Editor’s note: This commentary is by Patrick Flood, the former commissioner of the Department of Mental Health, the Department of Disabilities, Aging and Independent Living and former deputy secretary of the Agency of Human Services. He is now retired and lives in East Calais.
Finally. Thanks to Auditor Doug Hoffer, the people of Vermont finally have an unbiased and accurate assessment of the current so-called health reform effort and the accountable care organization designated to implement it. And the picture, as many of us have been maintaining for years, is not pretty.
The Auditor’s report does not dig that deeply into the problems with the effort or the ACO, but he did not have to dig deep to find a shocking lack of accountability. His report states unequivocally that after almost three years of operation, the Green Mountain Care Board does not even have a method for determining if the effort is cost effective. Three years into a five-year pilot, tens of millions of tax dollars spent on administration, and no reliable, accurate method for determining the costs of running the pilot compared to savings for Vermonters.
Those of us who have been monitoring this effort for years could have told the Auditor: The financial information that is public shows convincingly that the ACO model is a failure. Savings have been miniscule compared to losses, with all three payers (Medicare, Medicaid and commercial insurance).
To make it worse, the state has not released the 2019 financial results, even though we are halfway through 2020. How can anyone evaluate the model with that kind of reporting? Does the Green Mountain Care Board have something to hide? They just might. Although not released officially by the state, it is a fact that the ACO was $17.4 million over budget in Medicaid for 2019. It is understandable why the state might not be in a hurry to let us know about this failure.
Then, the CEO of One Care is quoted in VTDigger saying that she does not know why they were over budget by $17.4 million. That is an astonishing but revealing statement. The Medicaid program tracks expenses in great detail. It is fairly straightforward to identify what categories are over budget. If the ACO can be that much over budget, and not even know why, then Vermonters should be outraged.
The whole effort is misguided and has struggled from the start. Actually, the concept of an “all payer model” and “fixed payments,” if done right, could help reform our health care system. But so far, after three years of operation, only 7% of Vermont’s health care expenses are paid with “fixed payments;” at that rate it will take 50 years to complete the job. Furthermore, we don’t need the additional bureaucracy of an expensive, for-profit monopoly ACO to transition to fixed payments, especially in the Medicaid program. And we don’t need to turn control of our health care system over to the most expensive entity in that system, the UVM Medical Center. And we don’t need a Green Mountain Care Board if it won’t do its duty to regulate the ACO and ask the tough questions.
The project is so flawed it would take many commentaries to describe all the problems. Let’s focus on a few key issues. The ACO was supposed to reduce expenses. Hasn’t happened. In fact, costs continue to go up, even faster than the 3.5% growth that was planned, and that does not include the ACO’s administrative costs. The ACO was supposed to improve primary care. Hasn’t happened. In fact, Vermont continues to lose primary care providers, a problem that we know how to fix. The ACO was supposed to improve quality of care. Hasn’t happened in many key areas; for some measures the results have gone backwards. The ACO certainly has had no impact on health insurance rates; they continue to grow by double digits. The ACO has done nothing to improve access to care; the uninsured are excluded from the ACO. Lack of health insurance is going to be a much bigger problem now, thanks to the pandemic and the loss of jobs. Those are the issues Vermonters care about, along with the high cost of medications, which this project does not even include.
According to the Auditor’s report, the Green Mountain Care Board staff maintain it is difficult to quantify costs that were avoided as a result of the ACO. That is a ridiculous diversion from the real failures. What are these avoided costs? Let the public judge if they are worth the tens of millions of dollars of investment. This project was devised to attain certain concrete, measurable goals involving cost and quality, not vague, unquantifiable results.
Minor changes are not going to fix these problems. The effort is so flawed there is no choice but to end it and begin anew.
The fact is that there is a better way, one that is cheaper, will get real results sooner and that Vermonters can understand. It is built on prevention, early intervention, universal primary care, universal mental health and addressing the consequences of trauma. Vermont could institute such a system quickly, building on what already works. The millions being spent on a failing, unnecessary, additional bureaucracy could be put to better use actually providing care to Vermonters.
Vermonters should be grateful that the Auditor is going to continue to monitor and analyze this effort. Those of us who have been following this and trying to point out its failures for years can guarantee him that he will uncover many more examples of lax oversight, lack of accountability and failure.
Vermonters deserve better. With the impending election, Vermonters should demand an administration that provides real health care reform.