Health Care

State enters $93 million ‘pilot’ program for Medicaid care

Phil Scott
Gov. Phil Scott appears at a news conference Wednesday to announce a deal between the state and OneCare Vermont to treat 30,000 Medicaid patients. Behind him are Tom Huebner, the CEO of Rutland Regional Medical Center, left, and Dr. John Brumsted, the CEO of the UVM Medical Center. Photo by Erin Mansfield/VTDigger
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.

Al Gobeille
​Al Gobeille, the secretary of the Agency of Human Services, speaks about the all-payer model at a news conference Wednesday. Photo by Erin Mansfield/VTDigger
“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.


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Erin Mansfield

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  • Aula DeWitt

    What is the reason OneCare will be required to have a monthly visit with each patient? That sounds excessive to me unless they have chronic conditions which require close monitoring.

    • Tim Patterson

      See Todd’s comment above – only 5% of highest risk enrollees will have monthly interactions.

  • Holly Lane

    What part of the $93m will be spent to run OneCare? What percentage will go to OneCare administrators’ salaries and what percentage will go directly to patient care in the pmpm payments? For comparison, how much money was spent on Medicaid in the last fiscal year? Where is Dr. Dinosaur in all of this? If the intention of the pilot is to save money, these “administrative” questions need answers.

  • Todd Moore OneCare

    Thanks for the coverage Erin. A couple of quick clarifications: (1) in addition to doctors who work for the four hospitals, there are also doctors participating from independent practices and Federally Qualified Health Centers (FQHCs) in the areas served by the four participating hospitals; and (2) It is only for the highest risk enrollees, approximately the top 5%, that we will be working toward monthly interaction. This interaction can be a combination of in-office appointments, telephonic contact, and home visits by our community partners. There are other approaches for engaging enrollees outside of the high risk category, designed to be appropriate for their needs.

  • Brian Scott

    Until something is done to control pharma costs, we will never see affordable health care in this country.

  • John McClaughry

    Suppose the patient needs an MRI. Will the UVM Medical Center, which controls the ACO, let the ACO send the patient to a standalone MRI center in South Burlington for $800, or insist the patient go to UVM Medical Center which will bill (something like) $1900? Will the ACO make the most efficient use of all providers, or will it send its business to the high-cost providers (namely, UVM and D-H, which control the ACO)?

    • Lisa Nicholson

      Good questions

  • Lisa Nicholson

    So -someone gets a flat rate per individual PT and that PT has needs higher than their per capita amount? If the whole group has higher needs one month but the cap has been hit?
    Incentive to Treat? Or just take your monthly fee and hit your cap and be done. Who monitors the balance of that to ensure people get the care they need?

  • Are all the elected Republicans onboard with this? I’m scratching my head.. did we reelect Peter Shumlin. I really can’t tell the difference between the two of them.

  • John McClaughry

    Suppose the patient needs an MRI. Will the UVM Medical
    Center, which controls the ACO, let the ACO send the patient to a standalone
    MRI center in South Burlington for $800, or insist the patient go to UVM
    Medical Center which will bill (something like) $1900? Will the ACO make the
    most efficient use of all providers, or will it send its business to the
    high-cost providers (namely, UVM and D-H, which control the ACO)?

  • Edward Letourneau

    This entire plan sounds like a give-away to the UVM medical center. I see no benefit to people who live in other areas of the state.