Gov. Phil Scott has announced that the state is moving forward with the next steps to set up the all-payer health care model started by his predecessor two years ago.
Scott said Wednesday that the state has entered into a contract with the accountable care organization known as OneCare Vermont to have its doctors look after 30,000 Medicaid patients.
The contract will pay OneCare, which is jointly owned by the University of Vermont Medical Center and Dartmouth-Hitchcock Medical Center, monthly fees totaling $93 million in calendar year 2017.
The patients in question all have primary care doctors who work at one of four hospitals that are part of OneCare — the UVM Medical Center in Burlington, Central Vermont Medical Center in Berlin, Northwestern Medical Center in St. Albans and Porter Medical Center in Middlebury.
Scott said the contract would “allow providers to dedicate more time and energy to patients by eliminating some of the time doctors and administrators spend on claims with Department of Vermont Health Access.”
Currently, doctors and hospitals must submit bills to the Department of Vermont Health Access to get paid for treating patients. Under the new contract, the state pays OneCare up front every month, and OneCare gives the money to the hospitals to cover care for those 30,000 patients.
OneCare will pay the hospitals based on whether they meet 12 quality criteria, such as reducing readmissions at the hospitals, getting young people to have well-care visits, screening for depression and controlling diabetes.
Under the contract, if OneCare spends more than $93 million treating the patients, the company will have to absorb the loss. If OneCare spends less than $93 million, the company and the state will share the leftover money.
The chief executive officer of OneCare, Todd Moore, said affected patients will still be able to visit any doctor they choose and will not see any negative changes in their care. He said OneCare will contact the patients to tell them they are part of the program.
Scott called the new contract, whose negotiation process started under Gov. Peter Shumlin, a “pilot” that will allow his new administration to decide whether to move forward with additional agreements under the all-payer model.
The all-payer model is based on a six-year contract with the federal government that sets Vermont up to require most insurers — including Medicaid, Medicare and commercial insurance companies — to fund care in a way similar to the contract announced Wednesday.
“I think Vermonters deserve to be fully educated on what this means, so I think having this program put into place as somewhat of a practice or test session of sorts … will allow us to be transparent,” Scott said.
Scott said the administration would “monitor the situation during the one-year period” and expect Human Services Secretary Al Gobeille to “stay in touch.”
Because the contract is considered a pilot, Moore said, OneCare is seeking to spend close to the $93 million on treating the patients. He said the company needs to prove it can manage to the revenue.
Moore said doctors for the 30,000 patients will not be forced to get prior authorizations for their care. That means patients will not need to follow the current Medicaid practice that requires patients to get referrals to see most specialists.
That also means Medicaid will not be able to deny care to the 30,000 patients. Instead, Moore said, the doctor would have to have the conversation with the patient about whether each test and procedure is appropriate for the patient.
“You’re going to have a much different relationship with your primary care provider practice,” said Dr. John Brumsted, the chief executive officer of the UVM Medical Center. He said doctors and their staff would reach out more and do more coaching to keep people healthy.
Under the model, Brumsted said, “the last thing that you would ever want to do is withhold care because that’s clearly going to end up down the road with an escalation of a process that’s going to be more damaging.”
Moore said OneCare will be required to have a monthly visit with each patient, so the company will work with home health agencies to perform those home visits.