Betty Rambur is the newest representative of the five-member Green Mountain Care Board, created in 2011 as part of Act 48. Board members are charged with delivery of a reformed single-payer health care system by 2017. Rambur is the board’s first and only nurse.

It was friends who urged her to apply, she recently told Vermont Woman. The opening on the board wasn’t on her radar; it was summer and she was gestating ideas to simplify health economics for her students. During the school year, she was a health policy and nursing professor, a researcher at the University of Vermont. She served on boards and committees at Fletcher Allen Health Care.

It made sense, with her long history of involvement and interest in health financing reform. That the board did not yet have a nurse made the fit feel right for Rambur. She applied just before deadline, and got the job.

“As a nurse, I feel I have a particular responsibility to the public,” she says. “Nurses have the opportunity to see things that are not always visible to policy makers or other providers. Nurses are often the connection between the patient and the health systems. Nurses are everywhere in the system, and have a particular, up-close vantage point.”

Give the Job to the Busiest Person

Originally from North Dakota, Rambur’s education and career progressed from registered nurse, to nurse practitioner, and then on to two graduate degrees from Rush University in Chicago. She worked in community medicine and institutional cooperation. With a Ph.D., she began teaching at the University of Mary in Bismarck, N.D., becoming a professor and ultimately chair of the nursing division.

But Rambur says Vermont is her “heart home.” When a position opened at the University of Vermont, for dean of the then-separate School of Allied Health Medicine and School of Nursing, it was a clear calling. She and her family moved east.

“When I arrived at UVM, my charge was ‘to do something about the two schools,’” Rambur explains “[The separate schools of Allied Health Medicine and Nursing] had years of declining enrollments with a high cost of instruction. The ‘what’ was up to me. It could have included closing programs. But instead, with the help and support of the faculty, it seemed that merging and redesign was the best strategy.”

During her nine years as a dean at UVM, her accomplishments included the creation of the Office of Nursing Workforce Research, Planning and Development, and the merger of two separate schools into one: the College of Nursing and Health Sciences.

Combining the schools enabled interprofessional education and interdisciplinary research “within a more affordable configuration of programs,” she says. Rambur's research has focused on workplace issues, such as workforce retention, workforce quality, and ethics.

Rambur credits the Chekhov story, “Ward No.6”, with shaping what drives her. It describes an educated doctor who becomes immobilized by the hopelessness of his appointment to a lunatic ward; he succumbs to rationalizing his inactivity.

“Here was a man who had an opportunity to change something, and didn’t,” says Rambur. “And that really stuck with me.”

Dr. Rambur (left) mentors Doctor of Nursing Practice student Carolina Baldwin on the details of payment reform.

A Familiar Dance

Rambur’s interest in health care policy is not just academic. While finishing her doctorate in rural health care, she was asked to represent the nurses association in North Dakota. She joined its healthcare reform initiative, begun in response to President Bill Clinton’s call for reform.

After a year on the board, she was invited to chair it, a position she held for four years.

“It was a different state, a different era,” Rambur says. “But it gave me the foundation and experience for complex details.” Though the board did not achieve its intended goal of universal access, under Rambur’s leadership the nurses did succeed in implementing medical malpractice reform, winning direct reimbursement for nurse practitioners, and expanding of Medicaid services from 33 percent to 100 percent of those below poverty level.

Just beginning her term with the Green Mountain Care Board, she says she is “growing into a new position. Yes, there’s a learning curve, but I feel well-prepared and solid. Yet it’s all new, too, with different grants and opportunities.” She calls it “delicate work,” holding nursing care for patients together with overarching policies and finances. Rambur sees herself as a multifaceted player, and says, “I am interested in the whole ball of wax.”

For Rambur, the wax ball is a large one. My conversation with this quiet-voiced powerhouse led us to dry economics terms, such as payment reform and its incentives and disincentives, but also to more juicy topics, equally close to her heart.

