In the words of that popular adage: "If it ain’t broke, don’t fix it." But fixing what isn’t broken is exactly what John McClaughry wants to do. In his recent opinion piece in this newspaper, Mr. McClaughry suggests that the community-based, community-run system of home care services, that has assured Vermonters of universal access to this vital service, should be changed to allow competition from for-profit companies.

Mr. McClaughry is right that Vermont’s system of regionalized not-for-profit agencies is unique – uniquely good. Historically, according to Medicare, the 12 Visiting Nurse Associations (VNAs) of Vermont have ranked in the top three nationally in two important categories: serving a higher percentage of those eligible for home care and at the lowest cost. Vermonters know a value when they see one. Thus, they have supported this system annually with generous town appropriations. They have also indicated their satisfaction with this system in independent and confidentially-obtained surveys which have consistently rated the services and staff of VNAs as being between very good and excellent. Furthermore, as a mark of the quality of care available in Vermont, all the VNAs have passed rigorous standards to become nationally-accredited by objective review programs.

Before we tamper with this system in the name of granting greater choice to consumers, we should look at the facts. Vermonters do have choices in obtaining home care services. If an individual or family is unhappy with the care they are receiving from a staff member, the agency providing the service will, no questions asked, assign another staff member. If an individual or family member is unhappy with the care they are receiving from an agency, arrangements are in place so that they may transfer their care to a neighboring agency. In the case of a Medicaid client in Vermont’s Home and Community-based Waiver Program, there is the opportunity to bypass the home care system entirely and hire their own personal care attendant, paid for by the state.

In addition to these cases, choice becomes important only if the current VNA system is unable to deliver needed services. Need is the important word here; Vermont’s VNAs have been especially effective over the years in providing medically necessary care. Admittedly, sometimes this cannot always accommodate client’s wants and convenience, but every effort is made to adjust care and visits to satisfy clients. It is insulting to our dedicated staff that Mr. McClaughry claims that clients are "stuck" in a system that puts "providers’ interests first, consumers’ interests later." Our client satisfaction results indicate something different.

Mr. McClaughry favors a system that would regulate home care providers and set up quality survey and reporting systems. He should be aware that such systems are in place and that the VNAs’ performance under them and adherence to them are the major reasons that, over the past 30 years, state policy makers and all of Vermont’s governors (Republicans and Democrats) have advocated maintaining the VNA network. The state’s Department of Aging and Disabilities (DAD) conducts annual site visits to assess VNA performance under Medicare’s conditions of participation. The results of these assessments are available to the public. Under the Home and Community-based Waiver Program, managed by DAD, the department annually surveys the recipients of services. In the most recent survey, our agency, Caledonia Home Health Care & Hospice received a 100% overall satisfaction rating by those we serve. The VNAs voluntarily submit their own client satisfaction survey results to the state as well.

So, if the current home care system in Vermont is so good, what would be the problem if there were competition? Wouldn’t the current VNAs continue to do well given their track record? The experience in other states indicates otherwise. By their nature, for-profit agencies exist to make a profit. Thus, it is to their benefit to target wealthier and insured clients. Because of their charitable mission, non-profit VNAs cannot and will not do so. Thus, the risk of competition is that VNAs may end up serving a disproportionate share of those who are unable to pay, who are sicker, and who are located in more remote locations – situations that can threaten the VNAs’ economic viability. Furthermore, with a limited patient base and often scarce staff, competition drives up the cost of care as agencies vie for resources.

Mr. McClaughry states that Maine allowed competition in 1991 "with very positive results." Yet, Medicare data shows something different. Prior to competition, Maine and Vermont had similar statistics in terms of charges per person and number of visits per person. Nine years after the introduction of competition in Maine, home care charges were $368 more per person in Maine than Vermont and Maine provided 6 fewer visits per person than Vermont. In short, Maine now has higher costs and provides less service. In addition, according to the Home Care Alliance of Maine, agencies have gone out of business and there are now areas of the state that are no longer served by home care agencies.

Vermont has a tradition of supporting not-for-profit health care. Like home care, the hospital system in our state is also not-for-profit and non-competitive. If competition is good for home care, why doesn’t Mr. McClaughry also advocate having a choice of hospitals in the towns that have a hospital? It’s because such duplication would be costly and unnecessary. Home care is no different.

No, the VNA system is not perfect, but it strives to be. And yes, there will be some who are not satisfied. But, in an era of constrained resources for health care, dramatic policy shifts should be made based on fixing real systemic problems, not on the basis of anecdotal evidence or a few incidents. To do otherwise puts in jeopardy a system that has served the vast majority of Vermonters well and at much less cost than other states. We maintain that the health care system in this country would be better if more care was provided by not-for-profit entities who put the community’s needs first instead of by organizations that are profit-motivated for the benefit of their owners and shareholders.

Paul A. Cillo, President

On behalf of the Board of Directors,
Northern Counties Health Care, Inc. (NCHC):

Emilie Adams of St. Johnsbury
Polly Biron of Island Pond
Frank Braun of Greensboro
Beryl Eddy of Lyndon
Judy Kendall of St. Johnsbury
Gordon Lefebvre of Island Pond
John Mandeville of Hardwick
George Mathias of Lyndon
Carmen Murray of Island Pond
Sally Neylon of St. Johnsbury
Peggy Pearl of Ryegate
Janice Peaslee of Guildhall
William Piper of Waterford
Hilary Smith of Peacham
Ryan Stewart of Derby
Barbara Warden of Barnet
Robert Ware of Burke
Terri Williams of Concord
Virginia Wing of Island Pond
Julie Wright of Walden