Editor’s note: This commentary is by Richard Slusky of South Burlington. He is a retired CEO of 28 years of Mt. Ascutney Hospital and Health Center, retired director of payment reform for the Green Mountain Care Board. Slusky has served on boards and committees of the Vermont Hospital Association and the American Hospital Association. He currently serves on the Vermont Information Technology board of directors, and is a lifetime fellow in the American College of Health Care Executives.
[T]his past July, I wrote a VTDigger commentary expressing concerns about Blue Cross Blue Shield’s request for an 11.2 percent premium increase for its 2019 large group health plans and their apparent lack of initiative to educate and enroll more of their members into Vermont’s health care reform programs.
As I noted in that commentary, “Vermont has chosen to implement some very progressive health care reform initiatives by choosing a path that encourages collaboration among payers and providers within the framework of a strong regulatory environment, overseen by the [Green Mountain Care Board].”
In this regard, the state negotiated an agreement with CMS/Medicare (the all-payer model) that puts an annualized cap on per-capita health care cost growth for all payers (including Medicare, Medicaid and commercial payers) at 3.5 percent per year for five years through 2022. In addition, the state committed that 70 percent of all Vermont insured residents and 90 percent of Medicare beneficiaries will be covered under the all-payer model agreement by 2022.
These goals can only be accomplished if payers move away from fee-for-service payments and toward multi-year, fixed payment arrangements to providers through the State’s one accountable care organization (OneCare Vermont) and a significant percentage of the approximately 260,000 Vermonters who are enrolled in commercial or self-insured employer-based health plans become covered under this all-payer model agreement.
In his latest blog in A Vermont Journal (Oct. 31), Hamilton Davis notes that “Vermont’s health care reform initiative, now in its eighth year, has achieved a significant level of success, and is within sight of its ultimate goal of sustainable costs for its acute care hospital-doctor system. No such system in the United States has accomplished that since health care spending began to soar in the late 1960s. At the same time, however, the reform landscape is marked by powerful tensions between the players that could derail the whole enterprise.”
He cites concerns regarding the governor’s commitment to health care reform, poor decisions by the Green Mountain Care Board, animosity toward the UVM medical system, reluctance by the primary care community to participate, the Legislature’s hostility toward, and ignorance of, the specifics of reform, and the inability thus far of BCBSVT and OneCare to reach agreement on risk-based insurance plan contracts that could bring over 100,000 Vermonters into the reform initiative.
While the enrollment of Medicaid and Medicare beneficiaries has been promising, only 10 percent of the approximately 260,000 Vermonters who are insured through commercial plans or through self-insured employer plans are currently enrolled in the all-payer model. The rest continue to be enrolled in traditional fee-for-service plans with ever increasing premium costs.
I recently came across an article written by Patrick Conway, CEO of Blue Cross of North Carolina. In the article Dr. Conway notes that “a new way of paying for care is taking root and it’s working. Value-based payments change how we pay for care … with health care providers … creating incentives to deliver high-quality care at a lower cost.” As a result, according to the article, BC North Carolina achieved an historic rate decrease for Affordable Care Act plans in 2019 and its Medicare advantage premiums were reduced by 30 percent. They are also investing in programs to recruit more students into the primary care field, increasing payments to primary care providers, and have made significant investments in social determinants that influence a person’s health such as access to healthy food, housing and transportation.
Achieving the health care reform goals that Vermont has initiated will require committed leadership from all aspects of government and the private sector, including providers and payers working together and in a coordinated fashion. It will also require sustained investments in primary care, care coordination on a local level, social determinants of health (as noted above) and a concerted effort to educate consumers and business leaders about why these reform initiatives will constrain the growth of health care costs and could improve the health of most Vermonters.
I know that many people are working very hard to make Vermont’s health care reform succeed, but I remain concerned that, despite these efforts, neither the overall will, commitment, or leadership currently exists to achieve these goals. I hope I will be proven wrong.
