Editor’s note: This commentary is by Meg Hansen, of Manchester, who is executive director of Vermonters for Health Care Freedom, a Montpelier-based health policy nonprofit.
[T]he all-payer accountable care organization model, pioneered by the state of Vermont and the Centers for Medicare and Medicaid Services (CMS), is an alternative payment system that aims to curtail health care costs and improve the quality of and access to care. Facilitated by a statewide ACO called OneCare Vermont since 2017, this model diverges from traditional fee-for-service reimbursement. Instead, participating hospitals and physician groups receive a fixed monthly amount to cover the services for their patients.
In 2019, OneCare projects that it will need $851million for its payer programs, and $53 million for reform programs and infrastructure expenses (roughly half to come from providers and the rest from taxpayers). Under 18 V.S.A. § 9382 (b), the Green Mountain Care Board must exercise oversight of OneCare by reviewing varied criteria such as: (1) utilization of health care services delivered; (2) the ACO’s fiscal responsibility; (3) the ACO’s efforts to prevent duplication of services offered by existing community-based providers; and (4) public comment on the ACO’s costs and proposed budget.
Early findings of an investigation by Vermonters for Health Care Freedom indicate that OneCare’s 2019 budget proposal and public discussion hitherto do not fulfill these regulatory requirements. Red flags arise regarding the ACO’s proposed expansion of its advanced care coordination, health information technology informatics, and primary prevention programs.
Complex Care Coordination
At the Oct. 24 Green Mountain Care Board meeting, the OneCare team reiterated a prior claim that they have trained over 500 care coordinators to use their analytic tools (Care Navigator and WorkBench One) as a measure of their ed expansion of its advanced care coordination, health information technology success. However, the Green Mountain Care Board needs access to detailed information about the actual usage of the ACO’s informatics – such as the number of unique users, how many times each trained user logged in, and how long users stayed online – to evaluate the true performance efficacy of these tools.
Consequently, OneCare needs to provide (a) complete and unredacted user login reports including user names, session counts, dates, and duration of sessions dating to Q1 2017; and (b) the network request log comprising all network requests and the source of the data (Health Catalyst or the Legacy SQL database) dating to Q1 2017.
Vermonters for Health Care Freedom submitted a public comment to this end, and asked for clarification about pervasive technology problems plaguing OneCare’s health information technology and data management, which appear to dispute the ACO’s alleged ability to conduct seamless, technology-driven care coordination across Vermont. OneCare CEO Todd Moore dismissed these legitimate queries as “head scratchers” (watch 1:49:31).
Health Information Technology
Vermont Information Technology Leaders manages OneCare’s health information exchange. Multiple data analyses have shown drastic inconsistencies between clinical records from the VITL database and the University of Vermont electronic health record system. In a previous commentary, we explained that the VITL database had no blood pressure readings for 39.7 percent cases of hypertension, further evidencing the incomplete and inaccurate nature of the clinical data driving OneCare’s informatics.
At the Nov. 7 meeting, Green Mountain Care Board member Robin Lunge appeared to substantiate our claims about OneCare’s faulty technology by arguing that the usability, connectivity, and quality of data lie beyond the state’s control. She said, “If the technology does not improve, there is nothing that the state government or VITL can do,” adding that they should not be held accountable for the lack of technological success because they are on the “right track” (watch 1:52:33).
Why does Lunge contend that the public should absolve OneCare and VITL for unreliable data and poor health information technology performance? Why are taxpayers expected to throw good money after bad on a multi-million dollar analytics project that cannot navigate the technology at its heart?
Primary Prevention Programs
OneCare has requested $16 million for operating costs in 2019, which is up from $12.5 million last year. The increased amount includes $3.4 million to integrate an organization called RiseVT into its operations. The additional funds will pay for four full-time RiseVT staff as well two staff for mental health efforts.
What are the job descriptions, qualifications, and salary and benefits packages of OneCare’s new employees? These details are required to clarify whether this expansion would duplicate the health services already offered by existing and effective community-based providers like Blueprint for Vermont.
During our investigation, RiseVT executive director Marissa Parisi refused to speak to us (citing a busy schedule), and ignored follow-up communications, because we asked for information that quantifies the results of their various primary prevention programs. For example, how have RiseVT’s efforts specifically reduced adult obesity in Vermont? What is the methodology used to collect the data needed to track outcomes?
The pattern of absent or inadequate transparency with OneCare and its affiliates should offer Vermonters ample cause for concern. Other stakeholders have expressed similar misgivings about the “lack of clarity” regarding the ACO’s operations and outcomes. The Office of the Health Care Advocate stated that OneCare has not supplied the GMCB with sufficient information about quality measures and financial performance results that would enable “meaningful oversight.”
Actionable Steps Moving Forward
First, the Green Mountain Care Board should postpone voting on the budget (that could occur as early as Nov. 28) until OneCare’s leadership offers candid and comprehensive responses to the many unanswered questions raised by public advocates. Second, state legislators should demand that the ACO disclose reports quantifying the utilization of its analytics.
Finally, CMS should be notified of any possible infractions of its all-payer agreement with Vermont, as a result of OneCare’s failure to offer transparency and accountability about its actual statewide health outcomes, quality of care targets, and financial performance.
