[V]ermont regulators asked health care provider groups to meet nearly every Monday for roughly two years as part an effort to create a health care organization that combines all the hospitals in the state, all of the health centers and independent doctors.
The negotiations led to the creation of a monopoly — the so-called all-payer model that Gov. Peter Shumlin’s administration has fast-tracked in the waning months of his term. The Green Mountain Care Board is expected to approve the sweeping reform to the state’s medical system on Wednesday.
Correspondence between the stakeholders paints a starkly different picture than what Shumlin and Al Gobeille, the chair of the Green Mountain Care Board, have said publicly.
The documents show discrepancies between what the board and the Shumlin administration have said about the negotiations and what actually happened or what the implications of the regulated monopoly will be.
Gobeille has said, for example, that it will be easy for the state to get out of the agreement. But communications between the board and providers show that the Centers for Medicare and Medicaid Services do not want the deal to be easily undone.
Last month Gobeille said that lawmakers directed his board and the Shumlin administration to negotiate the all-payer model with the federal government.
But regulators began negotiations with the Shumlin administration and the federal government on the all-payer model as early as January 2015 — before lawmakers knew about the plan.
Sen. Tim Ashe, D/P-Chittenden, says when the administration came to the Senate Finance Committee in 2015 they were already negotiating.
“We did not give them any new authorization” to pursue the model before negotiations started, said Ashe. “They were already having discussions with Washington about pursuing this kind of arrangement” during the 2015 session.
“They continued to say that somehow in that language we (put into the 2015 health care law) had given them authorization,” Ashe said. “They were already asserting the authority from Act 48,” the law that planned for single-payer health care.
Documents also show that the staff of the Green Mountain Care Board and the University of Vermont Medical Center pressured smaller groups of doctors to join the accountable care organization owned by the state’s largest hospital — OneCare. In some instances, the board and hospital officials questioned the loyalty of smaller organizations to health care reform.
Patrick Flood, who led a community health center and questioned the process, said officials knew they wanted a top-down system in advance, as opposed to one that prioritizes community-based care.
“They decided from day one that they were going to have a single (accountable care organization) and it was going to be managed by the medical system,” Flood said. “So here we are. It’s a done deal. In order to get a waiver, we have to produce this ACO.”
Gobeille said in an interview that he disagrees with Flood. Gobeille said that the state knew that the largest groups of providers, called accountable care organizations, would work best under the model because ACOs pool enough money to take on more risk.
The state worked with stakeholders to create a monopoly — the Vermont Care Organization, which is an offshoot of OneCare. The Vermont Care Organization includes representation for community health centers and independent doctors.
On Sept. 15, the day Shumlin said the state would likely get an all-payer deal, he said the providers would benefit from a single health care organization because they would be able to coordinate care and see patients for more than 15 minutes at a time.
“Have we been encouraging of it? You bet,” he said. “But I think the biggest drivers of it have been the providers who know that they’re walking a tightrope between wanting to provide great quality care and stay in business.”
How the all-payer idea was formed
The Green Mountain Care Board started coordinating meetings between Community Health Accountable Care, HealthFirst, and OneCare Vermont in early 2015.
Political tension was high at the time. Shumlin had just barely won his own re-election in 2014 and he had abandoned plans for single-payer in late December that year, much to the chagrin of the Progressive Party and liberal Democrats who were waiting for Vermont to be the first state to pass a single-payer financing system.
The negotiations set up by the Green Mountain Care Board in January 2015 marked a titanic shift between the abandoned goal of a publicly financed health care system, and what the administration has now partially set up — a system in which a single corporation decides what all doctors in Vermont will be paid.
The Legislature appears to have learned about ongoing meetings between the Shumlin administration and federal officials in March 2015, when Gobeille presented the board’s proposed budget to lawmakers.
Sen. Kevin Mullin, R-Rutland, said the Shumlin administration came into the Senate Finance Committee in the 2015 session and asked them to write language into that year’s health care law directing them to hold negotiations, and the committee gave them the language.
Mullin said that what has now been proposed should not be called an “all-payer model” because that name implies that Vermont’s proposed system would be similar to Maryland’s, which requires all insurance companies to pay hospitals the same rate for each service.
At a meeting of the Legislature’s Health Reform Oversight Committee in July 2015, Ashe and other lawmakers told the Shumlin administration they didn’t understand the all-payer proposal that was being negotiated. They asked officials for more details, and were given updates on the all-payer model at subsequent meetings.
