In a budget presentation last week, OneCare Vermont executives grumbled to regulators that the company is being unfairly characterized by the press and the public as it takes on the state’s most ambitious health care reform effort to date.
As OneCare made a case for $1.43 billion in expenditures, executives complained about media reports about the company’s budget.
State regulators share many of the company’s concerns about press coverage. Kevin Mullin, chair of the Green Mountain Care Board, says a poor public image is an existential threat to the survival of the reform program and suggests that the company needs to launch a media relations campaign. In an interview, the chief regulator said that it’s necessary to get the public on board because there is “no Plan B” for reining in health care spending in Vermont.
OneCare Vermont administers the state’s novel all-payer health care system, which was launched in 2016 to lower health care costs and prioritize preventive care. The all-payer system collects money from Medicaid, Medicare and private insurance. Through OneCare, hospitals and doctors are paid a flat monthly per patient fee instead of reimbursements for specific treatments.
In its third year of operation, the company is ramping up the amount of money it manages and the number of patients in the all-payer system. This year, the company managed a budget of $903 million.
Next year, the company will distribute $1.36 billion in insurance money to hospitals and providers — or about a sixth of all health care spending in Vermont. In addition, OneCare will spend $62 million on administration, chronic and mental health treatment and housing programs.
By 2022, if all goes as planned, nearly all Vermont patients will be part of OneCare and the majority of funding for health care will pass through the company.
The idea is that as more patients get access to primary care, the system will save money.
But promised savings have not yet materialized, and there has been a lack of significant progress on patient access to preventive care.
Last Wednesday, over the course of a two-hour presentation, executives highlighted OneCare’s accomplishments, touting increased diabetes testing for Medicaid patients in Central Vermont and fewer emergency room visits among high risk patients in the Brattleboro area.
CEO Vicki Loner said the accountable care organization has made “significant headway” in meeting its mission.
At points during the hearing, OneCare officials presented themselves as the victim of a targeted misinformation campaign in thinly veiled references to coverage by VTDigger.
Loner described OneCare as one of most highly regulated accountable care organizations in the country, subject to public scrutiny and oversight by regulators. “It’s really easy to sit on the sidelines and criticize, said Loner. “It’s another thing to roll up your sleeves” and do the work.
The previous week, Loner had sent a letter to OneCare staff and members of the Green Mountain Care Board with a six-point rebuttal of VTDigger’s recent coverage. The letter, which was obtained by VTDigger, contended that a recent article on the budget only included “selections [of interviews with OneCare] that fit the biased narrative that they are working hard to develop.”
Green Mountain Care Board chair Kevin Mullin echoed her concerns, and urged OneCare Vermont to launch a vigorous public relations campaign. The head regulator of the organization suggested that the need for increased public awareness is essential to maintaining the all-payer system’s viability.
“I’m just afraid if you don’t start telling your story, there’s not going to be a story left to tell,” Mullin said.
Mullin also said that with more public outreach, perhaps “people will stop criticizing and become more participatory” in the work of launching the state’s all-payer health care system.
‘A break-even budget’
The public hearing served as an opportunity, in part, to gauge the success of OneCare and the state’s broader health care reform effort.
Vermont’s three-year-old all-payer model aims to control costs and improve health by helping people access preventive care. Specifically, the state aims to reduce suicides and overdose deaths, increase access to primary care, and mitigate chronic disease such as heart disease or diabetes. Doctors who choose to participate in the system receive a set payment per member per month.
On Wednesday, OneCare officials sought to address concerns of overspending in the next fiscal year. Director of finance Tom Borys repeatedly called it “a break-even budget”; OneCare is not seeking a profit, he said.
Most of the $1.43 billion budget goes directly to hospitals and providers. Of the $62 million directly allocated by OneCare, about $43 million will support initiatives to improve the health of the population broadly, including money for primary care doctors, community health teams to coordinate local care, mental health agencies, and area agencies on aging, Borys said.
The remaining $19.3 million goes toward operating expenses, including 77 employees, up from 58 last year. Borys said the growth of the all-payer model required more staff. When Mullin pressed him on how much is an appropriate proportion of overhead, he said he didn’t have an exact figure.
