Editor’s note: This commentary is by Patrick Flood, the former commissioner of the Department of Mental Health and 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 Woodbury.
The health care reform debacle continues and is only getting worse. Recently OneCare Vermont presented its 2021 budget to the Green Mountain Care Board. Unbelievably, OneCare is proposing 2% “cost of living” increases for its staff, plus other administrative increases totaling over $1.4 million. When unemployment in Vermont is over 7%, and many Vermonters have lost their health insurance and the whole economy is reeling, what can justify such an increase? What bubble are the leaders of OneCare living in?
Could it be because OneCare has done such a great job and saved Vermonters so much money? Just the opposite. Recently, OneCare did a presentation on their finances for 2019. (Let’s overlook the shocking fact that Vermonters didn’t know for 11 months what the initiative cost in 2019.) OneCare reported losing (being over budget) in the Medicaid program by $13.5 million. They reported being over budget for the Blue Cross/Blue Shield part of their budget by $6.5 million. They reported saving $11 million in the Medicare program, but in reality, the actual savings are no more than $4.8 million because the balance was spent on OneCare programs and thus cannot be considered savings. Add up the losses, subtract the savings, and add in the administrative cost of $15.4 million for 2019 and the stark reality is that OneCare cost Vermonters a net $30.6 million. At the same time, OneCare is cutting community programs designed to improve care by $6 million. This performance is worthy of raises? What happened to “value-based payments”? Supposedly hospitals and other providers are “at risk” and if they perform poorly, they face a fiscal penalty. Why does this not apply to OneCare?
This initiative is failing badly. It is time for a whole new approach, which I address at the end of this commentary. But first, let’s review the other recent failures in the health care reform debacle.
Let’s start with OneCare’s callous approach to primary care doctors. Strengthening primary care is one of the universally acknowledged goals for health care reform. Yet OneCare proposed cutting primary care reimbursement with the promise that physicians could earn back the reduction if OneCare met its goals. We must stop blaming primary care doctors for health care costs; they are not the problem at all, at less than 10% of our total spending on health care. At an October meeting of the Green Mountain Care Board’s primary care advisory committee, state officials got an earful from physicians who don’t see how the ACO is helping them, who feel they now have even more paperwork, and in general have no idea how the ACO operates. The physicians asked good questions and made good suggestions but got no meaningful responses. Instead, they are left with reduced reimbursement.
OneCare was formally criticized by the federal government for not achieving their goals for participation in the ACO two years in a row. So, part of the state’s plan is to move the goalposts and ask the Centers for Medicare and Medicaid Services to reduce the goals so OneCare might achieve them. The state also plans to require Vermont state employees to join the ACO to boost participation. The state is also pressuring the teachers association to join.
The central concept of the all payer model and the ACO is that health care providers will bear risk: they will receive fixed payments and if they spend more, they have to absorb the cost; if they spend less they get to keep savings. But now the state proposes to move those goalposts, too, and reduce the risk. In 2021, the hospitals’ risk will drop from 4% to 2%. The Agency of Human Services “reboot” proposes dropping the risk further to 1.5%. What is the point of all this effort and wasted money if the model is going to minimize risk for the largest and most expensive sector of the health care system?
The Vermont auditor of accounts has done a review of the ACO and found that neither the ACO nor Green Mountain Care Board even has a method for determining if the effort is cost effective. Recently the chair of the board is quoted saying, “We have got to have some measurement of what OneCare is bringing to the system.” Vermonters could expect after four years of operation that such a measurement exists, but it doesn’t. This is a failure not only of OneCare but the state and Green Mountain Care Board.
What about the quality of care? Is OneCare improving outcomes for Vermonters? Unfortunately, the results are very mixed. For some key indicators, including controlling blood pressure and preventing unnecessary readmissions to hospitals, OneCare’s results are headed in the wrong direction. Blue Cross has stated that they see no difference in quality between their patients in OneCare and their other patients.
As the pandemic unfolded several OneCare and state administrators claimed the ACO model of “fixed payments” saved the hospitals. That is grossly misleading. Less than 15% of hospital funding comes in fixed payments. The real savior was the over $400 million in payments from the federal government and the state.
But OneCare and its supporters are doing everything they can to gloss over these failures. OneCare is now buying media ads to tout their efforts and apparently has five staff positions for public relations and marketing. If OneCare was accomplishing its main goals and restraining the cost of health care, instead of making it worse, Vermonters would see it in their insurance rates and not need costly PR staff to convince us it was succeeding.
Now the state is doubling down on the effort, issuing a report of how it intends to “reboot” the initiative. However, nothing in the reboot proposal is going to fix this boondoggle. The whole ACO model is based on the false premises that primary care doctors are the problem, that a hospital-run ACO can reduce costs, and that we need a private, for profit, unaccountable ACO to achieve reform.
It is time for a new approach. We need an open and inclusive public discussion of how to achieve real reform that will make a real difference in the lives of Vermonters. This public discussion should have happened before the all payer model was proposed to CMS, but it did not. All the planning for the all payer model happened behind closed doors. The reason for that is obvious: The policymakers knew Vermonters would reject their plan as unnecessary and unworkable. The state needs to end the current agreement with CMS and replace it with a model that is affordable, effective and understandable.
The path to a healthier Vermont is surprisingly straightforward: strengthen primary care so every Vermonter has affordable access to a doctor; invest in prevention and early intervention; strengthen our mental health system so everyone who needs it can readily access affordable services, since mental health issues underlie or worsen many physical health problems; invest in addressing what are called the non-medical determinants of health like poverty, hunger and homelessness. State government, not a private entity, should manage this approach so it is accountable. Vermont could end the ACO model and put this new model in place with relative ease.
Hopefully the new legislative leadership recognizes the critical importance of health care for Vermonters and the growing burden of the cost and begins a formal, independent process to review the all payer model, the ACO and the Green Mountain Care Board’s role. The current model is failing and wasting both time and money.
For a more comprehensive and detailed analysis of these issues, review the comments submitted by Julie Wasserman to the Green Mountain Care Board.
