My answer to this is, of course, to change how we view health and who is responsible for taking care of it. It is obvious to anyone who thinks about it that we would significantly reduce our health care spending, as well as our personal pain and suffering, if we didn't get sick in the first place!

Personally, I don't believe that the rising cost of health care will change as long as people continue to live in ways that promote disease. But I also understand that changing lifestyle habits that have developed over decades is not something that will happen overnight. And so, in the meantime, something does need to be done to stem, in the short-term, the current tide of rising costs. Vermont has "taken the bull by the horns" so-to-speak, and is implementing its own solution to our present conundrum. I have no idea whether it will work. But I'm here to stay and I'd like care at HeartSong to be accessible to everyone who wants to receive it through available health care systems.

Most people think that the expression "optimal health" refers to being in peak physical condition. In a way, nothing could be further from the truth. First of all, optimal health is not a fixed condition, rather it is about realizing a potential that is equally available to all of us, regardless of physical and mental capabilities, or emotional temperament. That is, someone who does not have legs, is just as capable of experiencing optimal health as an athlete who just ran a marathon.

Optimal health depends upon how we live in the bodies we have and how we use our minds and emotions as we live our lives. Do we care for them well? Do we eat healthy foods? Do we control chemical abuses such as alcohol, tobacco, and recreational drugs? Do we get medical care when we need it? Do we get enough sleep? Do we exercise in accordance with our physical capabilities? Do we think positive thoughts? Do we allow ourselves to feel the feelings that we have? Do we find ways to relax and soothe our minds when things happen to us that cause us to experience feelings of stress? Do we celebrate ourselves and others? Do we contribute something to the well-being of others and the planet? Do we have mutually supportive relationships with others? Do we honor our true nature and spend time outdoors, experiencing the wind, the sun, the seasons, the land, the flora and fauna that inhabit it? Do we take care of our living and work spaces? Do we nurture our children? Basically, do we make the most of what we have and cherish ourselves and others?

What does this mean? The Vermont Blueprint for Health is a state-led initiative for transforming the delivery of health care care services in Vermont with a focus on providing Vermonters with seamless, effective preventive health services. Although it was originally designed using a chronic care model for health care, the model soon shifted to emphasize the importance of services and systems that prevent disease rather than simply "manage" it.

The Blueprint is overseeing the establishment of a network of Advanced Primary Care Practices across the state that include patient-centered medical homes (PCMHs), medical practices that are certified in accordance with the National Committee for Quality Assurance standards (NCQA) for PCMHs, and Community Health Teams (CHTs), teams that work closely with APCPs to provide resources and support, such as counseling and education, that are essential for many patients to achieve personal health goals, live health-promotive lifestyles, and improve their health status. Since this is has been the focus of care at HeartSong since the medical clinic opened in 2008, participating in a state-wide initiative with similar goals is a natural transition for the organization, especially since we are committed to ensuring parity of care and access to CHTs will increase services available to HeartSong users. Medical practice which do not provide care within the Blueprint will not be able to offer CHT-sponsored services to their patients.

For more information about the NCQA Standards for PCMHs, see the NCQA-PCMH Policy Statement, under About Us.

For more information about medical homes, see Medical Home

For more information about the Vermont Blueprint, go to http://hcr.vermont.gov/blueprint.

What is perhaps even more interesting, perhaps, is that here in Vermont we have created financial incentives to encourage primary care practices to practice medicine in a certain way, for example, to use evidence-based guidelines for managing people with chronic diseases. Here is where things get really interesting!

First of all, there is the ethical question, of using money to entice primary care providers to change how they practice according to a particular set of standards. One issue is the standards themselves. Who sets the standards? How do we know that they are the ones we would choose for ourselves? Perhaps I would like to treat my high cholesterol with a natural medicine. But the standards require the use of a statin drug. Will a primary care provider get paid more if he or she gives patients statins than one who does not? If so, is this ethical?

Then there is the question of using money to "entice" our health care providers to offer what is considered to be adequate and appropriate care. Shouldn't they be doing this already? Isn't this their commitment as health care providers? Why do they need an incentive to do their job? Why doesn't the patient, who has to take the medication, get paid the incentive for taking responsibility for improving his or her health? Of course, the same thing could be said of the person taking the medicine. That is, shouldn't people want to take care of themselves? Using money as an incentive for doing what we should all already be doing, i.e. taking care of ourselves and our patients, seems to be a slippery slope and one that leads away from self-responsibility towards dependence on something outside ourselves.

Ethical questions not withstanding, one difficulty with creating financial incentives to get primary care providers to do things differently is that we have to come up with some basis for deciding whether a doctor is going to get the incentive, i.e. get paid more. While the adoption of an electronic medical records system is a fairly observable criteria upon which to base incentives, determining how to calculate an incentive for changes in clinical practice is more difficult.

One proposal is that incentives be based upon improvements in clinical markers for health, such as cholesterol levels (as a measure of cardiovascular function) or hemoglobin A1c (as a measure of blood sugar metabolism). While on the surface this seems like a pretty good idea, what are some of the long-term possible practical outcomes:

1. Accessibility: First of all, primary care providers are not the ones who are responsible for whether or not clinical markers improve -- the people for whom they are providing primary care are! So, if providers are going to get paid more for treating people whose clinical markers improve, they will be less inclined to focus as much attention upon people who do not improve because they do not want to do what their provider prescribes. In a setting where there are not enough primary care providers, people whose health does not improve as well as expected may find it progressively harder to receive medical care.

2. Cost: If increased pharmacology costs are a desired outcome of incentives related to improved clinical markers, then using the markers as a basis for payment incentives will, indeed, accomplish this, because there is no quicker way to lower cholesterol or A1c than with a drug. That is, if a physician knows he can bring someone cholesterol down in a month with a statin, versus six months with a lifestyle change, the incentive program will "push" both physicians and patients toward the "quick (short-term) fix" of the statin. However, this will ultimately be more expensive, since the person will need to stay on the medication, see the provider regularly to have its impact evaluated, and to get prescriptions for medications to treat the side effects of earlier medication.

3. Disease-based health care: An incentive system based on the reduction of clinical markers after they have gone out of range promotes disease-based medicine. It does not cultivate health promotive medicine because there is MORE incentive for a provider to let people get sick and then treat them, than there is for the same person to help people avoid illness altogether. This is because the system rewards practitioners who practice the former and, in so doing, penalizes providers who do the latter.