VERMONT

‘Leap of faith’: New health payment system expected to touch 122,000 Vermonters

April McCullum
Burlington Free Press

COLCHESTER - There's a long-awaited shift happening behind the scenes in Vermont hospitals, doctor's offices and nursing homes this winter.

Dr. Jim Ulager meets with Clinical Care Associate Donna Blanchette at the UVM Health Network in Hinesburg on Tuesday, Oct. 31, 2017, to review recent and upcoming patient care at the office.

Through the accountable care organization OneCare Vermont, 10 hospitals have agreed to take financial responsibility for health care spending for certain patients in their local areas.

That spending will be measured against a set target. Hospitals and other local health care providers can keep some of the savings if patient care costs less than the target. Hospitals will be on the hook for overages, even if they never saw the patient.

Starting in January, the new model could reshape the health care payment system for more than 122,000 people, or about one out of every five Vermonters.

The effort has drawn intense interest — but the prospect of a new organization handling health care costs makes some observers nervous.

The leader of OneCare, Todd Moore, calls the model a "leap of faith by the hospitals." He hopes the experiment will pay off by mitigating increases in overall health care costs and making Vermonters healthier.

OneCare Vermont wants to take some money that would have been spent on hospital care and use it to support lower-cost care at doctor’s offices and elsewhere in the community, as well as new computer systems for analyzing data and sharing information. The model is supposed to make health care more efficient without limiting care available to patients.

OneCare Vermont CEO Todd Moore, right, and OneCare Vermont Director of Finance Tom Borys speak to the Green Mountain Care Board in Montpelier on Thursday, Nov. 2, 2017.

"We can't deny care. We can't determine medical necessity," Moore said at a Thursday hearing at the Green Mountain Care Board in Montpelier. "We can't control where people go to get their care, if their benefits allow them to see any provider that they would like.

"So we've got to do it the old-fashioned way," Moore continued, "which is just deliver highly-effective, efficient care, and try to keep people from getting sick in the first place. And if people are already sick, try to keep them engaged in their own health and as healthy as possible — and out of the most expensive settings of care."

Patients are expected to be counted in the OneCare model if they are covered by Medicare, Medicaid, Blue Cross Blue Shield’s qualified health plans or the University of Vermont Medical Center employee plan, and if their primary care provider has agreed to participate in the effort. OneCare has not yet signed final contracts with the three insurers.

Health care regulators at the Green Mountain Care Board are currently weighing whether to approve OneCare’s $620.8 million budget. About $600 million is budgeted for patient care, about $12.5 million is budgeted for OneCare's operational expenses, and the rest would go toward pilot projects and other initiatives to support the health care system.

The Green Mountain Care Board's decision is due by December.

Gearing up

OneCare is an accountable care organization founded by the University of Vermont Medical Center and Dartmouth-Hitchcock Medical Center.

For 2018, OneCare has gathered a group of about 160 health care organizations — hospitals, nursing homes, home health agencies, independent doctor’s offices, mental health and substance abuse agencies and specialists — who have signed up to participate in the new payment system.

OneCare’s model is building upon an agreement between Vermont and the federal government that was negotiated under Gov. Peter Shumlin, allowing more flexibility in health care payments in exchange for improvements in Vermonters’ health.

Health care providers currently get paid for each patient visit, test and procedure in what’s known as a fee-for-service system.

“They’re highly incentivized to see patients, treat ’em, get ’em out,” said Dr. Mark Depman, the medical director of the emergency department at Central Vermont Medical Center, at a recent OneCare event. “Rack up as many charges as you can.”

Doctors say the payment system places their focus on sickness, rather than overall health.

“We should be incentivizing the good provision of care and not how many widgets you’re checking,” said Dr. Jim Ulager, associate vice president of medical group operations at University of Vermont Medical Group and a doctor at Hinesburg Family Health.

