is worth working on, and I continue to be intellectually challenged by, and why I agreed to come back on the OneCare board and service as vice chair.
What excites you about the work OneCare is doing to bring a more affordable, trusted, and equitable health care experience to Vermonters?
First, we have a wonderful staff. And next, I think the OneCare ACO and the all-payer model combined are easily the most powerful possibility for aligning incentives. It has not been fully realized, but it has the best opportunity to do that. It’s also been a place that has welcomed every community across the state—it’s not just Burlington or Montpelier, it’s the “Rutlands,” it’s the “Benningtons,” it’s everybody—and OneCare has found a way to create collegiality in that regard. And that’s really hard work some days because the communities are not all the same—and there’s a balance between having a standardized approach, and allowing for individuality in each community. But for me? OneCare and the all-payer model offer the best hope for creating the incentives that the system really needs to change in the way I think would be most meaningful and beneficial.
What do you think are the key changes needed in negotiations with the Centers for Medicare & Medicaid Services (CMS) to build on the accomplishments of the first all-payer model (APM) and accelerate success in the APM 2.0 agreement?
Some of them are not in CMS’s control, and some of them are. First of all, the Medicare model itself needs to move beyond still being a reconciliation back to fee-for-service—we need to move beyond that, that day needs to go away. It needs to be much more of a fixed payment system with reasonable risks associated with it. To me, that’s the biggest single change on the federal side that needs to be made.
We also know it’s very important that we change some of the targets for the volume of patients in the shorter term. Beyond that though, we really need to find ways to bring commercial patients more realistically into the system. We especially need to make it attractive for employers who are self-insuring and we have not done that very effectively yet. We need to do it with some of our payer partners—and that has been sticky, we have not made as much progress there and we really need to. The Medicaid model probably comes closest to what we should be shooting for, but those are the big ones.
The other thing is that two years is not even close to enough of a time period. I see it as just a stopgap until we get to a longer deal because the system is not going to change that much in a two-year period. It’s been particularly difficult coming through COVID and the aberrations in spending that have occurred as a result of that in both directions that has resulted in target-setting that is quite difficult. To get to a fair set of targets, it’s going to be tough.
I think the other one coming up—I’m drifting a little bit from your actual question—but in setting targets in the years ahead, we are going to have to recognize the real inflation—especially wage inflation and labor inflation that is happening. If we think we’re going to just keep rolling over 3% increases every year, right now, it will fail. Costs are way, way higher than that and we’re going to have to deal with that while we change the underlying center.
As vice board chair of OneCare, what do you hope to accomplish under your leadership?
Keeping this thing moving and helping Anya [Rader Wallack, board chair] and the rest of the board—and of course OneCare management team—to achieve the goals. And the goal really is to help create those payment incentives that will lead to a more efficient and effective system.
I am retired but still passionate about this and happy to help out and help work with people across the entire spectrum to achieve the goals that that we have set.