Editor’s note: This commentary is by Trinka Kerr, who isthe chief health care advocate at the Office of the Health Care Advocate, a special project within Vermont Legal Aid that provides individual consumer assistance and represents the public on health care policy in Vermont.

[C]hange is coming to the way health care is paid for in Vermont. In order to address rising health care costs, state officials and providers have been working to develop an all-payer model that aims to cut costs while providing Vermonters with better care. The state is negotiating the terms of this new model with the federal government, and an agreement is expected soon.

Reducing costs while improving care sounds promising, and it may work if the interests of patients and communities, not just those of insurers and providers, are at the heart of the new system’s design.

The goal of the all-payer model is to motivate doctors and other care providers to think about the cost of the services they provide and to shift toward providing high-value care (better care for less money) instead of high-volume care (more care for more money). In theory, providers will be paid for results rather than for providing or ordering more services, which should eliminate services that are not necessary or not best practice.

Under this model, the state and the federal government would agree on how much health care spending on some services provided by all health insurers (Medicare, Medicaid and commercial insurers) could grow. The federal government would lift some of its rules to allow insurers to pay providers in new ways that are supposed to promote high-value care. It is important to note that the model would not change what services each insurer covers.

To implement the model, the state’s three accountable care organizations (ACOs), which include all hospitals in the state as well as many other providers and health centers, are seriously discussing the possibility of merging into a single statewide organization. This single ACO would take on the cost and delivery of care for much of the state’s population.

Many health care providers like this model because it would give them a predictable source of income. It also has some potential benefits for patients. For example, if the model works as intended, doctors and hospitals should focus on giving patients the services they truly need, rather than focusing on generating revenue by providing more services, some of which might not be necessary. Providers could also use some health care dollars to help address problems that affect people’s health, like lack of access to housing or healthy food.

In many ways, the new model is similar to the health maintenance organizations (HMOs) that were common in the late ’90s. HMOs have been criticized for their restricted provider networks and in some cases for failing to provide necessary services because of cost (“rationing”). Those designing the all-payer model say it is different from the HMO model in that patients will have the freedom to choose which providers they see, and access to care and quality of care will be monitored. However, so far state leaders have not produced any detail about these or other vital consumer protections.

Many questions about the all-payer model remain. How will the state hold the ACO accountable for giving patients the care they need? What recourse will patients have if their ACO providers deny them services or give them sub-standard care? Will the state regulate the ACO like it does commercial insurers? Will the inner workings of the ACO be transparent to the public? Will consumers have a voice in how the ACO is run? Will we know whether or not the system is improving the health of Vermonters?

Patient and community interests should be central to the design and implementation of any new health care system. Advocates and members of the public must insist that policymakers translate these unanswered questions about the all-payer model into robust consumer protections.