Norwich
The key to making such gains, Shumlin said, is a so-called all-payer plan, which is designed to boost payments to primary care doctors and increase their role in a now-fragmented array of health care services.
“I think this system could fundamentally alter the priorities in our health care system,” the outgoing governor said at a two-hour public meeting at the Montshire Museum of Science.
The plan, as spelled out in a draft agreement between officials from Vermont and the federal Centers for Medicare and Medicaid Services, is essentially “a private sector, provider-led reform with government oversight,” said Al Gobeille, the chairman of the state’s Green Mountain Care Board, which regulates hospital expenditures and health insurance rates.
“There’s nothing in this that’s the heavy hand of government forcing providers to do something,” Gobeille said earlier in a meeting with Valley News editors and reporters.
Currently, about 95,000 Vermonters covered by Medicare, Medicaid or commercial insurance get care coordinated by primary care providers who participate in an organization called OneCare Vermont.
The all-payer plan would build upon that framework, under an arrangement called capitation that pays providers a set amount for each patient and allows them to parcel out care and attention where it is needed.
About 30 percent of Vermonters would need to be assigned to the all-payer organization by their doctors to make it viable, Gobeille said.
The current health care system is run by insurance companies, or payers, Gobeille said at the public meeting.
“The all-payer model takes the payers out,” and puts doctors and other providers in control, he said.
That system would allow doctors to give “less care to people who really don’t need that care,” said Mark Nunlist, a primary care doctor who retired from White River Family Care practice in White River Junction.
One questioner worried that the quality measures used in the all-payer system might “inspire the provider to do less for you because he knows” regulators are counting how often certain services are given.
But Shumlin said that “in a capitated payment system, (providers) would make sure you are back on your feet before you walked out the door.”
Capitation could also affect a provider’s approach to caring for a patient with diabetes, he said: “You suddenly care deeply what the blood sugar is every day.”
Noting that fewer than half of the primary care practices in Vermont are now accepting new patients, Gobeille said that a key to the all-payer model would be greater reimbursement of these family doctors: “If we don’t pay primary care more, the model won’t work, and it won’t be good for us.”
In its final months, the Shumlin administration has turned its attention to health care reform despite the well-documented and politically damaging pratfalls in its earlier efforts. Meeting with editors and reporters on Monday, Shumlin said those problems were in the past.
A $200 million expenditure on Vermont Health Connect, an website for individual health insurance shoppers and Medicaid recipients, suffered a plague of glitches and breakdowns.
No more, Shumlin said. “Vermont has the best functioning exchange in America,” he said, after acknowledging that “it was very painful … getting where we are.”
Shumlin also quickly dismissed the abandonment in December of a yearslong effort to install a “single-payer” system in which all Vermonters would be covered by publicly financed health insurance. That push was dropped because of its excessive costs, he said.
Gobeille said at the Montshire that while he couldn’t guarantee that the new system would work, it is already clear that the current system doesn’t.
“Doctors get paid when you’re really sick, not for keeping you healthy,” he said.
But reorienting health care toward efforts to make people healthier could pay off, he added: “You don’t have to make everyone vegan or everybody a triathlete, you just have to make them a little bit better.”
Approval of the new deal with the feds also could give a boost to Vermont’s fiscal health, according to Gobeille.
Approval of the draft agreement would keep going an otherwise about-to-dry-up flow of Medicare money of nearly $50 million over six years. It could also generate $209 million in federal Medicaid funding that could be invested in the all-payer project, he said.
Several executives from local social service agencies showed up at the Montshire and voiced their support for the all-payer concept.
But not everyone left convinced.
“I still have lots of questions,” said Tracey Kawecki of Norwich, a single-payer supporter. “Health care is a right, not a privilege,” she added. “I’m seeing all kinds of cobbled-together solutions.”
Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229.