With state regulators set to vote today on OneCare Vermont’s $903 million budget, critics are stepping forward to slam the performance and transparency of the Colchester, Vt.-based accountable care organization.
Detractors charge that OneCare — which is coordinating the state’s “all-payer” attempt at health care payment reform — is using public money to set up a new layer of bureaucracy that will not lower costs or increase patient access.
“I am deeply troubled by the amount of public money Vermont has spent on the floundering (all-payer) experiment while Vermonters struggle with the costs of paying for basic medical care,” said Deb Richter, a Montpelier-based physician. “This experiment is putting the cart before the horse and should be terminated until we ensure that all Vermonters are covered with comprehensive coverage.”
The Green Mountain Care Board has not taken an official stance on the OneCare budget and is scheduled to vote on the matter today. But at a meeting last Wednesday, several board members took exception to criticism of OneCare, the all-payer model and the board’s regulatory practices.
“Innovation takes time. Fundamental system change takes time,” care board member Jessica Holmes said. “We need to be patient. It’s important to remember we’re in year one of a five-year model.”
All-payer, which stems from an agreement between the state and the federal governments running through 2022, is an attempt to control health care costs and improve quality by moving away from the current fee-for-service model of payment.
Rather than rewarding providers based on the number of procedures and tests they perform, all-payer envisions a shift toward a model in which doctors and hospitals who opt into the system receive a regular, predetermined payment with a focus on preventive medicine and improving health outcomes.
Such “population-based payments” are supposed to provide more stability for insurers and more flexibility for providers.
OneCare is supposed to be driving those changes, and the organization has proposed a 2019 budget that shows an increasing number of Vermonters and health care providers signing on.
That budget features growth in the “total cost of care” — the money flowing from insurers to providers — from $607.2 million in the current year’s budget to $850.7 million in 2019. A significant chunk of that money doesn’t actually flow through OneCare, though it is still within the organization’s oversight because it is subject to all-payer cost-control mechanisms.
Two other, much smaller portions of the OneCare budget are $37.2 million in population health management spending and $15.9 million in operating costs. The first category covers an array of health care investments designed to further the all-payer model, while the latter category includes salaries, benefits, contracted services and other administrative expenses.
All told, OneCare’s budget as currently proposed would increase by about $257 million in 2019. Related documents are available on the care board’s budget review page.
The public comment period for the OneCare budget ended on Friday. As of Wednesday, a majority of those comments were sharply critical of the accountable care organization and the care board’s oversight.
Ellen Schwartz, of Brattleboro, who said she is a Medicare recipient who is attributed to OneCare, told the board that “$903 million is a huge budget for a model with no track record.”
Schwartz also took note of the fact that OneCare is a limited liability corporation created by University of Vermont Medical Center and Dartmouth-Hitchcock Medical Center.
“I urge you to bear in mind that the goal of our healthcare system is not to create additional layers of bureaucracy or additional opportunities to profit from people’s health, especially not on the public’s dime,” Schwartz wrote. “Nor is it to foster the monopolization of healthcare by a few large hospital conglomerates and the for-profit corporation they have created.”
Susan Aranoff of the Vermont Developmental Disabilities Council raised a variety of concerns including the use of Medicaid money to fund OneCare’s growth; the effectiveness of the organization’s population health management spending; and what she sees as a lack of care board supervision.
“The Green Mountain Care Board has not tracked or evaluated the total cost of operating (OneCare),” Aranoff wrote. “Nor has the Green Mountain Care Board determined what it costs Vermont taxpayers to regulate and supervise OneCare. Finally, the Board has failed to properly evaluate the quality and financial performance of the (organization).”
Health consultant Julie Wasserman submitted comments noting that it’s difficult to measure OneCare’s health care quality performance, which is partly linked to funding. For half the 2017 Medicaid quality measures, OneCare either “received no points due to poor performance, or they received the highest score possible regardless of performance,” Wasserman said.
“As a result, OneCare ended up with an impressive overall quality score of 85 percent,” Wasserman wrote. “This does not pass the straight-face test.”
Wasserman also pointed out that OneCare is not meeting annual growth targets in the state’s all-payer agreement. “Vermont taxpayers are paying for this publicly supported project, but only a minority of Vermonters is being served,” she said.
The Vermont Office of the Health Care Advocate — in comments filed Nov. 9 and again this week — has taken issue with OneCare’s transparency and has said the organization’s “activities and 2019 budget proposal do not meaningfully address Vermont’s health care affordability crisis.”
At Wednesday’s care board meeting, Chief Health Care Advocate Mike Fisher said his office supports the goals of the all-payer model. He also acknowledged that reforming health care payment “is a big ship to turn.”
“But sticking with that metaphor, when you have a really big ship to turn, you put the right amount of pressure on it consistently,” Fisher said.
In response to Fisher, Aranoff and other critics of OneCare and the care board, Holmes took issue with what she said are “unrealistic expectations” early in the all-payer experiment. She said the state is “already seeing signs of change” and argued that “we need to take the long view.”
“It may take years before we see significant quality and financial results,” Holmes said. “Achieving scale will take time, too. And it should.”
Holmes added that “no other (accountable care organization) budget could possibly have undergone such careful regulatory and public scrutiny as this one.”
She also took direct aim at the Health Care Advocate’s office, in reference to Fisher having raised a concern about UVM Medical Center and UVM Health Network extending a “monopoly” on Vermont health care via a stake in OneCare.
Holmes said she “found it particularly disappointing that the state’s Health Care Advocate chose to ignore the steps we’ve taken and the progress our state has made toward a better health care system with unsubstantiated and misleading accusations.”
Care board members Robin Lunge and Tom Pelham said they agreed with Holmes’ call for patience.
“I would just ask people to step back and look at anything in the public sector that is significant and transformational,” Pelham said. “It takes time. It doesn’t happen overnight.”
In addition to comments critical of OneCare, the care board also has received a smaller number of comments supporting the organization and the all-payer program. The latest include praise from the VNAs of Vermont and the Vermont Association of Hospitals and Health Systems.
“Few if any other states are working so boldly, deliberatively and collaboratively to coordinate care and redesign the delivery model to focus on wellness,” wrote Jeff Tieman, the association’s president and chief executive officer. “This work is compelling and critical.”
Also on Wednesday, OneCare Chief Executive Officer Todd Moore issued a statement in response to criticism of his organization and its proposed budget.
“We believe OneCare is implementing the right payment reform and population health programs, which enjoy broad stakeholder support, and which are designed to advance results even further beyond the early and very promising results under all-payer model programs,” Moore said.