Health Care

Feds proclaim Vermont’s all-payer model enrollment targets ‘unattainable’

Phil Scott, Mike Smith and Ena Backus
From left, Gov. Phil Scott, Human Services Secretary Mike Smith and Director of Health Care Reform Ena Backus in 2019. File photo by Mike Dougherty/VTDigger

Federal regulators said they won’t penalize Vermont for failing to reach the enrollment benchmarks in the state’s health care reform plan.

The federal Centers for Medicare and Medicaid Services called the enrollment benchmarks for the state’s all-payer model “unattainable” and “unnecessary,” prompting the agency to suspend its enforcement of these targets until the agreement could be revised. 

The agency will continue to enforce other standards, according to the Oct. 12 letter.

Vermont has consistently fallen short of its enrollment goals, the letter said. State leaders committed to having 70% of all Vermonters participate in the all-payer model by the end of 2022, but only 57% are enrolled so far according to Vermont’s most recent report to the Centers for Medicare and Medicaid Services. 

“The federal government is saying that they recognize that enforcing targets that are unattainable is not appropriate,” said Ena Backus, director of health care reform at the Vermont Agency of Human Services. “ … They’re not saying that we should not be working toward increased participation.”

Critics, however, say missing the enrollment benchmarks is the latest in a series of failures for the all-payer approach and OneCare Vermont, the accountable care organization that’s become almost synonymous with the model in the public eye. OneCare funnels hundreds of millions of Medicare and Medicaid payments to providers statewide. 

Patrick Flood, who formerly served as commissioner of the Department of Mental Health and the Department of Disabilities, Aging and Independent Living, called Vermont’s all-payer model “a failure from the start.”

“So they (the federal government) have to boost it by making it easier for (the state),” said Flood, who previously served as deputy secretary of the Agency of Human Services. “It lets them off the hook because they’re never going to reach those targets.” 

Vermont and the federal government entered an agreement in 2016 that would allow the state to experiment with a statewide value-based care model. Under the state’s all-payer model, Vermont’s public and private insurers would pay providers to keep patients healthy, rather than for every blood test, checkup or X-ray. If enough patients participate, the thinking goes, health care in the state would be cheaper and better. 

In its most recent letter to the state, federal regulators attributed the state’s enrollment challenges to Medicare enrollees either getting care out of state or participating in Medicare Advantage plans that do not have an agreement with OneCare. 

Vermont leaders have also said that commercial insurers were slow to shift enrollees to OneCare. As of 2020, roughly 20% of all commercially insured Vermonters were part of OneCare, compared with more than 90% of the state’s Medicaid enrollees, the state said in its most recent report to the feds

In addition to enrollment targets, the 2016 agreement sets quality standards, such as increasing access to care and reducing suicides, which the agency will continue to enforce, according to the letter.

Kevin Mullin, who chairs the Green Mountain Care Board, a regulatory body that oversees OneCare, said the letter from the Centers for Medicare and Medicaid Services is “accepting the reality” that Vermont’s initial targets were overambitious. 

“Why have a cloud hanging over everyone’s head, including the state of Vermont, to come up with a corrective action plan to get to someplace that you can never get to?” Mullin said. 

Mike Smith, secretary of the Vermont Agency of Human Services, is expected to go before the Green Mountain Care Board to discuss the all-payer model agreement early next month. In conversations this week, both Mullin and Backus hinted that attaining Vermont’s enrollment goals may require another approach.

“The targets aren’t OneCare targets per se,” Backus said. “But because OneCare is the only one that’s doing it, the scales are measuring participation in OneCare.”

These discussions coincide with substantial changes to OneCare. John Brumsted, longtime University of Vermont Health Network executive, recently announced he was stepping down from his leadership role on the accountable care organization’s board. Last month, the University of Vermont Health Network became the sole parent organization of OneCare.

The nonprofit organization was originally a joint venture of Dartmouth-Hitchcock Medical Center UVM Medical Center. Brumsted said the new governance structure was part of an effort to course-correct after the Centers for Medicare and Medicaid Services put the state on notice for missing enrollment benchmarks in 2018 and 2019

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Liora Engel-Smith

About Liora

Liora Engel-Smith covers health care for VTDigger. She previously covered rural health at NC Health News in North Carolina and the Keene Sentinel in New Hampshire. She also had been at the Muscatine Journal in rural Iowa. Engel-Smith has master's degrees in public health from Drexel University and journalism from Temple University. Before moving to journalism, she was a scientist who briefly worked in the pharmaceutical industry.

Email: [email protected]

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