Pitcher of Health

Navigating the health care rapids

by Will Lindner

vahhs0312Marie Beatrice Grause uses every bit of her knowledge from an impressive career in legislative issues in her position as president and chief executive officer of the Vermont Association of Hospitals and Health Systems.

When Marie Beatrice Grause was hired in 1992 as a legislative assistant on domestic issues for then-U.S. Rep. Joseph P. Kennedy II (D-Massachusetts), she was warned that it was a generalist’s position. Truer words were never spoken.

“I was in charge of whatever happens to people from the time they’re born to the time they die,” says Grause, recalling the scope of her duties in Kennedy’s Washington, D.C., office. “It was a job they said would be a mile wide and an inch deep. After I’d been there for a year I felt like asking, ‘Let me know when I get to an inch, will you?’”

In the fullness of time, Grause’s career has burrowed to the inch mark and well beyond. As president and chief executive officer of the Vermont Association of Hospitals and Health Systems (VAHHS), Grause, known to all as Bea, is immersed neck-deep in one of the most complex challenges of our time: health care reform.

It would be knotty enough if this were a subject only at the state level — which it is, since the passage in 2011 of Act 48, which seeks to create a system covering the health care needs of all Vermonters while controlling the growth of health care costs. However, Vermont has set itself on this course precisely while the Obama Administration is trying to engineer significant health care reforms nationwide through the 2010 Affordable Care Act. Certainly federal requirements under the ACA add complexities to Vermont’s initiative, but Grause sees the effort holistically.

“I generally think about Act 48 within the larger context of the federal Patient Protection and Affordable Care Act,” she says. “There’s so much overlap because Medicare is a huge part of both. We need to start knitting them together. It’s the next step in our evolution — building that health care marketplace at the same time that we’re working on how to change the way we pay doctors and nurses, making sure patients don’t fall through the cracks, finding out how to take care of the frail elderly …

“It might take years to solve the problems, but to me, everyone has Vermonters’ interests at heart,” says Grause. “That keeps me coming back. This state has a can-do attitude.”

The VAHHS is a trade association primarily representing Vermont’s hospitals. Its 20-member board of directors includes CEOs of all but one of the state’s acute care hospitalis (Springfield), plus the Veterans Affairs Medical Center in White River Junction, the Brattleboro Retreat, and the temporarily homeless Vermont State Hospital.

With its staff of 10, the association manages activities such as advocacy, policy development, research, and member education. Current priorities include achieving the best health care outcomes possible for patients, while exploring alternatives to the fee-for-service payment system that has spiraled health care costs beyond affordability. They see these changes as opportunities to control their own destiny.

Grause has been at the helm of the VAHHS since November 2001. “Early on,” she says, “my board was split: About half wanted to preserve the status quo and others wanted the organization to be forward-thinking and stand for something. Ultimately that sentiment won the day. It’s a dream come true to work for a board that’s supportive of reform. You don’t find that everywhere.”

Grause is not a legislator, free to act upon policy ideals. She is the CEO of an organization whose members negotiate enormously complex, often divergent, payment systems.

There are, for example, eight “critical-access hospitals” in Vermont (it’s a federal designation) that agree to limit their daily inpatient capacity to 25 patients and are paid on a cost basis, receiving 101 percent reimbursement for approved Medicare Costs.

In contrast, Grause explains, Medicare pays larger hospitals such as Central Vermont Medical Center, Rutland Regional Medical Center, and Fletcher Allen Health Care in Burlington per episode, where the hospital is at financial risk for delivering care efficiently. On a case-by-case basis these hospitals might lose money with some patients, but overall, total patient volumn provides sufficient revenues to cover the total costs of care.

Welcome to Bea Grause’s world. The facilities she represents are starkly dissimilar in matters that affect their survival, yet she must answer to all of them and help them find common ground.

She and her staff must also provide leadership in other areas, like helping the hospitals meet EHR (electronic health records) goals.