First, Do No Harm

In the current system of fee-for-service, Rambur explains, each medical service is paid for separately. This encourages physicians to provide more services, favors quantity over quality, and results in overtreatment.

“Incentives drive behaviors,” says Rambur, “So we need to redesign the system with incentives to really make a difference to the patient and family. For that to happen, we need to understand the patients’ preferences and values. The nation is a paradox of overtreatment and undertreatment,” Rambur says.

Undertreatment happens when people don’t receive preventive services or timely treatment. Lack of insurance or money to pay for a treatment can eventually result in more expensive and serious crisis care.

Overtreatment refers to unneeded lab tests, procedures, and screenings that inflate patients’ medical bills, and can even cause harm.Rambur thinks it is important to address both systemic flaws, but says,

“As a nurse I am particularly concerned about the often invisible harm of overtreatment. Overtreatment not only harms the individual, but—because of the associated expense—harms all of society. There have been few effective handbrakes on the health care system, and we now have a totally unsustainable model. That is why payment reform is such an exciting element of current reform initiatives. As we move away from fee-for-service for acute episodic cure-based care, we have the potential to create a care-based delivery system.”

This view echoes what fellow board member Dr. Karen Hein spoke about in a previous Vermont Woman profile. Rambur reiterates that the social determinants of health, or the way we live our lives--eating, drinking, smoking, exercising--have the greatest impact on a person’s health--yet assistance with these currently draws only 10 percent of health care dollars.

Overconfidence in high-tech interventions also contributes to overuse. “In medical school there is much simulated learning,” says Rambur, “but very little simulated learning when the right answer is watchful waiting. Eighty percent of the diagnosis should come from patient history, and 10 percent from the physical exam, with the rest coming from special tests. Unfortunately, too large a part now comes from special tests.”

Consumer expectations can contribute to overtreatment. “This is where a program like shared decision-making becomes important.” That process helps patients to understand the pros and cons of a particular approach, as well as the value of not treating. Patients then have a better-informed sense of their options.

“When we spend too much on health care, we don’t have the money to invest on education and prevention--the very factors that are the best predictors of health and wellbeing.” Rambur gave other examples of resources strained by health care costs. “There was a study in The New England Journal of Medicine that talked about housing as a medical prescription. In another study, it says that the best predictor of a child’s health status is the education of the child’s mother.”

Rural Sustainability

The basic tenet underlying all Rambur’s work gets to the question: What allows humans to flourish, in a sustainable way, especially in rural areas? Sounding similar to Maslow’s hierarchy of needs, a theory taught in basic nursing courses, Dr. Rambur argues that an individual can’t begin to think about improving her situation until basic physiological needs are met. There are progressive levels in health care, depending on the need: medical care when one is acutely ill and needs treatment; health care for the ongoing treatment of chronic diseases; health and wellness maintainancee and prevention of illnesses, and finally human flourishing, or realizing one’s dreams.

“When health care becomes unaffordable, and with all of us baby boomers moving into old age together,” Rambur explains, “there is a negative impact on human flourishing. Not just now, but for generations to come.” Rambur explains. “We have to have longer accountability-horizons, to think of our children and grandchildren leading a vibrant life, and not having to pay for the health care indulgences of the present generation.”

Although Rambur grew up in western North Dakota, her particular love for rural health emerged when she was a graduate student living in Chicago. Working in a tough, inner- city neighborhood, Rambur says, “I saw that urban areas had some of the problems shared by rural ones, such as out-migration of talent, and poverty, for example. But I also realized that rural life is a unique and precious thing, both resilient and fragile at the same time. My lifelong professional work, from that point on, has been on the rural health infrastructure, as just one contributing factor to people’s ‘flourishing’ in rural areas.”

Interested in how elders could remain in their own home, Rambur’s dissertation focused on the question of what people needed to thrive in a rural state. She was funded by the National Institutes for Health to study barriers to delivering home health services in rural areas.

