Editor’s note: This commentary is by Peter J. Limon, a retired physicist living in Irasburg.
[T]he Green Mountain Care Board held a public meeting in Newport on Oct. 13 to discuss the proposed Vermont all-payer model for funding health care. As a citizen with no professional connection to the health care system, I found the meeting informative, but I also found some of the information troubling.
Without doubt, our medical delivery system needs fixing. Many of the goals of the all-payer model are laudable and should be put into place. Nevertheless, I believe that the GMCB should reject the all-payer model at this time. My reasons follow.
Most Vermonters that I encounter have never heard about this proposed change to the system of paying for health care and are confused about its goals and methods. Among those who have heard of it, many are skeptical that such a payment system will pay for itself, never mind generating the revenue necessary to support additional private accountable care organizations. Vermont, and especially the GMCB, must do a better job of educating and involving Vermont citizens in a decision of this magnitude that will affect so many of us. The kinds of discussion that are only happening now, just weeks or days before the signing of the contract, should have been going on statewide for months leading up to the decision.
Additionally, I do not understand the need to approve and embark on this route in haste, except as protection against the soon to be implemented new payment models, the Medical Access and Children Health Insurance Program Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS) already approved by Congress. These quality-based payment systems strive to implement many of the goals of the all-payer model. In particular, MIPS has a payment method based on medical outcomes. However, MIPS differs in at least one key respect from all-payer, namely that all-payer rewards health care providers for good outcomes, but does not penalize them for poor outcomes, whereas MIPS does both.
That may be a reasonable decision for a nationwide organization that thinks in large statistical terms, but I do not wish to be a guinea pig for the nation as a whole.
The no-penalty feature was inserted into all-payer in order to attract support from hospitals and medical professionals. In other words, all-payer puts a safety net under the incomes of doctors, nurses and hospitals in Vermont. No wonder that it has received such resounding endorsements from Vermont health professionals. If you do well, you get more money, but if you do poorly there are no financial consequences. Hospitals in Vermont are among the largest employers in the state and have considerable political clout, but this aspect of all-payer is not appropriate.
Since there are no financial consequences for poor outcomes, I do not see where the system will accomplish the savings to turn the health care cost curve over. Hoped-for improvements to overhead costs are unlikely to generate sufficient savings to make up the added administrative costs and profits of the private ACOs needed to implement the model. Where are the data to indicate that such a payment model will generate any improvements in efficiency, much less at the level required?
I was somewhat amazed that the all-payer model was approved by the federal Centers for Medicare and Medicaid Services, the organization that makes the payments for Medicare and Medicaid. I believe they agreed, and supplied some additional one-shot funding, in order to encourage Vermont to be a guinea pig, if you like, to generate the data to see if such an ACO system will work. That may be a reasonable decision for a nationwide organization that thinks in large statistical terms, but I do not wish to be a guinea pig for the nation as a whole. Furthermore, I do not think that Vermont is a good model for the nation. It is too small and too rural, and already has one of the most efficient health care delivery systems in America. Conducting an ACO experiment in Vermont will teach us little about what might happen in the nation as a whole.
What’s the rush? Is it the promise of $50 million from CMS to bolster some of Vermont’s good programs? Is it the promise of up to $200 million in Medicaid “funding capacity”? (What is funding capacity?) In any case, the real problems of current health delivery systems are not going to go away. If all-payer is such a good solution, it will return in a better and better-understood form.
I urge the citizens of Vermont to encourage the Green Mountain Care Board to table the approval of the all-payer model until it has been discussed and debated by a much greater proportion of our citizens, and until studies provide the data to indicate that the all-payer model is a good one for Vermonters. The only way to have a reasonable and thoughtful discussion of the issues and potential solutions is for each citizen to speak up. It is the only way to slow down this headlong rush by the health care establishment.
