Commentary

Richard Slusky: Ways Vermont could fix its all-payer health care model

This commentary is by Richard Slusky of South Burlington, who was CEO at Mount Ascutney Hospital and Health Center in Windsor from 1982 to 2010. After retirement, he was director of payment reform for the Green Mountain Care Board for six years. He now owns Slusky Consulting LLC.

This is an open letter to the Green Mountain Care Board, OneCare, and the Scott administration regarding Vermont’s all-payer model.

Recent articles in VTDigger, other Vermont publications, and a state auditor’s report provide more indications that, after nearly four years, the all-payer model is not achieving the financial and clinical targets that were negotiated in the plan. 

When the chair of the Green Mountain Care Board, the organization ultimately responsible for overseeing the plan, decries the progress as “abysmal,” maybe it’s time for a new course of action.

As one of the health system leaders who developed the “framework” for the Accountable Care Organization Model Agreement, and for 28 years the CEO of one of Vermont’s hospitals, I have come to understand that when, after an extended period of time, a plan is clearly not working, it’s time to either change the plan, and/or change the people who are responsible for implementing it. In the case of the all-payer model, I would recommend that both be considered.

As far as the plan itself, as I have noted previously, I think the principles upon which the all-payer ACO model is based are still worth pursuing. Specifically, these principles are to:

  1. provide quality health care services to as many Vermonters as possible under the auspices of a collaborative health care system that is focused on the health of the population and not on the volume of services provided.
  2. transition from a fee-for-service payment model to “value-based” payments that offer providers a secure revenue flow as long as they meet reasonable targets for patient access, improved quality, and cost containment.
  3. improve the health of Vermonters by increasing access to primary care, lowering the prevalence of chronic disease and reducing deaths from suicide and drug overdose.

Unfortunately, most Vermonters still have no idea what the all-payer ACO model is, and have not seen any perceptible reduction in health care costs or improvements in their ability to access timely health care services. For most Vermonters, it is also not at all clear what benefit/value they have received from this “new” model of health care delivery. 

Let me give a personal example of what I mean by this. I am 75 years old and am a Medicare beneficiary with supplemental insurance through a private insurer. I have a primary care physician who is employed by the University of Vermont Medical Center and therefore I am considered “attributed” to the ACO all-payer model. 

I have two chronic conditions that require periodic follow-up, but do not significantly interfere with my lifestyle. I cannot say I am displeased with the health care services I receive, but I also can’t say that anything has changed over the past four years that would indicate that there have been any significant changes in the way my health care is delivered or paid for. There has been no ongoing correspondence from OneCare informing me of what it is doing to improve my health care services or reduce the costs of my care and I continue to find that it is easier to be scheduled for expensive tests than it is to get a 15-minute appointment with any of my specialists. 

A recent state auditor’s report indicates that the ACO, OneCare, has failed to adequately communicate its purpose or the value it brings to the system relative to the costs it has added. Although the report is limited in its scope, there is clear evidence significant improvements need to be made in the way costs are defined, calculated, reported, and measured against targets.

Despite being participating members of the ACO, Vermont’s hospitals continue to operate, for the most part, as separate entities, with each more focused on their own survival, and maintaining the status quo, than the success of the system as a whole, and the efforts of the state’s largest health care insurer, Blue Cross Blue Shield of Vermont, to transition away from fee-for service to value-based payments have been inadequate, at best. 

Clearly, there is not a sense of “system identity” that one would expect to find in a high-functioning health care system. Major health care systems like Mayo, Kaiser, and Intermountain Health care in Utah have clear cultural identities and expectations that set the standards for all their participating entities and providers. I see no evidence of that type of “systemwide” cultural identity in Vermont.

In addition, health care advocates continue to express concern about the organizational structure of OneCare, given its relationship to the UVM Medical Center. Specifically, there is not confidence that OneCare, as currently organized, recognizes the value of primary care and the importance of integrated community-based approaches to the reform model.

So, what needs to change in order for the ACO all-payer model to be successful? I would offer the following suggestions for consideration.

