Seven Days

Posted By on Wed, Feb 16, 2022 at 10:04 AM
Updated at 4:25 p.m.

A state investigation into medical appointment delays has found that patients are waiting an average of two months to see a specialist in Vermont, far longer than the most recent national figures, according to a report released on Wednesday.

The average wait exceeded 100 days in some specialities, while at least one clinic was booking more than a year out.

The report follows a monthslong investigation that began after a Seven Days cover story detailed lengthy delays for care at the University of Vermont Medical Center. More than two dozen people told the paper that they had struggled to get timely appointments in recent years despite suffering from painful and debilitating ailments.

A team of state officials and regulators led the probe. Their findings represent the most comprehensive assessment of wait times in state history — and paint a bleak picture of Vermont’s health care system.

“There’s no metric that we could find where it appeared like Vermont was performing better than states or areas similar to us,” said Mike Pieciak, the state commissioner of finance.

Hospital leaders, who held a press conference Wednesday after the report was released, questioned the report’s methodology and said that it glosses over the many challenges medical centers face, from workforce shortages to regulatory burdens.

“It only tells part of the story,” said Jeff Tieman, president and chief executive officer of the Vermont Association of Hospitals and Health Systems trade group.

Launching their investigation last fall, state officials declared the ambitious goal of documenting wait times across provider types, including primary care, within just a few months. They later scaled back their efforts to focus solely on specialty care but say they want to explore the issue further; the Department of Financial Regulation plans to ask state lawmakers for the authority to track and publicly report wait time metrics on a regular basis.

Outlining the report’s findings at a press conference on Wednesday morning, state officials said efforts to quantify Vermont’s access problems are complicated by the fact that there’s no agreed-upon standard for tracking patient wait times. “We really had to start from scratch,” Peiciak said.

Investigators ultimately landed on a “secret shopper” approach that replicated the experience of patients trying to schedule new appointments. They called more than 400 clinics across 21 different specialty areas this winter and asked for the next available date for various non-urgent medical issues.

Clinics in Vermont reported an average wait time of 60 days, though the results varied widely by specialty. Ten areas exceeded this average, while four posted delays of more than 100 days: dermatology (141), neurology (114), endocrinology (113) and rheumatology (101). At least one clinic in almost every specialty area had patients waiting more than three months.

Wait times also varied across providers. Five hospitals performed worse than the state average. The UVM Medical Center topped the charts with an average wait of 100 days. That’s nearly twice as long as Dartmouth-Hitchcock medical center in New Hampshire.

It’s impossible to know how current wait times compare to previous years because no state agency regularly tracks this data. But when viewed against the most recent national figures, Vermont falls well short. A 2017 study by the health care recruiting and consulting firm Merritt Hawkins used the same secret shopper approach and found that the average wait time across 15 midsize metro areas was 32 days.

That was before the pandemic upended health care systems across the nation. But complaints about wait times at Vermont hospitals long predated COVID-19, and the state investigators confirmed that the problem has been years in the making.

Researchers from Oliver Wyman, a state consultant, analyzed a state database that compiles health care claims to find that patients with chronic conditions such as asthma, anxiety and heart disease waited more than three months to see a specialist on average in the three years leading up to the pandemic.

Vermont performed far worse than neighboring Northeast states. While two-thirds of chronically ill patients across the region saw specialists within 60 days of their referrals, Vermont providers scheduled only about half of their patients in that window.

Officials said the findings raise equity concerns, as the burden of medical delays falls hardest on vulnerable patients who do not have the time, resources or understanding of the medical system to advocate for themselves.

“The risk of patient mortality is increased when wait times are longer than 31 days for older and more vulnerable patients,” said Ena Backus, Vermont’s director of health care reform, who led the investigation. “There is [also] an emotional impact. People experience frustration, anxiety, suffering, when they or a loved one is not able to access the care that they need.”

Vermont hospital executives said at their press conference that they have not had enough time to thoroughly vet the report’s findings. But they took issue with the secret shopper survey, arguing that its timing — at the height of the Omicron coronavirus wave — put unneeded stress on hospital staff and may have even skewed results unfavorably, since many employees were missing work due to COVID-19 when the calls were placed.

The executives also argued that the report lacks other vital context: about the extent of the Vermont’s workforce crisis, and the challenge of running hospitals in a rural, highly regulated state. It’s unfair to compare the UVM Medical Center to Dartmouth-Hitchcock, for example, without noting that New Hampshire does not have a regulatory body like the Green Mountain Care Board that limits hospital budgets, said Dr. John Brumsted, the president and chief operating officer of the UVM Health Network.

“I would be very, very careful to put any credence into the comparisons that are drawn from these data,” Brumsted said.

The report acknowledges that the survey’s timing could have made wait times appear longer than they typically are at some hospitals. On the other hand, the approach assumed patients had everything they needed to make an appointment, such as a referral from a primary care doctor or diagnostic imaging. That process can take weeks if not months for actual patients, meaning the survey could have significantly underestimated actual delays, the report said.

The report also raises potential contributing factors beyond the pandemic that hospitals have more control over, starting with the often complicated and unreliable referral process.

In a perfect world, primary care doctors refer complex cases to specialists, whose offices then triage cases based on urgency before reaching out to schedule appointments. But breakdowns regularly occur during those few basic steps.

A referral might get lost in a hospital’s system — or it might fall into a slush pile at clinics with big backlogs, where it can languish for weeks or months. Several independent doctors recalled for Seven Days last year the difficult experience of referring patients to the UVM Medical Center, while a former hospital employee said there were about 900 unscheduled referrals in the urology department when she left last summer.

Vermont’s health care system may also be relying too much on specialists, according to the report. Doctors told investigators during several state-run focus groups that some patients are needlessly referred to specialists when they could be better served at the primary care level. Primary care doctors, meanwhile, said patients are requesting to see specialists far more than they ever have, even when the doctors say they could handle the problem themselves.

The report offers several broad recommendations on how to begin reducing wait times. It says providers should share successful strategies with each other, while hospitals should task committees or board members with monitoring their individual wait times. The state also plans to work with providers on developing some best practices for the referral process.

But perhaps the most substantial recommendation centers around further efforts to study the problem, since that will allow the state to better understand whether the situation is improving.

“This is really new ground,” said Isaac Dayno, a member of the investigative team. “It’s not an area that’s studied academically by other states. Vermont is really the tip of the spear here in trying to get our arms around it. And I think we’re learning some hard truths.”

Officials say it would be useful to know whether patients with urgent matters are receiving necessary care. Using the 141-day average wait for dermatology as an example, Pieciak said, “That might be the appropriate wait time for Vermont if everyone that needs to be seen within two weeks has been seen within two weeks, and everybody that can wait a year has been waiting a year.”

“But we do not know that is happening,” he said.

Hospital leaders seem to agree that more nuanced data could be helpful. But they question whether more data tracking will make much of a difference.

“This is not new news to us,” said Claudio Fort, president and CEO of the Rutland Regional Medical Center.

“I think the real question is: How do we move forward together?” he said.