[A] Williston-based physical therapy business was denied entry last year to a medical reform group that will cover a large chunk of Vermonters, while physical therapists at the state’s largest hospital were automatically enrolled.
RehabGym owner Sharon Gutwin viewed the rejection by OneCare Vermont, an accountable care organization, as the latest in a pattern of exclusion by the University of Vermont Health Network, which includes the University of Vermont Medical Center and Central Vermont Medical Center. UVM Medical Center co-founded OneCare. The ACO leadership is comprised of higher-ups at the network and the Burlington hospital.
In addition to the ACO rejection, Gutwin recently told the Green Mountain Care Board, the state’s health care regulatory board, that physical therapy referrals from UVM Medical Center and Central Vermont Medical Center have declined significantly in the past several years. She believes the hospitals want to keep their PT business in-house. Hospital referrals to her company were down 27 percent from 2015 through 2017, she said.
A UVM Medical Center spokesperson denied the hospital was steering business to in-house physical therapists and away from outside providers. The spokesperson said the hospital figures showed no change in the number of referrals to RehabGym in the past few years.
Gutwin said she wanted to join the ACO not only for more business. She said physical therapy, particularly preventive care, can lower health care costs by helping clients avoid injuries caused by falls, which can require expensive care.
OneCare is a network of hospitals, doctors, nursing homes, visiting nurses and other providers. The ACO concept is to have providers coordinate care instead of each billing the patient separately for different services.
The ACO has a budget of $620 million and is expected to affect health care for 122,000 Vermonters, about one in five. The plan includes diverting some hospital care funding to support lower-cost preventative care in the community.
In late December, OneCare rejected Gutwin’s request for RehabGym to join the ACO. OneCare account specialist Kelley Beams told Gutwin: “Currently, we have not accepted PT’s in our ACO but I will forward your message to my Director and keep it on file in case this changes.”
Meanwhile, all of the physical therapists at UVMMC were listed as providers in the OneCare network.
Gutwin cried foul, telling Beams: “I feel strongly in patient choice and honest competition. If OneCare promotes exclusion in patient care, I will get involved to change that. Please let me know who I need to talk with.”
Gutwin said she did not receive a reply. A short time later, in early January, Gutwin laid out her concerns to the GMCB — with two of the board members, chair Kevin Mullin and Tom Pelham, asking Gutwin questions. Since she testified, Gutwin was invited to join a GMCB advisory board.
The ACO’s chief operating officer, Vicki Loner, told VTDigger on Thursday that “the door is not closed” on the RehabGym joining OneCare, perhaps in 2018, and said that the rejection was not designed to favor hospital PT services over those of independent providers.
Loner said the UVM Medical Center and Central Vermont Medical Center physical therapists were automatically enrolled as members of the ACO when the hospitals became members last year. If the ACO, which just started, is expanded to include outside PT groups, Loner said that all PTs would be welcome.
Communications with Gutwin could have been better, Loner said. For example, she said OneCare should have been clearer that no “private” physical therapists were among the ACO providers.
Loner described OneCare as an evolving organization and said last year’s setup was chaotic, similar to any new business. The ACO officially started Jan. 1. Loner said the ACO will be adding more providers this year, but said including them without a meaningful role would be window dressing and unproductive.
“We want to make sure we’re creating something for (new admitants) to join, to be involved in some of our prevention strategies, to be involved in our care coordination programs. That’s the whole premise behind what we think about what providers we’re going to bring in the following year,” Loner said.
The OneCare chief operating officer said joining the ACO is not automatically a financial boon — the types of contracts between providers and the ACO can range from a straight fee-for-service to a bulk payment to cover a designated group, the latter requiring some providers to take a financial risk, she said.
Loner also acknowledged that the communication between Gutwin and OneCare could have been better; OneCare should have made clearer that no private PTs had been invited and why the hospital PTs were already included, she said.
