Health care officials outlined results Wednesday indicating Vermont’s health care reform efforts are working — as they simultaneously acknowledged they don’t have enough information to state that conclusively.
It leaves lawmakers in an awkward position as they have to decide on future funding.
Six health care representatives laid out the 2018 results from OneCare Vermont, the accountable care organization charged with rolling out the state’s all-payer model. The three-year-old system is meant to change the way health care is funded, from paying doctors per procedure to providing a set fee per patient. The model focuses on wellness and keeping people out of the doctor’s office through preventive care.
Wednesday’s presentation offered the first look at figures that show whether OneCare Vermont’s efforts have paid off. But Alena Berube, who works for the regulatory Green Mountain Care Board, warned listeners not to draw conclusions: “This is not an evaluation of the all-payer model,” she said.
“It’s like a weather report,” said Kelly Lange, corporate director of health care reform for BlueCross BlueShield of Vermont.
OneCare is seeking approval of its $1.43 billion budget. The accountable care organization presented the budget last month, and the Green Mountain Care Board will vote on it in December. It’s also asking for funds that must be approved by the Legislature.
OneCare was launched in 2013, though the all-payer system didn’t get underway until October 2016 when the state signed off on a waiver with the Centers for Medicare and Medicaid Services. The first year, 2017, was only for Medicaid patients — officially dubbed “year 0.” Results for 2018, which OneCare is considering “year 1,” were released this fall.
That’s “absolutely standard practice,” said Michele Degree, who works for the Green Mountain Care Board.
That means as 2019, the third year of the all-payer model, draws to a close, there’s only one year of useful data.
“Success cannot be measured in one year,” said Lange from BlueCross BlueShield. It will take “three to five years” to gauge whether the system is working, she said.
The Green Mountain Care Board held the meeting at the request of Susan Aranoff, a senior policy analyst for the Vermont Developmental Disabilities Council. Aranoff praised the board for holding the meeting, but said she still had questions.
“We’re still a long way from getting the information we wanted to get,” she said.
The situation presents a chicken-or-egg dilemma: OneCare says they need more money to get a new approach to health care off the ground; legislators say the accountable care organization should first prove the system is working.
Sen. Ginny Lyons, D-Chittenden, vice chair of the Senate Health and Welfare Committee, said the uncertainty made it tricky to make decisions around funding. For example, this session, legislators must approve a portion of OneCare’s budget — a request for $13.1 million in state and federal Medicaid dollars, including $4.5 million in cash from Vermont taxpayers.
Whether or not OneCare would get the money is “very much related to their success,” she said in an interview.
Legislators would consider both health results and whether the system is leading to lower costs, according to Lyons, though she simultaneously acknowledged that the data is incomplete.
The limited data didn’t stop insurance executives and state officials from trumpeting OneCare’s victories to the regulatory board.
Primary care visits among teenagers had increased, a metric that’s “really important for the long-term health of Vermont,” said Lange. She said she was confident that the model was working. “There’s enough to continue to next year,” she said. “We see value, especially with collaboration.”
OneCare’s incentives had also led hospitals to invest in less profitable enterprises such as palliative care for patients with serious illnesses, according to Degree, of the office of the care board. Some primary care offices had increased access to psychiatric services as a result of the all-payer model, she said.
But the results weren’t all positive.
OneCare’s chief operating officer Sara Barry avoided mention of the poor scores; only after she was asked did she discuss the high readmission rates to the hospital, which ranked in the 25th percentile nationally. OneCare was trying to improve communication with doctors, and provide information in real time to help address the issue, she said. The state also performed poorly in getting patients into alcohol and drug treatment.
So when will Vermonters know whether the all-payer model is working? That depends on who you ask.
Officials disagreed about how long it would take to decide whether to keep investing in OneCare, or how they would be sure.
The all-payer model is a five-year agreement between the state and the feds, and it may take that much time to decide whether it’s a worthwhile effort. Both sides have the option to opt out earlier.
If insurance companies, hospitals, and doctors want to continue to participate after five years, that would be an indicator of success, said Stephen Leffler, chief medical officer of University of Vermont Medical Center and a member of the OneCare board.
It’s logical to expect that a system based around keeping people healthy will take time to evaluate, explained Susan Barrett, executive director of the Green Mountain Care Board. For instance, if kids are becoming more active as part of OneCare’s community wellness programs, it would take years — even decades — for those anti-obesity efforts to yield results, she said.
Only John Brumsted, CEO of the UVM Medical Center and chair of the OneCare Vermont board, was decidedly enthusiastic. He said in an interview that OneCare was already successful enough to merit investing in the all-payer model for another five years.
Rep. Anne Donahue, R-Northfield, pointed out that Vermont will have to decide whether to sign up for another five-year contract around 2021. That’s the ultimate deadline, she said.
As OneCare grows and becomes a larger part of the health care system, some have voiced concerns that the system becomes harder and harder to dismantle if it doesn’t work.
The high stakes and lack of information “makes it really scary,” Donahue said. “You always end up coming back to what are our other options?”
Of the viable options, she said, “I have not heard a better idea.”
So, she said, she and other legislators are left navigating the tension. “We all gotta chew on our fingernails and keep watching, but not give up prematurely.”
