The state’s accountable care organization produced no evidence of results from some of the community health programs it invested in, according to an analysis from the state auditor’s office.
OneCare Vermont “did not reliably monitor or accurately report” the community-based initiatives it promised to fund, including providing fresh produce to patients, helping house homeless families and helping to coordinate care.
State Auditor Doug Hoffer sent a memo detailing the shortcomings to the regulatory Green Mountain Care Board last week. OneCare “did not satisfy the GMCB’s certification criteria concerning community-based initiatives,” he wrote. The lack of data leaves regulators — and Vermonters — unable to be sure whether the programs are actually working, the letter explained.
OneCare was launched in 2016 to improve the health of Vermonters by focusing on preventative care. It collects money from Medicare, Medicaid and private insurance and pays doctors and hospitals a set fee for each patient, rather than for each visit. As part of that shift, the for-profit organization has promised to invest in community health initiatives, including subsidizing fresh vegetables, investing in programs that promote active lifestyles, and helping coordinate between different health agencies.
The Green Mountain Care Board required OneCare to allocate 3.1% of its 2018 budget for the community health projects.
In March, OneCare asked — and was granted permission — to invest less money, a total of 2.5%, or $15.5 million, into the community. Even that didn’t happen.
In later spring, Vermont health care advocate Mike Fisher heard from providers that OneCare “had no involvement” in the community health programs it was supposed to be overseeing or implementing. He reported his findings to the auditor’s office.
The auditor’s office found that there was no evidence that OneCare had done some of the projects they had described in their budget earlier that year.
The list included:
- Writing “prescriptions” for patients to purchase produce in the Windsor “health service area.”
- Providing patients with community supported agriculture shares and offering education in how to prepare food in the Newport area.
- Helping with rent or housing for homeless families in the St. Albans area.
- Helping encourage palliative care in the Bennington area.
“OneCare could not describe these activities in any detail,” the auditor’s office found.
OneCare representatives told the auditors that the information was gathered “by Clinical Consultant staff based on their local knowledge of initiatives in their local communities,” but that they had no “specific documentation,” according to the letter.
In response to the auditor’s memo, OneCare filed 94 pages of additional documentation to the Green Mountain Care Board. It also wrote a letter to the board disagreeing with the auditor’s conclusions.
“The expectation for documentation of every activity seems to arise from a misperception as to the model being implemented by OneCare and its many partners,” wrote OneCare CEO Vicki Loner. For instance, “OneCare is not testing the particular interventions, such as writing prescriptions for food.” Instead, it’s testing the overall health outcomes for the system as a whole.
OneCare director of public affairs Amy Bodette declined to comment on the issue, saying that the organization would be “responding to our regulator, per their request.”
“It wouldn’t be appropriate to discuss with the media before we respond,” she wrote in a text.
OneCare did ultimately give $2.2 million to the state’s Blueprint for Health community health teams, which help connect patients with health care options. It provided additional funds to its own nonprofit, RiseVT, which promotes overall wellness, including active lifestyle and healthy eating. It also gave money to help with elder care and with homelessness, according to the letter.
The auditor urged the care board to improve to adopt “more rigorous standards” for evaluating such programs.
In response, the Green Mountain Care Board sent the auditor’s office a lengthy list of proposed edits to their analysis.
Most substantially, the board fundamentally disagreed with the auditor’s assertion that OneCare “did not satisfy the GMCB’s criteria concerning community-based initiatives,” said Susan Barrett, the board’s executive director.
The board had a different interpretation of the rules governing OneCare, Barrett said, and OneCare did in fact meet the requirements. Barrett outlined her critiques in a response letter sent Wednesday.
The Green Mountain Care Board would try to improve its monitoring of the programs, according to the letter. “As a result of your inquiry, we recognize that OneCare Vermont should have a more robust system for tracking community-based initiatives,” Barrett wrote. “We plan to work with OneCare Vermont to address this weakness through our existing monitoring processes.”
In spite of the critique, Green Mountain Care Board Chair Kevin Mullin lauded the report. “It’s really good that the auditor is taking an active approach to help Vermonters understand the health care reform initiatives that are taking place,” he said.
So far, OneCare has shown few results of actually increasing preventative care. In an interview last week, company leadership said that it’s too early in the project to have such data.
But according to the auditor’s office, that’s partly because OneCare is not appropriately tracking the data.
“It is impossible for OneCare or the GMCB to demonstrate a causal relationship between community-based initiatives and health care outcomes without knowing which individuals received services and where and when the interventions took place,” Hoffer wrote.
OneCare submitted its $1.36 billion 2020 budget on Oct. 1. The Green Mountain Care board will discuss and vote on the budget by the end of the year.
Meanwhile the State Auditor’s Office has already launched a full performance audit of OneCare, according to deputy state auditor Andrew Stein. This spring, the office hopes to release the first part, a detailed description of what OneCare is, and how it operates. Then the auditors will start to investigate whether its work has been successful.
OneCare is “not really understood by a lot of decision makers,” said Stein. “Any additional analysis would do Vermonters justice.”
Correction: A memo from Auditor Doug Hoffer was misattributed to Geoffrey Battista in an earlier version of this story.