By October 2015, Flood, who was CEO of Northern Counties Health Care in St. Johnsbury, started raising concerns during the meetings sponsored by the Green Mountain Care Board. He told the committee “he had great concerns about financing,” according to meeting minutes.
(Flood said in a follow-up interview that his financial concerns were over how much money would “come off the top” of medical care for administrative expenses and other costs. He said he still doesn’t have answers to those questions.)
Three weeks later, Flood and John Michael Hall, the CEO of the Champlain Valley Agency on Aging, complained to the Health Reform Oversight Committee. Hall called the all-payer model “a top-down approach” that ignored home health care providers, who he said are instrumental in lowering health care costs.
Flood told the committee the process for the all-payer model was moving too fast. “At a minimum we need to slow down, and we need to get more input into the design from the people who really matter,” he said.
But Richard Slusky, the former CEO of Mt. Ascutney Hospital and Health System who went on to work for the Green Mountain Care Board, reprimanded Flood three days later when the committee of providers met again.
“Richard (Slusky) shared that he had received calls and emails expressing concern about the testimony provided during the HROC hearing and the detrimental effects it could have on the group’s progress, particularly the comments by Mike Hall,” the minutes said.
Todd Moore, the CEO of OneCare Vermont and senior vice president of UVM Medical Center, said the all-payer negotiations needed to go faster, and said that community health centers should not be acting as representatives of the whole health care system, the minutes said.
“Richard (Slusky) expressed hope that the concerns of the participants would be raised in steering committee meetings, and not in front of the legislature,” the minutes said. “Richard asked for confirmation of a commitment of the group members to work together.”
Slusky reprimanded Flood again in February, because “if the message being given to legislators and the governor is that the ACO approach is wrong … that is not helpful, and could undermine the process,” the meeting minutes said.
In January this year, Shumlin had proposed placing a provider tax on independent doctors and dentists in order to increase how much Vermont’s Medicaid program reimburses both doctors and hospitals. He said the measure would treat the doctors equitably to hospitals.
Flood said Shumlin’s proposal to tax independent doctors hurt the administration’s efforts to bring independent doctors on board. “He said in order to win back providers, we will need to answer some provider questions,” the minutes said.
Flood announced his retirement from Northern Counties Health Care in April 2016.
Pressuring competitors to drop their bid
Regulators designed the all-payer model so that an accountable care organization would take in payments from Medicare, Medicaid, and commercial insurance companies.
The Department of Vermont Health Access has control over Medicaid money. State rules require the state to allow for competitive bids for the administration of Medicaid funds.
But when DVHA issued a request for proposals in April, it stifled the competitive bidding process by specifying that only an ACO could provide care to the Medicaid population in Vermont.
Stakeholders believed OneCare would be the only biddder, an analyst said, but the process was thrown into flux because Community Health Accountable Care, which was on track to merge with OneCare, entered the bidding process.
The issue came up at a meeting on June 6, according to board documents, where representatives for OneCare and Community Health Accountable Care discussed strategies for filing competing bids. They talked about when they would submit their responses to the Shumlin administration, documents show.
Moore, from OneCare, “voiced concern” about Community Health Accountable Care’s bid “and said that it makes it very difficult to reconcile” the smaller ACO with a monopoly planned under the all-payer model, according to the June 6 meeting minutes.
At the same meeting, Gobeille pressured Community Health Accountable Care, saying that he needed a critical mass of participating doctors to set up the all-payer model. “If we can’t get scale, we need to know sooner, rather than later,” the minutes say.
Stakeholders discussed the bid again with representatives from Community Health Accountable Care again June 13. The group withdrew on June 27, according to meeting minutes, but the minutes don’t explain why.
Before Community Health Accountable Care withdrew, Tom Huebner, the CEO of Rutland Regional Medical Center, sent a memo to his staff on June 20 saying it was “troubling” that Community Health Accountable Care had submitted a bid because the ACOs should be presenting a “unified response.”
The minutes from June 27 said: “John (Brumsted, CEO of UVM Medical Center) voiced concerns about CHAC’s action against the will of the group. He asked if we are all still in this together? If CHAC doesn’t address the current situation, is it reasonable to assume nothing has changed?”
On July 5, officials reached an agreement on centralized management of the health care provider system. The new ACO, called Vermont Care Organization, is the basis for the all-payer model.