“That’s very hard work,” says Grause, who is on the board of Vermont Information Technology Leaders, the nonprofit organization charged with implementing parts of the state’s health information technology plan. “If you talk to a hospital CEO, they’ll tell you that EHR is one of those major tasks they’re facing.”

It’s unlikely this is what she had in mind when she went to nursing school at Boston College in the 1970s. Born in New Jersey, the middle child among seven, Grause followed the lead of an older sister.

“She went to nursing school, and I thought if she liked it I would, too,” Grause recalled. “That turned out to be correct.”

Interestingly, Grause’s mother returned to school and became a licensed vocational nurse at age 55. Grause’s father was an attorney, and, she says, “I later became an attorney, too, so I’m a product of both my parents.”

After graduation in 1979, Grause worked for a year as a registered nurse at Beth Israel Deaconess Hospital in Brookline, Mass., then moved to California — “because I was young and I could,” she says. She took various jobs as a per diem nurse in a California sojourn that lasted 10 years.

While serving as an RN at Santa Clara Medical Center, Grause became president of a nurses union, and worked closely with the union attorney. It was a turning point.

“She encouraged me to go to law school. I loved being a nurse and felt privileged to take care of patients, but my decision to go to law school was the beginning of having a focus on why things are the way they are in health care, and can I change them to make them better?”

Working as an RN, she supported herself throughout law school, and when, at age 33 in 1991, she moved to the nerve center of health care policy — Washington, D.C. — she worked the evening shift in an emergency room. During a decade in Washington she worked for two House members, represented the hospital associations of Tennessee and Massachusetts, and served as counsel specializing in government relations for a Boston-based law firm.

And she met her future husband. Mark Moore was, and is, an outdoor-recreation devotee, as is Grause. Still tall and athletic at age 54, she was a competitive swimmer in high school and college, and competed in triathlon in California. Perhaps not surprisingly, she met Moore while kayaking on the Potomac River. They were married, and in August 2001 they had their son, Blaine.

Barely a month later, planes struck the World Trade Towers and the Pentagon.

“We couldn’t wait to leave after that, honestly,” says Grause.

As it happened, a headhunter had recently contacted her, seeking advice for filling the leadership position at the Vermont Association of Hospitals and Health Systems. At her husband’s suggestion, she pursued the job herself.

Her visits to Montpelier for interviews charmed her — the association’s headquarters are in a lovely, spacious house on Main Street — and when she was offered the job a month after 9/11 she, Mark, and Blaine moved eagerly to Vermont.

They found a house and four acres in East Montpelier, and in the 10 years since, have added a daughter, Genevieve (now 8), to their family. All four are active in outdoor sports year-round. Moore is self-employed and teaches kayaking, river rescue, and outdoor leadership. He also trains college instructors.

“Coming to Vermont is the best thing that could have happened to us,” says Grause. “We live on a dirt road near the top of a hill, with woods in back of the house. I don’t think I could drag Mark back to Washington if I wanted to.”

And yet, who could have known in 2001 that a new president, nine years later, would introduce sweeping health care reforms? And that a year after that Vermont would take steps toward what could become the first single-payer health system in the country?

Cornelius (“Con”) Hogan has seen Grause’s work from afar, as an advocate for health care reform and coauthor of two books on the subject, following a career in human services in Vermont’s state government.

Now, as one of five members of the Green Mountain Care Board — the panel navigating the rough seas of reform set in motion by Act 48 — Hogan has a closer vantage point. He is taking the lead for the GMCB in setting hospital budgets, which puts him in negotiations with the VAHHS and Grause.

“She’s been doing that job for a while, and she’s gotten some very important work done,” says Hogan. “Bea has gone a long way toward professionalizing the hospital budgeting process. She’s also gotten the hospitals to think of themselves as a system, rather than as individual facilities. To be able to think in those terms is going to be extremely important as we move forward with reform.”

Twenty years ago Bea Grause wanted to get more than an inch deep in critical, society-changing work. She’s far deeper than that, and now finds that to complete the ambitious work before her, she’s going to have to keep digging. •