What more should we expect from OneCare Vermont?

On Wednesday, the Green Mountain Care Board may do something unprecedented in six years of reviewing budgets for accountable care organizations. It’s a punitive cut.

At a meeting last week, new board chair Owen Foster proposed cutting the 2023 budget of OneCare Vermont, a nonprofit that is part of the University of Vermont Health Network, by $216,219.

That amount is less than 1.5% of OneCare’s roughly $15.2 million organizational budget, but its removal would be a message.

“Given the lack of financial accountability, I don’t think it’s appropriate to include that amount in the budget,” Foster said, citing the organization’s own lack of patient health-related performance measures. ‘s management cannot decide how to deploy resources most effectively, and the board cannot serve as a regulatory body, he said.

Accountable care organizations play a key role in contracting with private insurance companies and federal and state governments to provide healthcare to specific patient groups. Vermont’s approach to health care reformOneCare Vermont is Only accountable care organizations I am playing that role now.

A major goal of the reform was to redirect healthcare spending in Vermont from paying for specific services such as visits, surgeries, and tests to rewarding health outcomes.

In Vermont’s current “all payers” experiment, an accountable care organization, specifically OneCare, aggregates payments and incentives from various payers, including Medicare, Medicaid, and certain types of private insurance. It has become a means to The organization passes these payments and incentives to participating hospitals and other healthcare providers in the form of regular monthly advance payments and year-end bonuses or penalties.

This is a much broader mandate than most of the hundreds of other accountable care organizations operating across the country. These organizations tend to either contract with one type of payer and operate within one integrated health care system, or contract with a limited number of different types of providers. .

Discussions at the Green Mountain Care Board virtual meeting last month Given the complexity of the task, setting up this system is more than the organization should have accomplished by now. How much more is it acceptable than just doing it? And if expectations are lowered for the effort, is it worth the ACO’s budget to manage them?

“We don’t want to be in the same situation next year trying to determine if the budget is the right amount without looking more closely at the impact of the program,” Foster said. Board deliberation session on December 14.

The Green Mountain Care Board regulates accountable care organizations in Vermont, along with hospitals and insurance companies. its regulatory role This is why Vermont ACOs are not subject to standard federal antitrust regulations. That oversight includes annual certifications and budget reviews that review the organization’s administrative costs and progress toward meeting its commitments to payment reform and delivering measurable public benefits.

At meetings over the past few weeks, Foster, Tom Walsh and David Merman expressed frustration over how that progress should be judged.

New members frequently referred to the Board’s mission to improve access, affordability, and quality of healthcare for Vermonters.

They said they expect to see a report on annual performance metrics from OneCare that addresses those goals. Instead, OneCare’s measure of progress focused on the number of patients and providers participating in the program.

“We’ve been with the company for six years, and I’m saying, ‘The most important results for Vermonters are: What we are doing to address the systemic problems facing the healthcare system. “We have a poorly performing entity and feel it would be a waste to approve the submitted budget.”

OneCare CEO Vicki Loner responded to the criticism during a public comment period at the end of the board discussion. “In the all-payers model, she believes there is a fundamental disconnect between what the ACO is supposed to do and what the state, policymakers, and the Green Mountain Care Commission are supposed to do. Maybe it’s a difference of opinion,” she said.

Loner said adjusting payments based on spending goals, quality of care and health status is OneCare’s core responsibility under the contract. at a previous hearingshe said the organization is developing its own quality of health outcomes index to be adopted at next year’s board meeting. administrators said the expansion made it difficult to accurately compare patient health care outcomes.

“Perhaps the conversation should be (about): What are the Board’s expectations for OneCare Vermont and its providers? We have worked in good faith as a partner to help implement a full-pay model,” said Loner.

Is OneCare’s work worth it?

It’s unclear if OneCare 2023’s budget will be cut to some extent.

Longtime board members Robin Lange and Jessica Holmes, as well as Merman, said they needed more time to consider Foster’s proposal. and communications spending and cuts equivalent to executive bonuses for 2022.