  1. Based on a directive from the governor and under the oversight of a representative from the secretary of the state Agency of Human Services and/or the Green Mountain Care Board, a stakeholder group should be formed to evaluate the progress of the all-payer model to date, identify the successes and challenges, and provide specific recommendations for changes that will need to be made in order for the plan to succeed.

    The group should consist of the highest-level leaders of the Hospital Association, Blue Cross Blue Shield, MVP, OneCare, the Department of Vermont Health Access, federally qualified health center, primary care associations, health care advocates, mental health, the state employees union, the Vermont Health Information Exchange board, business associations, and other community-based groups designated by the governor. Its recommendations should be made public within 60 days of its first meeting and should provide the basis for negotiations with Medicare regarding an extension of the all-payer model beyond 2022.

Specific items that I would suggest be addressed by the stakeholder group include, but should not be limited to;

  1. transitioning to value-based payments without reconciliation from all payers
  2. increasing the numbers of Vermonters attributed to the model
  3. evaluating the sufficiency and manner of payments to primary care practices
  4. increasing funding of care-coordination and chronic-care management on a community level
  5. considering the incorporation of payments for social determinants of health such as housing, transportation and supplemental food payments under state waiver agreements with Medicare
  6. encouraging self-insured employer plans to engage with the model and to voluntarily submit payment information to the all-payer claims database 
  7. evaluating the pros and cons of restructuring OneCare and its governing board to be more independent from UVM Medical Center and from Dartmouth-Hitchcock. 
  8. replacing key leadership positions within the state, OneCare, and the Green Mountain Care Board as necessary to successfully implement an agreed upon plan

I am aware that, in response to a letter of concern from Medicare regarding the progress achieved to date in implementing the all-payer model agreement, the Agency of Human Services has developed an “implementation improvement plan” that addresses many of the concerns raised by Medicare. However, in my opinion, what is lacking in the agency’s response is any evidence of stakeholder engagement or buy-in from those who ultimately will be responsible for achieving the required results. Without that buy-in from the participating providers, payers, advocates, etc., the chances of the ACO model achieving its goals are slim at best. For that reason, the formation of a stakeholder group to address these issues is critical to the success of the plan.

  1. Vermont’s participating hospitals and their medical staffs need to restructure their business plans to be more in line with the goals of the system as a whole. The issue is not whether Vermont’s 14 hospitals should continue to exist. The issue is what is the best way to configure Vermont’s health care services in a way that best serves Vermonters.

    In my opinion, OneCare is not, as some have recently suggested, simply a conduit for passing dollars from payers to hospitals and other providers. It is the one organization that can and should assume responsibility, through its participating members, for the success, both financial and clinical, of the all-payer model. It is called an “accountable care organization” for a reason, and it should be held accountable for its achievements, or lack thereof. This would mean that OneCare’s role in the hospital budget process and the determination of changes in clinical services needs to be increased, and the Green Mountain Care Board should rely on OneCare’s recommendations before making final decisions regarding hospital budgets and/or clinical service changes.

    For this to occur, however, the leadership and Board of OneCare will need to earn the trust of its participating providers and many more Vermonters, something it currently does not have. This may require significant changes in both the leadership and the structure of OneCare.
  1. In order to reduce costs and improve quality, the Green Mountain Care Board and the administration need to negotiate new agreements with Medicare, Medicaid and Vermont’s major commercial payers in order to transition the payment system more quickly and more universally away from fee-for-service payments to capitation and other forms of value-based payments, as intended in the all-payer model agreement. This would change the focus of providers from increasing the volume of services they provide to increasing the value of their services to Vermonters.

OneCare and the ACO all-payer model will only earn the trust and support of Vermonters when people begin to see that the quality and accessibility of their health care services have been improved and there is sufficient evidence that health care costs (that is, premiums) have been slowed or actually reduced. Then Vermonters will understand what the ACO all-payer model is all about. 

The question now is whether we have the leadership, the will, and the time to make that happen.

So, I leave you with the immortal words of my 11-year-old grandson from Colorado who, during his three-week visit to Vermont, has said to me repeatedly, “So what’s up, Pa? Are we going to do this, or what?”


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