Editor’s note: This commentary is by Julie Wasserman, MPH, 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 fundamental underpinning of a highly functional, cost-effective health care system. According to Kevin Mullin, chair of the Green Mountain Care Board, strengthening and expanding primary care is foundational to Vermont’s all payer model. Yet, in the middle of a pandemic with primary care practices struggling to survive, OneCare Vermont has chosen to reduce payments to these practices.
OneCare is Vermont’s sole accountable care organization and as such exercises influence over the system. OneCare recently decided to decrease upfront payments to primary care physicians from $3.25 per patient per month to a base of $1.75. This new ACO payment ladder has the potential to rise to $4.75. However, primary care physicians can ill afford to receive a lower initial payment and then wait over a year for the “bonus” payment. This change in payment rates raises a variety of critical questions:
- Is OneCare hoping to weaken independent primary care practices in order to leverage buyouts?
- Do we want to put primary care physicians “at risk” when so much of health care spending is out of their control?
- Why has the ACO overlooked the costly expenditures related to specialists and specialty care?
- Do we want to continue shifting control of Vermont’s health care system to OneCare, a private for-profit entity whose payment policies undermine primary care when its expansion and enhancement are so desperately needed?
- Why has the Green Mountain Care Board remained silent?
Let me count the ways this new payment policy is a retreat from the goals of the all payer model.
How was OneCare’s new payment plan developed? Successful plans affecting the “coalition of the willing” require collaboration and coordination. Did OneCare collaborate with the primary care practices in developing this new payment plan? Did OneCare provide statistics on how primary care practices might fare with gains or losses under this new approach using quality metric data? Rather, OneCare made a unilateral decision that clearly imperils many of the state’s independent primary care practices, thereby making them vulnerable to acquisition.
Primary care is not strengthened by reducing payments, and there is no rational justification for putting primary care physicians “at risk.” Primary care doctors do not need to be “incentivized” to keep their patients well. That is what primary care physicians are trained to do, and that is what they do best; it is insulting to assume otherwise. Even though primary care comprises a relatively small portion of overall health care expenditures, it plays an outsized and significant role in the system. According to a recent Green Mountain Care Board report, primary care comprises only 8% to 10% of total health care spending. Yet, contrary to OneCare’s new payment plan, increased primary care spending is associated with fewer ER visits, fewer hospitalizations, better outcomes, and lower costs. In other words, increased spending on primary care can reduce overall health care expenditures and improve outcomes, goals the Green Mountain Care Board strives to achieve.
Care provided in primary care settings is inexpensive compared to other specialties. It is unconscionable to squeeze primary care physicians when the system’s most costly expenditures reside with specialists and specialty care. OneCare needs to consider putting specialists “at risk” in order to contain costs.
Why does the Green Mountain Care Board remain silent when the ACO defies a crucial tenet of the all payer model? Vermont currently has a serious shortage of primary care physicians which these cuts threaten to exacerbate. This shortage reduces access for both insured and uninsured Vermonters, the latter of which has recently doubled to 7%. (Note: The OneCare ACO excludes the uninsured.) Additionally, Vermont’s health care expenditures under the ACO model have exceeded the 3.5% growth cap set by the Green Mountain Care Board, and OneCare had $17.4 million in Medicaid cost overruns last year (2019) prior to the pandemic. A recent State Auditor’s report concludes that hospital market consolidation (e.g. OneCare’s ACO model) inevitably leads to decreased competition and higher prices.
Given all these factors, turning the other cheek to One Care’s recent primary care funding decision and its more long-term failures is not the answer to Vermonters’ need for a high quality and affordable health care system.
