State regulators at the Green Mountain Care Board told OneCare Vermont this week that its 2023 approved budget must be formally amended to reflect the withdrawal of insurer BlueCross BlueShield of Vermont from its programs, as well as other substantial changes to the operations of the state’s only “all-payer” accountable care organization.
But by June 1, someone new will be responsible for clearing that bureaucratic hurdle, and the rest of what is involved in fulfilling contracts for an anticipated $970 million in Vermonters’ health care activity this year.
At a meeting Tuesday, OneCare’s board of managers selected Abe Berman to serve as interim CEO for the accountable care organization, or ACO, which is owned by the University of Vermont Health Network but contracts with health care payers on behalf of all 14 of the state’s non-federal hospitals and almost 400 care practices, representing more than 5,100 health care providers.
The ACO is called “all-payer” because it contracts with both the state and federal government, which funds Medicaid and Medicare respectively, as well as private insurance companies.
The organization announced earlier in May that Vicki Loner, its CEO since 2019, would depart at the end of the month.
Berman, currently vice president of revenue strategy at UVMHN, was part of the launch of OneCare and served as its director of finance before leaving for executive roles at a commercial insurer, according to a press statement.
“Abe’s leadership skills combined with his experience and knowledge of value-based care make him the right leader to guide the organization at this critical moment,” said the board of managers chair, Anya Rader Wallack, in the statement.
Wallack is also an executive at the UVM Health Network and was the first chair of the Green Mountain Care Board, which since 2012 has been charged with oversight of hospital budgets, healthcare investment certificates of need and private insurance rates, particularly as related to plans that qualify for sale on the Vermont Health Connect exchange. Its regulation of accountable care organizations began in 2016.
“Value-based care” generally means health care payment arrangements that are tied to measurable targets. These can either be process targets related to how well a particular type of provider is following best practice, such as the percentage of a primary care provider’s patients with high-blood pressure who receive follow-up care, or outcome-related targets, such as the percentage of patients visiting an emergency department who return with related symptoms within two days.
Part of the work of accountable care organizations like OneCare is to facilitate agreements between payers and health care providers around what targets are appropriate and how payment for care will be adjusted up or down based on whether a hospital or group of providers meets or exceeds those benchmarks. The payment might be set up on a per patient per month basis, often called capitated care, or for specific procedures and consultations, called fee for service.
Goals of health care payment reform in Vermont and elsewhere in the country are to increase the proportion of “value-based” care payments, and to create more capitated payment arrangements, particularly for primary care and behavioral health. Proponents believe the outcome will be health care that is both higher quality and more affordable.
The OneCare board is developing its strategic plan for the coming three years, 2024-2027, and has charged Berman with putting its ideas into action. The board plans to hold off seeking a permanent CEO until after the plan is implemented, according to the statement.
The organization’s budget tussle with the Green Mountain Care Board began after a decision by BlueCross in late December to withdraw from participation with the ACO in 2023.
The non-profit insurer said at the time that staff analysts were not seeing evidence that contracts with OneCare were improving outcomes or reducing the cost of care. But the company’s more immediate concern stems from a plan OneCare unveiled in August 2022 to start outsourcing its health care data management and analytics to UVM Health Network in 2023.
BlueCross, which recently agreed to become part of the much larger BlueCross BlueShield of Michigan if state regulators approve the deal, offers a Medicare Part C plan that competes head-to-head with UVM Health Advantage, a collaboration between UVMHN and the insurer MVP, for Medicare-eligible customers.
The announcement from the state’s largest private insurer came the day before care board regulators were set to vote on the organization’s 2023 budget, and 10 days before the start of the ACO’s fiscal year. Regulators approved the budget then with the understanding that the details would need to be revised at a later date.
The loss of participation from BlueCross meant that the number of Vermonters whose care payments are influenced by OneCare contracts has dropped by around 65,700 people to just under 231,000. That reduction decreased the bonus dollars available to providers to earn by around $9.7 million. It also brought down the amount available in direct support payments to primary care providers by around $4 million, according to a budget presentation made to the board earlier this month.
The state’s independent primary care providers who participate consider those payments essential to their ongoing stability. BlueCross BlueShield committed to continuing to make its share of the payments directly to primary care providers. But OneCare also made payments to providers for patients insured by BlueCross, which were lost when the BlueCross contracts lapsed.
OneCare was able to make up much of the difference there by counting Vermonters insured by MVP, which does have a contract with the ACO, into the primary care program, as well as people covered by the UVMHN self-insured plan.
Care board members said they appreciated the ACO’s swift action to shore up those payments, but that all those changes must be now included in an amended 2023 budget. The board’s action on Wednesday was a unanimous vote to direct OneCare to request an amendment from the board.
“It’s really up to OneCare to request an amendment,” staff attorney Russ McCracken advised board members. “The board can’t make the change or update the board’s approval without application from OneCare.”
Correction: A previous version of this story was inaccurate about the year that the Green Mountain Care Board began regulating ACOs, and about the year that OneCare plans to begin to contract with UVM Health Networks for data management and analysis.