[P]roposed legislation would ramp up oversight of Vermont’s all-payer experiment in health care reform.
H.181 says the state auditor should have access to “all records” of an accountable care organization – the entity that coordinates hundreds of millions of dollars in payments and investments under the all-payer model.
Auditor Doug Hoffer said he’s “not making any judgements about what we might find” in an all-payer audit. But he wants clear statutory authority to evaluate the finances and performance of the program.
“They’re basically talking about and have begun the process of changing how health care is paid for in this state,” Hoffer said.
The lone accountable care organization currently involved in the all-payer model is Colchester-based OneCare Vermont. In response to H.181, OneCare issued a statement saying the Legislature already has decided that the Green Mountain Care Board should regulate accountable care organizations.
“The Green Mountain Care Board provides continual, rigorous oversight of all aspects of our organization, in addition to federal oversight as required by the all-payer model,” OneCare Interim Chief Executive Officer Kevin Stone said. “As part of our regulation … OneCare receives an annual financial audit by a third-party auditor, and that audit is submitted to (the care board).”
The all-payer model, which is the product of a 2016 agreement between Vermont and the federal government, is an attempt to move away from the fee-for-service method of health care payment.
Rather than being paid for each procedure and test they perform, providers can receive a regular, predetermined payment with a focus on preventative medicine. The so-called “population-based payments” are supposed to give health care providers more flexibility while also giving insurers more stability.
The state’s all-payer agreement with the federal Centers for Medicare and Medicaid Services runs through 2022. The goal is to keep health care costs under control while also boosting quality, and the state has set three specific quality goals – reducing chronic disease; reducing deaths due to suicide and drug overdose; and increasing access to primary care.
OneCare’s work has attracted supporters who laud its payment-reform activities, as well as detractors who criticize the organization’s performance and state oversight. The Green Mountain Care Board in December approved OneCare’s 2019 budget – a more than $900 million plan that predicts growth in the all-payer program.
Hoffer said he requested legislative action to ensure that he can review all accountable care organization documents. OneCare handles public funds, but it is a private, for-profit company.
“While I have very clear and unambiguous statutory authority to ask for and be given anything I need to do an audit of state government, there are limitations for entities that are not part of state government,” Hoffer said.
H.181 says an accountable care organization certified by the state must make available any records that the auditor needs to evaluate the organization’s “financial statements, receipt and use of federal and state monies and performance.”
The bill was introduced by Rep. Anne Donahue, R-Northfield and vice chair of the House Health Care Committee. Donahue cited both the scope of the all-payer effort and the money involved.
“We’re hoping that the tradeoff is going to be savings that are greater than the costs,” Donahue said. “But it’s really big, and it just seems to make sense to have as many eyes on it as possible.”
Donahue said that, while it’s still “too early to tell” whether all payer will succeed, she’s “not thrilled with the progress on various levels.” She noted that OneCare is not hitting all-payer growth targets, and she said it’s not yet clear that the all-payer model is in synch with health care reform principles set by lawmakers in Act 48 of 2011.
“Ideally, the Legislature would be a part of looking at that, but we are so constrained by time that we can’t,” Donahue said. “And I think we rely a lot on the Green Mountain Care Board, but it’s also constrained by time.”
Hoffer said he hopes the all-payer model succeeds. But he also believes it requires “adequate, periodic oversight” in addition to budgetary oversight provided by the care board.
“The (accountable care organization) is so big, so complex, and one of many entities in orbit around others, and money is moved here and there,” Hoffer said. “It’s unlike anything else that we’ve needed to look at in the past.”
He said it would be premature to talk about the objectives of any audit his office might undertake. But Hoffer said he will have the resources to tackle an examination of the all-payer program.
“Whatever expertise we don’t have in-house, we will hire,” Hoffer said.