But in any case, fundamental questions about OneCare’s primary role, its capabilities, and its chances of success in its current structure have persisted since the project’s inception and will undoubtedly continue.

The impact of health care reform is not yet big enough to change the day-to-day decisions of hospitals and providers, say skeptics like Health First. Other provider groups you considered joining.

Fifteen of Health First’s 26 primary care practices have signed up to work with OneCare, network managers Susan Ridzon and Rick Dooley wrote in public comments. The monthly care coordination payments they receive through OneCare remain essential and highly valuable during the pandemic. However, they write:

In some respects, OneCare’s progress is considerable. About 40% of Vermont residents could receive care at least partially associated with outcome-based payments through their organization next year, according to Green Mountain Care Commission staff estimates. All 14 hospitals in the state will participate in some way, and his 82% of eligible primary care providers will participate.

However, OneCare contracts still account for only one-fifth to one-fourth of total medical costs in or on behalf of Vermont.

Monthly payments to hospitals and primary care providers, considered a key component, are expected to be worth $438 million next year, or just under 7% of Vermonter’s healthcare costs.

Participation by self-insurers is purely voluntary, and increasing numbers of patients participating in insurance-based Medicare Advantage plans will not be easily integrated, so regulators will not be able to expand the scope of “all payer” policies. I am raising concerns about the possibility. .

Murman, an emergency room physician at Central Vermont Medical Center affiliated with UVM Health Network, joined Foster on the board in October.

“OneCare of Leading vehicle for cost control health reform and quality improvement in Vermont. That was my impression before these hearings,” he said during board deliberations. We don’t think we will,” Murman said.

But if OneCare is primarily just a middleman for some healthcare costs, is it worth the cost? I have.

From 2017 to 2021, OneCare’s total funding exceeded $133 million, according to the organization’s audited financial statements. About $66 million of that was spent on administration and software to combine and analyze electronic medical records and distribute results to providers.

Approximately $60.4 million was used by OneCare for care coordination work or payments to primary care providers and other community-based health programs aimed at improving care. This amount does not include approximately $31 million in Medicare funding that went through OneCare for community-based organizations involved in the state’s Blueprint for Health program.

Nearly $52 million (39%) of the organization’s total funding during that period came from Vermont’s Medicaid program, with most of the remainder coming from hospital participation fees. At least half of Medicaid funds come from the Medicaid Global Commitment Fund, which the Vermont Department of Social Services has considerable leeway with.

At Wednesday’s hearing, Susan Aranoff, a policy analyst for the Vermont Council on Developmental Disabilities, asked members of the Care Board to consider what else Vermont invested with those funds. rice field.

“That Medicaid money … could have gone to our designated agencies and professional service providers,” she said, and could have been spent on more home care for people with disabilities. “I want to find a simple relationship between Medicaid investments and how they benefit Medicaid recipients.”

Meanwhile, OneCare executives said at a November hearing that their role is, and will continue to be, more than just payments. They share training in data analysis and best practices with their providers, which they say will improve with the move to new software available from the University of Vermont Medical Center.

They also said that facilitating relationships between hospitals and between hospitals and primary care and other providers has been a valuable factor in the state’s coordinated response to the Covid-19 pandemic. A number of OneCare member hospitals and provider groups wrote supportive public comments saying the same thing and urging the budget to be approved.

But at least one expert believes the evidence so far is not strong.

“It’s been an eye-opening few months,” Walsh said last week. “I struggled to see the value OneCare brings to Vermonters.”

Walsh is a professor at the Dartmouth Institute for Health Policy, and the idea of ​​an accountable care organization was developed before the Affordable Care Act, which introduced the structure, was passed in 2010. He also gets paid to consult with other of his ACOs across the country.

“I’ve been trained and taught this conceptual model where I came up with it. I’ve believed it really works. I’ve seen it in action. It’s not working here.” said Walsh. “How much more resources can I keep putting in? I’m struggling with it…because…I want to see it work.”