With agreements from Medicare, Medicaid and Blue Cross Blue Shield, OneCare is moving toward a model where health care providers get paid for the number of patients they care for. Primary care providers will be paid $3.25 per patient per month. For the sickest patients, every health care provider involved in their care will receive an additional $15 to $25 each month.

The 10 hospitals participating in OneCare will receive fixed monthly payments for the care they provide.

OneCare Vermont office in Colchester

Three independent primary care practices —Thomas Chittenden Health Care in Williston, Cold Hollow Family Practice in Enosburg Falls, and the statewide organization Primary Care Health Partners — will also receive a lump monthly payment through a special pilot project.

OneCare hopes that these predictable payments will give health care providers more flexibility to spend time on things that normally could not be billed to an insurance company.

A nurse practitioner might be able to spend more time with a patient during an office visit. A specialist might be willing to answer a question over the phone. An emergency room doctor might ask a patient more questions about the life choices that led to a hospital visit. And everyone will have access to more data.

"We're going to be looking at our patients in a whole new way that involves collaboration in every element of the health care spectrum in our communities,” Depman said.

After the year is over, each hospital will be held accountable for health care spending in their local area. Any savings will reimburse hospitals for their contributions in OneCare before flowing to other providers. Hospitals are responsible for a total of $21.5 million in financial risk.

The University of Vermont Medical Center, for example, is on the hook for up to $9.6 million.

OneCare will also judge providers on a suite of quality measures. If the organization does well, everyone will share a $4.3 million bonus, with the bulk of the incentive going to primary care providers.

An unproven step

OneCare is a new layer on a complex health care system, and patients and doctors alike are struggling to understand the new payment model. When contacted by the Burlington Free Press, several of the health care providers who have signed up to participate in OneCare next year said they didn't know enough to comment on their decision.

Some observers, however, have already raised concerns.

Actuaries for the Green Mountain Care Board have questioned whether OneCare will be able to hold annual health care spending growth to a target of 3.5 percent.

"OneCare needs to demonstrate the steps they are taking in 2017 and the future years are effective in controlling the increasing costs and utilization," the actuaries wrote in a letter Nov. 1. They added that OneCare needs to provide "much stronger documentation" to explain how its spending targets were calculated.

Dr. Allan Ramsay, a primary care physician who served on the Green Mountain Care Board until 2016, said he worries that OneCare is inching toward the health maintenance organization model of the 1990s, when doctors acted as "gatekeepers" and determined what kind of care patients could receive.

"None of us want to be moved down that path towards being a gatekeeper again," Ramsay said at the Nov. 2 hearing.

Moore replied that OneCare is trying to relieve administrative burdens and does not intend to impose a new system of prior authorizations.

Dr. Louis Meyers, a physician who lives in Williston and works at Rutland Regional Medical Center, is worried that the OneCare model will result in doctors relying too much on checklists and metrics during patient visits. He compared it to the national education law No Child Left Behind, which tied school funding to test scores.

"If the OneCare all-payer crashes and burns, we can't go back," Meyers said, "and it will make the problems of the Vermont Health Connect seem like child's play."

Dr. Joe Haddock of the Thomas Chittenden Health Center in Williston on Monday, July 24, 2017.

Dr. Joe Haddock, a primary care doctor at Thomas Chittenden Health Center in Williston, is taking a wait-and-see attitude.

In his 39 years in practice, Haddock said, most efforts to strengthen primary care have resulted in a greater administrative burden but no new money.  

The OneCare model, Haddock said, could be different.

"The biggest risk to primary care is not to change the reimbursement program in this country," Haddock said. "So we see this as a change which might work, and it might not."

Impact on patients

Many patients will see little impact from the OneCare model, according to state health care experts. Insurance plans are not changing.

"If you’re a healthy person, you’re not going to see much change," said Kevin Mullin, the chairman of the Green Mountain Care Board. "You may see a little bit longer office visit with your primary care provider, but that's probably the only change you would see."

