Patrick Flood: Misleading PR Rebuttal on All Payers Model Report


This comment is from Patrick Flood, former commissioner of the Ministry of Mental Health and the Ministry of Invalids, Aging and Independent Living, and former Deputy Secretary of the Social Services Agency. He is now retired and lives in Woodbury.

Recently, there has been a lot of media coverage of a report by the Centers for Medicare & Medicaid Services at the University of Chicago-NORC on the Vermont All Payor Healthcare Reform Model. Heads of state called the report’s results “promising.”

The report’s main finding is that Vermont “saved” millions of dollars in health insurance spending. However, a careful reading of the report calls this conclusion into question. There are a few key questions about the report’s findings and a number of other concerns.

First, the conclusion that Vermont saved millions is suspect. There are two reasons for this. First, the study authors came to this conclusion not by looking at Vermont Medicare spending year over year, but by comparing our spending to other states. These other states bear little resemblance to Vermont and include Missouri and Arkansas as well as Tennessee, Wyoming, South Carolina, and North Carolina, which have not even extended Medicaid under the Affordable Care Act. . The idea is that these other states’ health insurance spending increased in 2018 and 2019, but Vermont did not, so Vermont “saved” the difference.

Aside from the fact that comparing Vermont to these very different states is questionable to begin with, the reality is that, as noted in the report, Vermont health insurance spending has been relatively stable since 2014, years before the implementation. place of the all payers model. The report even states (page 56): “The observed reductions in Medicare spending – for both the Medicare ACO and statewide Medicare populations – reflect increased spending in health groups. comparison and relatively stable spending in the VTAPM groups over what began before the end of the reporting period and continued through the first two fiscal years. Anyone can see this clearly in the table on page 65 of the report.

Further, the report states, “For this reason, the results may also reflect the delayed impacts of other health reform initiatives in Vermont. “

It is highly debatable, given the failures of the All Payers model and OneCare Vermont, whether any of these initiatives should be credited with declining Medicare spending when Vermont Medicare spending has been flat for years without change. significant since the start of the set –payer model.

The report also states, “After factoring in shared savings and transferred payments from Medicare, the VTAPM Medicare ACO initiative achieved a cumulative reduction in net spending of $ 522.29 PBPY (-4.7%) which did not reach statistical significance.(Emphasis added.)

What this essentially means is that, after including some of the costs of the model, the alleged savings were even less, to the point of being insignificant, not the tens of millions of dollars that were reported.

The report also does not take into account the administrative costs of the responsible care organization, OneCare. This is really confusing, because any valid calculation of “savings” has to include costs. This casts further doubt on the so-called “savings”.

The second important point is that this report focuses only on Medicare. It’s confusing because the model is presented as “all payers”. Why is Medicare intended for the study when it only includes a third of the total number of participants? Is it because some parties believed they could show positive results for Medicare, when Medicaid and commercial insurance show significant losses, not savings?

The actual losses from Medicaid (well documented by the state auditor and Vermont Department of Health Access) and commercial insurance more than offset any “savings” from Medicare. Is it possible that there is an effort to give the best possible effect to this model? Any reasonable analysis of the all payers model clearly demonstrates that it does not save money, but costs Vermonters tens of millions of dollars.

The report states that there were other desirable outcomes in 2018 and 2019. One is the reported decrease in hospital stays. But the report does not say which interventions resulted in this reduction. In fact, the report states, “This decrease may reflect VTAPM’s emphasis on coordination of care, as well as a shortage of specialists in Vermont. A shortage of specialists, well noted recently by Seven Days, is not a desirable outcome. Others have suggested that the decrease may simply be an example of restriction of care. The reality is we don’t know why there has been a decrease in hospital stays, and that may not be a positive outcome that the model should take credit for.

The report states: “The model was associated with a significant drop in the number of beneficiaries receiving annual wellness visits over the two years of performance (-43%, -34% respectively). How can that be a good thing? Promoting and expanding access to preventive care is a fundamental foundation of the all payers model.

The report also documents a reduction in home health services. The report suggests that this could be the result of reduced hospital stays. Why is this a good thing? On the contrary, we should expand home health to amplify prevention efforts and prevent people from going to the hospital.

The report lists a number of other issues with the model. For example:

  • “The complexity of the model, the perceived lack of transparency and mistrust have contributed to the challenges of engaging practitioners and the public. “
  • “At the start of the model, there were ‘turf conflicts’ between OneCare and the Blueprint, centered on concerns that OneCare was building a redundant care coordination capacity. “
  • “Despite OneCare’s efforts to involve stakeholders, including additional financial incentives, evidence suggests that care coordinators, ESCs, and community organization staff have used Care Navigator inconsistently or not at all.” (Care Navigator is the computerized care coordination system designed for the responsible care organization, which has since been scrapped as a costly failure.)
  • “Suppliers also noted a significant administrative / documentary burden as the software (Care Navigator) is not interoperable with their electronic health records (EHRs), requiring double documentation. ”

Recently, the leadership of the UVM Health Network publicly stated that the responsible healthcare organization would become part of the UVM Health Network and no longer be independent. Additionally, UVM Health Network has entered into a Medicare Advantage plan partnership with MVP, which is odd because anyone on a Medicare Advantage plan cannot be counted in the responsible care organization either, which will make it more difficult. for ACO to achieve its participation goals.

Even more intriguing, the state has announced plans to convert the Department of Vermont Health Access, our Medicaid agency, into an at-risk managed care organization. If this ministry is taking risks and reinvesting the savings, then why do we need a responsible care organization? What is really going on? Is a new plan being developed? If so, how will this affect Vermonters? Don’t the people of Vermont deserve to know what’s in store?

On top of all this, UVM has requested, and the Green Mountain Care Board of Directors has approved, a 6% increase in its hospital budget for next year. It came after the hospital posted a profit of $ 127 million last year. What happened to the Green Mountain Care Board’s mandate to cap overall spending at 3.5%? Other hospitals receive increases of 5% and 6%.

Finally, the state said it was only asking the Centers for Medicare & Medicaid Services for a one-year extension of the all payers model. If the model has been so successful, why not ask for a full five-year extension?

Clearly, the state is considering dropping or seriously changing the all payers model and the role of the responsible care organization. Shouldn’t we tell the people of Vermont what this plan entails?

It is not a real health reform. The shame is that we know what real health care reform entails and that we could achieve it faster and more effectively than current efforts. Instead, we are wasting time and money on, in effect, preserving the status quo. Vermonters deserve better.


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