OneCare officials also tried to allay concerns about their request for $13.1 million in Medicaid funds. Care board members questioned whether more taxpayer money is necessary for the program. Some of that money will come from the feds, explained Loner; some of it is a request to continue to fund existing programs. All told, they’re asking the state for $4.5 million, she said.
If all goes as planned, OneCare will increase the number of Vermonters participating in all-payer programs by nearly 50%, from 160,000 people in 2019 to 250,000 next year. Even with those additions, OneCare will not hit the original 2020 target of about 302,000 individuals. Officials with the company say the “signers” of the all-payer waiver — the Green Mountain Care Board and the Centers for Medicare and Medicaid Services — are responsible for ensuring the targets are met.
Whether OneCare will be able to include 250,000 people in the program remains to be seen; the total number won’t be finalized until early next year — after the Green Mountain Care Board has voted on the budget.
Reflecting on 2018
OneCare laid out its 2018 results with fanfare. “2018 was a really strong start,” said Borys, the director of finance.
The organization reported saving $13.3 million in Medicare spending compared to its projections going into the year — about 3.9% of the total figure of $339 million — though they went $1.5 million over its planned spending for Medicaid.
It also claimed to have met its own quality metrics for 85% of Medicaid patients, 86% of BlueCross BlueShield members, and 100% of those on Medicare who participate in OneCare.
But critics have contended those figures don’t tell the whole story. For instance, OneCare performed worse in 7 out of 10 of its criteria for Medicaid patients between 2017 and 2018. OneCare says the growth in the number of patients in 2018 makes the two figures incomparable.
Members of the public voiced their own concerns. Susan Aranoff, senior policy planner and analyst for the Vermont Disabilities Council, urged OneCare to be more transparent about health care results, instead of briefly highlighting patient outcomes in a presentation overshadowed by the budget discussion.
Aranoff requested a separate hearing to discuss the 2018 results, adding that other groups operating on the public’s dime are held to strict scrutiny and results-based accountability. “I don’t hear the regulators asking those questions in a … basic evaluative function,” she said.
In a statement to the Green Mountain Care Board, Loner said the company is audited by a nationally known audit firm and its contracts and reports are publicly posted. Salary information has been provided to the board (though is not publicly available).
“OneCare’s proposed 2020 budget submission was 63 pages long and we are preparing to answer 70 follow-up questions,” she wrote. “All reasonable requests for information have been answered, including recent cooperation with the State Auditor on a non-audit inquiry. OneCare has made significant efforts to bring in news organizations, policy makers, and other interested parties to answer questions and share information. All combined, OneCare has invested hundreds of hours to be a transparent organization.”
Walter Carpenter, a local resident, said OneCare had failed to address the real issues: providing coverage to Vermonters without insurance, and helping them cover steep costs.
“The problem is access,” he said.
Vermont’s health care advocate Mike Fisher pressed OneCare on issues of affordability and savings. In a list of questions submitted to OneCare, he said customers saw rate hikes instead of savings in insurance rates for Blue Cross Blue Shield of Vermont. OneCare reps said they couldn’t say when Blue Cross Blue Shield members will see savings from the all-payer model.
He also asked OneCare to define “affordability” and how it plans to achieve it for Vermonters.
OneCare’s answer was obtuse. “OneCare is working as a vehicle to support the goals under the ACO-APM that was signed by the State of Vermont and CMS,” the organization wrote in written responses to Fisher.
Some questions were not answered at all. Other responses were wholly unsatisfactory, Fisher told VTDigger in an interview.
“We were frustrated or disappointed with a lack of detail in their answer to us,” he said of OneCare’s responses. “We’re trying to figure out how to get better answers from them.”
As the hearing drew to a close, Mullin offered OneCare words of encouragement. “Hopefully you don’t take away that we’re not proud of efforts you’re taking on,” he said. Every morning, “You can look yourself in the mirror and know you’re doing good things on behalf of the state of Vermont.”
Afterward, Mullin told a reporter that his praise for the company didn’t affect his ability to hold OneCare accountable, and it didn’t present a conflict in his role as chief regulator of the Green Mountain Care Board.
After all, he added, “We’re all in this together. Our job is to regulate, not to be adversarial.”
CORRECTION: Due to an editing error, the headline originally included inaccurate quote marks.
