Vermont’s state employees union says it won’t participate in OneCare next year, while the teachers union remains on the fence, potentially dealing a major blow to the roll-out of state-led health reform efforts.
The Vermont State Employees’ Association and the Vermont National Educators’ Association are in discussions with private insurer BlueCross BlueShield of Vermont about whether they’ll participate in the state’s all-payer system, which is administered by OneCare.
Union leaders are expressing qualms about the financial stability of OneCare, and wonder whether joining would benefit their members. If they opt out, it could prevent OneCare from hitting its goal of adding 90,000 individuals to the system this year, a figure that includes almost 30,000 of the unions’ members.
“We can’t measure success without scale,” CEO Vicki Loner told the Green Mountain Care Board at its budget hearing last month. The more people who participate, the more effective the system will be, she said.
Without the state’s largest unions, it will be difficult — if not impossible — for the organization to reach its participation goals, which in turn makes its broader goals around health care efficiency and costs harder to achieve.
Steve Howard, executive director of the VSEA, said he wouldn’t sacrifice the well-being of state employees to help prop up what he described as an untested health care experiment.
“Someone else’s crisis is not our emergency,” he said of OneCare’s goal to add people to the system. He said he wanted to wait to join until OneCare had been audited by the state, and when he was sure the organization was fiscally strong. State Auditor Doug Hoffer is working on two reports about OneCare, but his bid to conduct a full audit of the company was blocked by the Legislature earlier this year.
“We have some of the best health care in the country,” Howard said. “We don’t want to screw that up just to pursue someone else’s agenda.”
Members of the Vermont Education Health Initiative, which provides insurance to teachers, has been meeting with BlueCross BlueShield to figure out the impact of the change, said Laura Soares, who’s part of the management team for the health initiative.
The NEA has not yet told its 44,000 members about the option to join OneCare. They’ll bring the question to the board on Nov. 21 for discussion.
Regardless of the ultimate decision, added Mark Hage, who manages the benefits for the teachers union, they’d take it slowly. “OneCare is different from anything the state has tried before,” he said.
Sara Teachout, spokesperson for BlueCross BlueShield of Vermont, said no self-funded group, including the VSEA, had given her a definitive “no” regarding participation in OneCare next year.
Self-insured and skeptical
The all-payer system was launched in 2016 to create a more streamlined approach to health care; all doctors and hospitals would be aiming for the same goals and metrics of success, broadly defined as improved outcomes and lower costs. OneCare Vermont, an accountable care organization co-owned by the UVM Health Network and Dartmouth-Hitchcock, is the umbrella company hired to implement that system.
It hoped to save money by improving the overall health of the population and focusing on preventative care, in part by paying doctors a set fee per patient, rather than compensating providers for each procedure they perform.
Government-funded insurers — Medicaid and Medicare — were the first to join. Now, OneCare is counting on the two private insurance companies in Vermont, BlueCross BlueShield and MVP Health Care, to jump in.
That includes both individuals and entities who get private insurance from those companies, as well as self-insured groups like the unions, whose plans are administered by BlueCross BlueShield.
Under self-insured plans, the company — or in this case, the union — pays the premium and covers the cost of claims for procedures. The plans are higher risk for employers, but have the potential for greater savings.
This fall, BlueCross BlueShield notified all its self-funded groups that they would be added, or “attributed,” to OneCare.
To become part of the accountable care system, those groups must decide to join — and so must their doctors.
In the case of VSEA, about 40%, or roughly 10,000 people, meet that criteria and would be part of OneCare if the union opts in. About 19,000 of the total 44,000 people from the NEA see doctors in the all-payer network.
MVP Health Care also has self-funded groups, though none of those will be added to OneCare in 2020. MVP did not respond to a call seeking comment for this article.
A rocky roll-out
BlueCross said it initially planned to negotiate with each company individually regarding terms of an agreement with OneCare, but that proved costly and time-intensive. Instead, the insurer informed all the companies with self-funded plans that they would be participating in OneCare.
According to Teachout, the BlueCross spokesperson, the change shouldn’t be a big deal. Nothing should change for patients, she said, including their primary care provider of choice. Costs won’t go up for companies or patients; insurance plans won’t change; and patient care should be as good — or better, she added.
The companies, too, will pay the same amount, though the payment will be structured in a different way. “There’s really no downside,” Teachout said.
In the long term, there are perks as well. If health care reform efforts work as intended, more people in OneCare will help drive down overall costs — or at least that’s the hope. And doctors are incentivized to be more engaged in preventative care, helping patients stay healthy.
There are also additional programs for OneCare members, such as DNA testing for some patients who see doctors in the UVM Health Network.
Andrew Garland, vice president of client relations and external affairs for BlueCross, said there was substantial upside with no additional cost. Even if it only means a few people see a primary care provider who wouldn’t have otherwise, “it’s still a win,” he said.
Garland said he takes the concerns of clients seriously. “We’ll evaluate the program every quarter and every year. We’ll ask hard questions. Are we making a difference? Are we doing the right things?”
Teachout characterized the union’s hesitation as a “concern about paying administrative fees to OneCare Vermont,” which she chalked up to a lack of information.
OneCare is only paid “if they achieve savings,” she said. “We need to do a better job explaining it.”
Leaders from the NEA said they are also seeking answers around how it would affect their members. And Howard, of the VSEA, said he needed to be sure that OneCare was on firm financial footing.
“We’re in no rush,” he said, adding that he planned to wait at least a year until the VSEA joined OneCare. “Our health care plan is great. Maybe [OneCare] should be looking at how we manage our health plan.”
He added that state employees had no interest in supporting a state initiative at their own expense. “Our members are not interested in building anyone’s empire for them,” he said.
Reaching scale
The NEA and VSEA members make up about a third of the people that OneCare is counting on to join their system next year.
Of the 90,000 people OneCare hopes to add, 50,000 would come from BlueCross BlueShield’s self-funded groups, according to Amy Bodette, director of public affairs for OneCare. The unions would make up roughly 29,000 people of that total.
OneCare Vermont is already behind on the targets for growth set by the federal government, which granted Vermont a five-year waiver to pilot the accountable care model, which is unique nationally. It’s supposed to include more than 300,000 people by the end of 2019. Instead, the company has said it would reach 250,000 by 2020. Without the unions, OneCare won’t even hit that target, unless it can find tens of thousands of new patients elsewhere.
A larger number of Vermonters joining OneCare, the thinking goes, will allow the state to transition fully to the payment model, shifting more funding to programs that improve health before people get sick, and generating more data to track what’s working and what’s not.
OneCare Vermont representatives downplayed the risk of not reaching those goals; Bodette said it’s the state, not OneCare, that’s responsible for recruitment.
“The entire model is voluntary, so we would welcome anyone who wants to come in and be part of the model and have access to the benefits of it. We are an open door,” Bodette said in an interview this week.
Uncertainty around the process remains and people need time to do research and ask questions, she said. “This is still new for people,” she acknowledged.
Regardless of what happens, she said, “we feel prepared to press forward with wherever it shakes out in the beginning of next year, and we’ll continue to work and prepare for future years.”
The state’s director of health reform, Ena Backus, said that the onus is on OneCare to make its case to Vermonters. “When value is demonstrated, that’s when people come to the table and want to participate,” she said.
Gov. Phil Scott’s administration has seen the value, she said, which is why the state’s Medicaid patients joined OneCare. But unless other people see it as a benefit, they may opt out.
“The effort of reform is, and should be, a voluntary one,” she said.
