Robert Hoffman: OneCare should be placed in a corrective action plan

This commentary is by Robert L. Hoffman, a former resident of Stowe and seasonal resident of Manchester, Vermont. He is a mental and public health teacher/practitioner/consultant in private practice, and teaches graduate-level psychology at Chestnut Hill College. His lawsuit alleging wrongful termination is headed for trial.

Before the Green Mountain Care Board currently is a decision to vote to approve the 2023 modified budget for OneCare, the accountable care organization, “exactly as submitted.” This, despite multiple board members underscoring that the accountable care organization has become 50% more costly to administrate. 

But because it has become “too big to fail,” it’s unlikely the Green Mountain Care Board can do anything but approve as submitted. However, the care board is not without other remedies. 

Vermont’s All-Payer Model Agreement contains specific prescriptions for “triggering events,” occasioned by failure to satisfy specific milestones. One such triggering event has already occurred, and enforcement waived, for “attribution” — the total number of lives covered by the model. Attribution was “temporarily” waived by the federal Centers for Medicare & Medicaid Services when the Green Mountain Care Board compelled it to understand the targets were not viable. 

However, several recent events necessitate once again triggering a corrective action plan.

Additional triggering events as defined in the All-Payer Model Agreement can be:

—A disapproval by Centers for Medicare & Medicaid Services of the state’s assessment describing how the scale target accountable care organization initiatives’ designs align across payers on key design dimensions.

—A determination by the Centers for Medicare and Medicaid Services that the quality of care provided to Medicare, Medicaid or CHIP beneficiaries has deteriorated. 

—A determination by the Centers for Medicare and Medicaid Services that the state has taken actions that compromise Medicare trust funds.

BlueCross BlueShield: Nothing in the aforementioned attribution waiver can be understood to be dispositive for the recent event of BlueCross BlueShield VT leaving the singular accountable care organization partner — OneCare VT. This loss represents an irrevocable loss of one-third of potential attribution and therefore must occasion a triggering event unrelated to the attribution waiver.

Medicaid deterioration: As evidenced by the Medicaid scorecards, Medicaid quality of care deteriorated in both 2019 (2020 waived for pandemic) and 2021 — the data available at this time. While 2020 appeared to be a stellar score of 95%, unearned points were assigned for process milestones. Careful reading of actual performance demonstrates a real score of 71.8%. In 2021, the Medicaid scorecard shows further deterioration to 68.75%

Compromised Medicare trust funds: The Vermont Medicare Participation agreement and the VT VMNGO Agreement expressly outline compliance with law. The Vermont Health Care Advocate has specifically cited concerns regarding the following potential violations of law:

1. Antitrust violations of law related to data analytics being contracted back to the parent company, UVM Health Network.
2. Misappropriation of All-Payer Model funds — $10.5 million in primary-care support payments, intended for providers, ultimately falling as confirmed by OneCare Vermont CFO to the bottom line mainly of UVM Health Network as well as accountable care organization executive compensation taken not compliant with contractual stipulations for same.
3. Wrongful termination probable violation of law: “Hoffman’s claim regarding his presentation and statements at the meetings is that OneCare was aware of Hoffman’s concerns about OneCare’s analytics and its effect on the public’s health. In addition, the email …  shows that OneCare had received reports of Hoffman’s allegation that OneCare was misusing federal funds and that he might be reporting that to the government.” His primary supervisor “admits that she was told by other employees that Hoffman felt our current use … constituted fraud and abuse of federal, state — of federal and state funds.” Hoffman has, therefore, met his burden of showing a prima facie case of retaliation.

Particularly egregious is the fact that UVM Health Network’s contracted analytics work will be overseen by those accused of committing a violation of law, preventing Hoffman from expressing his concerns that the accountable care organization was not viable. 

BlueCross BlueShield of Vermont confirms OneCare VT not viable: Despite having collaborated with OneCare every year since its inception, Blue Cross is unable to reach an agreement this year due to the lack of tangible quality outcomes, inability to bend the cost curve, and the new data approach that introduces concerns about security and privacy.

Allegations dating to 2018 are realized in the BlueCross decision to withdraw one-third of Vermonters from the accountable care organization. The decision underscores deteriorating care and concerns about OneCare’s fiduciary role in its agreements. 

For all the foregoing reasons, and consonant with the Health Care Advocate’s similar request, the public would call upon the Centers for Medicare and Medicaid Services and the Green Mountain Care Board to proceed as follows, consistent with triggering events: Place OneCare VT in a corrective action plan:

1. 2024 budget must include Medicaid quality measure improvement plan
2. 2024 budget must include a proposed BlueCross BlueShield reattribution plan.
3. A comprehensive diligencing by the Green Mountain Care Board and the Centers for Medicare and Medicaid Services of potentially misappropriated funds.
4. Analytics transfer to UVM Health Network must be paused until:
   1. The health network is found innocent of wrongful termination for expressing a public policy concern.
   2. Those responsible for violation of law are no longer employed or contracted by the health network and its affiliates.
   3. In event of being found guilty, all parties must be referred to appropriate law enforcement agencies and barred from administering federal Medicare and Medicaid funds.
5. Absent successful completion of the correction action plan items 1 and 2, per statute, a referral to the Vermont Attorney General’s Office should be made and opportunity provided to OneCare VT to respond.

Members of the public are encouraged to write to the following members, urging that they pursue this strategy: GMCB.Board@vermont.gov, owen.foster@vermont.gov, elizabeth.fowler@cms.hhs.gov, christina.cryder@cms.hhs.gov, tequila.terry@cms.hhs.gov, lachelle.smith@cms.hhs.gov, jason.maulucci@vermont.gov, jason.gibbs@vermont.gov.