This commentary is by Julie Wasserman, of Burlington who is a health policy consultant. She has worked for Vermont state government in a variety of capacities including director of Vermont’s Dual Eligible Initiative, division director of Policy and Planning for the Vermont Department of Aging and Disabilities, and as legislative staff to Vermont’s Senate Health and Welfare Committee.
Primary care is the heart of high quality cost-effective health care. Robust primary care leads to better health at lower costs and is defined by easy access to a personal relationship between physician and patient. Primary care serves as the first point of contact, delivering person-focused coordinated care, promoting health, and preventing disease. Expansion and enhancement of primary care are fundamental underpinnings of successful health care reform and are purported to be central components of Vermont’s All Payer Accountable Care Organization Model. However, the promise of primary care is not being fulfilled.
Kevin Mullin, chair of the Green Mountain Care Board, stated in a VPR interview on Sept. 6, “Primary care is so important to be spending the dollars on. That’s really the center of what the All Payer Model is all about.”
Vermont’s bold experiment with the all payer ACO model began in 2017 with promises of a high performing primary care network that would increase access to care, improve health outcomes, and reduce costs. As initially designed, the all-payer ACO model “would help up to 12,000 Vermonters get primary care physicians who don’t already have them.”
Vermont’s Joint Fiscal Office published an issue brief on Oct. 21, 2016, prior to the signing of the all-payer model agreement. It identified a variety of risks regarding the proposed model, one of which was the lack of a detailed plan to improve access to primary care. “Over the long term, the goal is to increase access to primary care, but the short-term and long-term plans to address that goal are not clear.” The Joint Fiscal Office also noted, “Over the past five years, however, published research has indicated that savings and quality improvement are generated much more often by independent primary-care doctors than by large hospital-centric health systems.”
Now, three years later, it is important to ask: Was a detailed plan to increase access to primary care created and implemented? How many additional primary care practitioners have been trained or recruited since the inception of the all-payer model? Did the ACO’s strategy for expanding primary care capacity focus on bringing existing primary care physicians into its network rather than on increasing the total number of primary care practitioners? Has access improved?
“We are on our way to a statewide network that focuses on primary care and population health for all Vermonters,” stated Todd Moore, former CEO of OneCare Vermont, the state’s sole ACO implementing the all-payer model. Expansion of primary care was to be a fundamental and pivotal component of OneCare’s ACO efforts. However, results are not encouraging to date. OneCare’s Dashboard Data on Medicaid ACO enrollees for the three-year period 2016-18 show a decline in primary care physician office visits. For adults 18 years old and older, there was a 9% decrease in visits over the period; and for those 17 years and younger, there was an 18% decrease. (OneCare board meeting materials, February 2019)
The state’s promise of increased access to primary care has not been realized. Accounts of shortages have been documented in Chittenden County where new appointments with primary care physicians are elusive; in Central Vermont where UVM Health Network closed Barre’s only downtown primary care clinic; and more recently with UVM Health Network and Central Vermont Medical Center stating, “All our primary care practices are full and not accepting new patients” when pressed about access to primary care for Medicaid patients in Central Vermont. (Verbal communication, Aug. 27, 2019)
The just released Vermont Department of Health 2018 Physician Census reports a decline in the number of primary care physicians (634 in 2008, 615 in 2018) as well as decreases in full-time equivalents. The report further states “15% of primary care physicians are planning to retire or reduce hours within 12 months.” OneCare’s 2020 budget and testimony failed to make any mention of attracting additional primary care physicians or other primary care providers. The Green Mountain Care Board needs to prioritize initiatives that encourage primary care physicians to practice in Vermont. Inaction will lead to further decreases in access to primary care.
Effective primary care leads to improved population health at lower costs, primarily due to reduced hospitalizations. Vermont’s health care reform efforts could capitalize on this if its overarching framework centered on an expansion of primary care practitioners, prevention, and early intervention in collaboration with home and community-based services which are instrumental in lowering health care costs.
As we near the halfway mark of the all-payer model, the pledge of improved access to primary care has yet to be fulfilled. In order to address this, Vermont may want to consider other models that show a strong potential for strengthening primary care (Plan B). Success of these models lies, in part, with primary care practices managing the reforms rather than a hospital-based organization. The potential for savings is much greater when physician practices are in charge because physicians strive to keep their patients out of the hospital.