In her testimony to the GMCB, Gutwin also raised concerns that OneCare is too dominated by UVM Medical Center and UVM Health Network officials. UVMMC and Dartmouth-Hitchcock co-founded the network and provided “substantial financial support and human resources for the establishment of infrastructure and operational support” for OneCare Vermont, according to the ACO website.
“For this ACO to work fairly, there should be people leading it who are not also working for the hospital,” Gutwin said.
OneCare CEO is Todd Moore, who is also a senior vice president at the University of Vermont Health Network. Jennifer Parks, the chief compliance officer of OneCare, holds the same title with UVM Medical Center. Dr. Norman Ward, OneCare’s chief medical officer, holds that same title at the Burlington hospital. The OneCare board of managers was designed to have a majority of members from UVM Medical Center and Dartmouth and includes UVMMC’s CEO Dr. John Brumsted.
Loner categorically denied the hospital or network unduly influenced OneCare’s agenda. She insisted the ACO acted independently, despite a board of managers that includes UVM Medical Center officials.
“We are all fully employed, dedicated to, march to OneCare Vermont board of managers, not UVM Medical Center,” Loner said.
Gutwin told the Green Mountain Care Board she was concerned about the future of her business, which has three sites, in Williston, Colchester and Barre. She told regulators they were unwittingly worsening the disparity between what she can pay PTs and what the hospital can afford by approving hospital budgets that have produced surpluses. Her businesses offer physical therapy and also have equipment and coaches for clients to do exercises on their own.
“I’m afraid,” Gutwin said about the future of her business, saying UVM Medical Center has been rapidly growing into a monopoly and that she can’t compete on salaries. She has 56 employees. “My referrals are dropping” and insurance reimbursements have plateaued, she said.
If UVM Medical Center continues to direct referrals away from her physical therapy group, she predicted, her company will be out of business in five years.
“Budgets of the hospitals are supporting behaviors that put small business and health care at risk,” Gutwin told the board. Board member Pelham asked if the “closed shop element” she alleged has “become more prevalent.”
Longtime clients, Gutwin charged, have left and returned “and say I’m sorry I didn’t come back to you but the doctor at the hospital had me see their own physical therapist and I said I want to go to the RehabGym, but they said I had to go there.” Former clients, she said, were sometimes not aware when they went to an adjoining room to their doctor that they were receiving PT services and not a further exam.
Ten years ago, Gutwin told the board, UVM Medical Center required its orthopedic doctors to justify in writing when they referred a patient to a PT provider outside the hospital, a practice she said they stopped once it was made public.
UVM Medical Center spokesperson Michael Carrese denied the hospital steered patients to in-house physical therapists. He said patients were free to go where they wanted. Half of the recent PT referrals from UVM doctors went to outside providers, he said.
“If the patient does not have an existing relationship with a PT, they are referred to our therapy providers if we can provide what the patient needs. Therapy services are also co-located with some of our physician practices, such as cardiology and orthopedics at Tilley Drive in South Burlington, which often makes it more convenient for patients,” Carrese said Friday.
The PTs employed by the hospital have seen only a 2 percent increase in business in the last several years, he said, primarily because of the co-locating of doctors and PTs.
Carrese said hospital figures showed no change in referrals to RehabGym in the past few years.
In an interview, Gutwin also questioned the practice of insurers, including the dominant carrier, Blue Cross/Blue Shield of Vermont, to pay hospitals with medical schools, like UVM Medical Center, a higher fee for services than outside providers. She said the higher reimbursements tilted the competitive advantage further to the hospitals, giving them more revenue to pay their employees.
Blue Cross Vice President Andrew Garland confirmed the insurance company pays higher reimbursements to hospitals with a medical school for most services, including PT, than to private providers. He said the practice is typical nationwide, with hospitals requesting the higher rates to help cover the cost of the academic institution.
Gutwin told the board she was “not a complainer. I’m a problem solver” and wants to find a way to work within the changing health care system to help patients get better and avoid injuries with preventative exercises.
“What floats my boat are the clients who say you’ve changed my life,” Gutwin said.