“I found that for many people, the tipping point that took them from home to nursing home was a seemingly small thing that cascaded into illness.” Rambur gives examples not farfetched for Vermont: An elder lives alone in a rural area in a harsh winter, is not able to get the mail, doesn’t pay her bills, and the heat is turned off. Or perhaps, going out to the mailbox for her heating bills, she falls down on the ice.

Rambur Flourishes

For Rambur, the best health care system will be one that impacts positively, quietly, and for generations to come. She cites the saying: “There is an Eastern saying on leaders that says, ‘‘While bad leaders are hated, and good leaders are loved, the best leaders are unnoticed.’ My adaptation is, ‘While bad health care systems are hated, and good health systems are loved, the best health systems are unnoticed.’ By this I mean that people have what they need, when they need it, and are unencumbered by excessive cost or complexity.”

Rambur is the mother of three, two of whom are grown, with one teen still at home. She maintains a long-distance relationship, and is a long- time student of movement meditation and Tai Kwon Do, with a more recent shift to Zumba and yoga.

To relax, she works on her user- friendly health economics book, and enjoys making health finance and policy come alive for her students. During her board service, which lasts until August 2015, she will take a partial leave of absence at UVM, which will allow her to advise graduate students and teach online. She says she is inspired by her students.

What Will Look Different?

Rambur describes a picture of what Vermont health reform will look like, and admits, as all other board members have said in this series, reform is all a work “in process.” However, Rambur says her bottom line is accountability to Vermonters.

“Every piece of info has to be viewed through that lens,” she says. ”Though I am educated in health policy, it’s very different to be plunged into the working world. It’s one thing to think you know what to do. The real challenge is how. How do you get this thing done? I bring my knowledge of health financing, health economics, the healthcare workforce, an understanding of large data bases and quality metrics, and an understanding and passion for life in a rural state.”

Much of Rambur’s research has focused on creating a good workplace for nurses, so that nurses are retained. She says healers need to work in a place that allows them to give their best self. “Most people become health care professionals because they want to help. Yet, there are challenges in creating a robust and flexible health care work force, one that can really respond to situations. Nurses can also be change agents to redesign the care of patients,” she says.

“For example, most of the nurses in today’s workforce were trained in fee-for-service acute episodic care, not in the chronic condition management that will be so important to an aging society.”

Along with an aging population, we have an aging nurse workforce, headed to retirement. Currently, according to statistics from UVM’s 2011 Board of Nursing Relicensure Survey, the average age of working nurses that year was 52. (The voluntary online survey had a 12 percent response rate.)

“While we want to retain the wisdom of the seasoned professional, it is a problem when more nurses are leaving than coming in,” she says. “Our office [of nursing workplace research and planning] did a lot of work around retention and recruiting young people, and we had success with that. We targeted a fork in the road of career decision-making as early as sixth grade. We found that students’ greatest interests were in not being bored. So we tried to reach out to young men and women to think about nursing as a career. We showed how they would not be bored by this choice.”

Rambur explains her research includes study of “moral distress” in the workplace. “This is different than a moral dilemma, when you don’t know what to do because it’s hard to tell what is right or wrong,” she says. “Moral distress is when you feel you do know what to do, but aren’t able to execute that [action] because of organizational hierarchy or other constraints. So we have studied how we can create systems in which people can respond from their ethical core, in terms of what’s best for the patients.”

Rambur has also lent her energy to a recommendation from the Institute of Medicine’s 2010 Future of Nursing report. It recommended more nurses be placed on hospital boards and politically appointed boards, like GMCB. “Nurses have a perception of health care that is closest to the patient experience,” says Rambur. “But most nurses don’t think about being on a board position. I secured a grant to prepare nurses in these leadership skills.”

Finally, Rambur turns to a famous nurse leader to summarize her responsibility to the people of Vermont. From Florence Nightingale’s Notes on Nursing: What It Is, and What It Is Not, she quotes, “Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?”
Apt words in 1859, and now—as Vermont health care comes up for review in 2014.