Vermonters with chronic health conditions or major challenges may see more coordination between their doctors, hospitals and specialists.

Medicare patients could see some changes because of waivers of three Medicare rules. Medicare may now cover telehealth services for patients in Grand Isle, Chittenden and Franklin Counties. Medicare patients who have been discharged from the hospital will be eligible to receive a home health visit from someone who can check in on new medications. And patients can access nursing home services without having to stay three days in a hospital first.

It’s not clear whether OneCare will have any impact on patients’ pocketbooks.

At a recent Green Mountain Care Board meeting, Walter Carpenter, 62, of Montpelier, stood and asked whether the OneCare model would reduce health care costs. Will there be any relief for people with a $10,000 deductible?

"Will the ACO, down the road, mitigate out-of-pocket costs, eliminate or exacerbate them?" Carpenter asked. "That's my question, because that's the real problem."

Walter Carpenter, 62, of Montpelier, wants to know whether Vermont's new accountable care organization model will mitigate patients' costs for health care or eliminate administrative barriers to care. Pictured outside a Green Mountain Care Board meeting on Nov. 2, 2017.

Other patients are concerned that the OneCare financial model will lead to rationing of care, and denial of essential services.

"We need to keep a really close eye on it. And I think that we need to get as much feedback from patients about any changes for the positive or for the negative in their experience in getting access to good quality care," said Mike Fisher, a former legislator who now serves as the chief health care advocate at Vermont Legal Aid.

Mullin, the chairman of the Green Mountain Care Board, says the state will be keeping tabs on data about health care quality, in addition

"It's really our job as the regulator to make sure that the quality side of the equation is being met," Mullin said, "because if it’s not, the plug should be pulled."

OneCare players in the Burlington area

The following Burlington-area health care providers have agreed to participate in the OneCare network in 2018, according to OneCare.

Hospital:

  • University of Vermont Medical Center Inc.

Primary care providers:

  • Alder Brook Family Health, P.C.
  • Charlotte Family Health Center Inc.
  • Christopher J. Hebert, PC
  • Essex Pediatrics, PC
  • Evergreen Family Health Partners, LLP
  • Gene Moore MD, PLC
  • Green Mountain Internal Medicine PLC
  • Hagan, Rinehart & Connolly Pediatricians, PLLC
  • Pediatric Medicine PLC
  • Primary Care Health Partners - Vermont LLP
  • Richmond Family Medicine PLLC
  • Richmond Pediatrics and Adolescent Medicine LLC
  • Thomas Chittenden Health Center, PLC
  • UVM Nursing and Health Sciences Practice Group

Specialists:

  • Affiliates in Obstetrical and Gynecological Care Inc.
  • Arthritis & Rheumatology Center, PLC
  • Associates in Gastroenterology, PLLC
  • Eye Vermont
  • Mary Stanley MD PC
  • Matrix Health Systems P.C.
  • Neurological Associates of VT
  • NFI Vermont, Inc.
  • Paul Kenworthy, DMD, PC
  • Planned Parenthood of Northern New England
  • Retina Center of Vermont, Inc.
  • Timber Lane Allergy & Asthma Associates PC
  • Vermont Gynecology, PC
  • Vermont Orofacial Pain Associates PC

Special service agency:

  • Champlain Community Services, Inc.

Skilled nursing facilities: 

  • 300 Pearl Street Operations LLC (dba Burlington Health & Rehabilitation Center)  
  • Starr Farm Partnership

Naturopaths:

  • Champlain Center for Natural Medicine
  • Lorilee Schoenbeck N.D., P.C. DBA Mountain View Natural Medicine

Home health and hospice:

  • Bayada Home Health Care, Inc.
  • Visiting Nurse Association of Chittenden and Grand Isle Counties, Inc.

Designated agency:

  • HowardCenter, Inc.

Contact April McCullum at 802-660-1863 or amccullum@freepressmedia.com. Follow her on Twitter at @April_McCullum
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