Vermont is only just starting to negotiate another five-year deal with the federal government that would extend its all-payer health-care model into 2028.
But the organization responsible for implementing that program, OneCare Vermont, is banking on a long-term future — though the details of that future remain fuzzy.
OneCare has vowed to refocus on improving its health care data and revamping its relationship with doctors, hospitals and insurance companies, but experts and state officials are divided on how exactly the bulky health care organization should move forward, and how long they want to wait to see results.
“There’s no manual for this,” said Alena Berube, director of health systems policy for the Green Mountain Care Board.
But others said they wanted to see results soon. “I’m very frustrated with the pace of change,” said chief health care regulator Kevin Mullin.
OneCare Vermont took charge of the state’s health care reforms in 2016, soon after Gov. Peter Shumlin abandoned his plan for single-payer health care. It aimed to work with hospitals and health care providers to change the way health care is paid for, to incentivize high-quality health care and lower cost. After a trial “year 0,” the organization began a five-year plan that ran from 2018 through 2022.
The trajectory has been rocky. The organization has consistently fallen short of its targets for growth, with fewer doctors and patients participating than expected. This year, for example, roughly 45% of the population was part of OneCare, or 228,704 Vermonters, compared to the goal of 62% of state residents set by the federal government.
In 2021, the organization lost membership, according to recent data. It also faced pushback from health care providers. Last fall, several independent doctors said that participating in OneCare was more trouble than it was worth, and they left the organization. Hospital officials told the Green Mountain Care Board that the dues and financial risk made participation too expensive. In November, Human Services Secretary Mike Smith launched an improvement plan to get OneCare back on track.
‘What works’
OneCare, too, is looking to revamp its mission and has spent months developing a new strategic plan that extends through 2023, said CEO Vicki Loner.
As OneCare has grown and evolved, “we’ve tried things and we know what works and what doesn’t work,” Loner said.
The organization’s goals are both sweeping and vague.
By the end of 2023, OneCare aims to identify ways to improve its data and analytics, and then implement those changes. Its leaders plan to find new metrics for health quality, and then work to meet them.
It will try to work with Medicare, the health care program for older Americans, and to work more deeply with private insurance companies to include Vermonters in its programs.
OneCare also said it would rebuild its portal, the physician-facing dashboard that’s meant to provide data and analysis to help doctors see health trends among their patients, and improve care.
Doctors overwhelmingly told regulators that the existing system is too clunky to be helpful, Mullin said. “There’s good information, but it doesn’t really work for them,” he said. “It’s just so cumbersome.”
Mullin criticized the strategic plan as “fuzzy” and said it lacked specificity. “I was hoping for more,” he said.
Backus, the director of health care reform, said the vision seemed promising. But, she added, “we need to see how it shakes out in terms of implementation.”
A long-term future
Members of the Green Mountain Care Board expect the state to come to some kind of agreement with the federal government for another five-year contract. The Centers for Medicaid and Medicare Services is pushing states and organizations such as OneCare to shift away from paying doctors for each service they provide, according to Loner — and will likely continue at least some version of its current deal with Vermont.
But what that agreement will look like is yet to be determined, and it will help dictate OneCare’s role in Vermont’s health care system, according to Berube. The negotiations are “going to shape the role of OneCare and what the state should expect going forward,” she said.
That deal will be hashed out later this year. The Care Board is currently accepting public comment on the future of the all-payer model.
Those involved in the process disagree on the specifics: whether hospitals should take on more financial risk or less, for instance, and what approach OneCare should take to persuade more doctors and hospitals to participate more fully.
Those questions remain details to be worked out, Loner acknowledged. But no matter the outcome, OneCare plans to continue to work with interested doctors and hospitals, “regardless of where the state goes,” she said.
Those disagreements are natural, said Backus, the director of health care reform. After all, she noted, Vermont’s approach to a statewide all-payer model run by a single accountable care organization is unique nationally.
But according to Backus, and others, there’s work to be done.
In the next five years, OneCare must increase its reach across the state and focus more heavily on providing high-quality data to its doctors, said Michael Bailit, head of the consulting firm Bailit Health that presented its recommendations to the Green Mountain Care Board in May. The majority of a doctor’s patients need to be participating in order to see broad-scale change, he said.
OneCare needs to improve its data and analytics, Bailit said. Bailit also encouraged the Green Mountain Care Board to play a more active role in overseeing the organization.
Vermont’s approach to health care reform could work, he said, but to be successful, “it’s going to require additional modifications.”
The consultant advised a dose of patience.
“There’s no clear blueprint for how to do this,” he said. “Far, far too often, we decide to commit to a new health policy, and … we give up too early. It’s not reasonable to expect it would change the health care system on a dime.”
Mullin put it more bluntly. “As fast as you want things to happen, sometimes you have to hang in there and grind it out,” he said. “That’s just life.”
Correction: Due to an editing error, an earlier version of this story incorrectly described Medicare.
