Richard Slusky: Ways Vermont Could Fix Its All Payor Healthcare Model

This commentary is from Richard Slusky of South Burlington, who was CEO of Mount Ascutney Hospital and Health Center in Windsor from 1982 to 2010. After his retirement, he served as Director of Payments Reform for the Green Mountain Care Board for six years. . He is now the owner of Slusky Consulting LLC.

This is an open letter to the Green Mountain Care Board, OneCare, and the Scott Administration regarding the Vermont All Payor Model.

Recent articles in VTDigger, other Vermont publications, and a report by a state auditor further indicate that after nearly four years, the all-pay model is not meeting the financial and clinical goals negotiated in the plan. .

When the chairman of the board of directors of Green Mountain Care, the organization ultimately responsible for overseeing the plan, calls the progress “abysmal,” it may be time to take a new course.

As one of the health system leaders who developed the ‘framework’ for the model caring organization agreement and, for 28 years, CEO of one of the hospitals in Vermont, I have come to understand that when after a long period of time a plan is clearly not working, it is time to change the plan and / or to change the people who are responsible for its implementation. In the case of the all payers model, I would recommend that both be considered.

As for the plan itself, as I noted earlier, I think the principles on which the ACO all-pays model is based are still worth pursuing. Concretely, these principles consist of:

  1. providing quality health care services to as many Vermonters as possible under the auspices of a collaborative health care system focused on the health of the people, not the volume of services provided.
  2. shifting from a fee-for-service model to ‘value-based’ payments that provide providers with a secure revenue stream as long as they meet reasonable goals of patient access, improvement of quality and cost control.
  3. improve the health of Vermonters by increasing access to primary care, reducing the prevalence of chronic disease and reducing deaths from suicide and drug overdose.

Sadly, most Vermonters still have no idea what the ACO all-payer model is and have seen no noticeable reduction in health care costs or any improvement in their ability to access healthcare. timely health services. For most Vermonters, it is also not at all clear what benefits / values ​​they have gained 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 I am a Medicare beneficiary with supplemental insurance from a private insurer. I have a primary care physician who is employed by the University of Vermont Medical Center so I am considered “assigned” to the ACO All Payers model.

I have two chronic illnesses which require periodic monitoring, but which do not significantly interfere with my lifestyle. I cannot say that I am unhappy with the health services I receive, but neither can I say that anything has changed in the past four years that would indicate that there have been significant changes in the way which my health care is provided or paid for. There has been no ongoing correspondence from OneCare informing me of what it is doing to improve my health services or reduce the costs of my care and I continue to find it easier to be scheduled for expensive testing than getting a 15-minute appointment with one of my specialists.

A recent report by a state auditor indicates that the ACO, OneCare, has not adequately communicated its purpose or the value it brings to the system versus the costs it has added. Although the report is limited in scope, it is clear that significant improvements need to be made in the way costs are defined, calculated, reported and measured against targets.

Although participating members of the ACO, Vermont hospitals continue to operate, for the most part, as separate entities, each focused more on its own survival and maintaining the status quo than on the success of the system as a whole, and the efforts of the state’s largest healthcare insurer, Blue Cross Blue Shield of Vermont, to move from fee-for-service to value-based payments have been, at best, insufficient.

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

Additionally, healthcare advocates continue to express concern over OneCare’s organizational structure, given its relationship with UVM Medical Center. Specifically, it is unclear whether OneCare, as currently organized, recognizes the value of primary care and the importance of integrated community approaches to the reform model.

So what needs to change for the COA 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 supervision of a representative of the secretary of the State Social Services Agency and / or the Green Mountain Care Board, a stakeholder group should be formed to assess progress of the All Payors model to date, identify successes and challenges, and provide specific recommendations for changes that will need to be made for the plan to be successful.

    The group is expected to be comprised of the highest level leaders of the Hospital Association, Blue Cross Blue Shield, MVP, OneCare, Department of Vermont Health Access, federally qualified health center, primary care associations , health care advocates, mental health advocates, state workers union, the Vermont Health Information Exchange board of directors, professional associations and other community groups designated by the governor. Its recommendations are expected to be made public within 60 days of its first meeting and should serve as the basis for negotiations with Medicare regarding an extension of the all payers model beyond 2022.

The specific elements that I would suggest to be addressed by the stakeholder group include, but should not be limited to;

  1. transition to value-based payments without reconciling all payers
  2. increase the number of Vermonters assigned to the model
  3. assess the adequacy and mode of payment of primary care practices
  4. increase funding for care coordination and chronic care management at the community level
  5. consider incorporating payments for social determinants of health such as housing, transportation, and additional food payments as part of the state’s waiver agreements with Medicare
  6. encourage self-insured employer plans to commit to the model and voluntarily submit payment information to the claims database of all payors
  7. assess the pros and cons of restructuring OneCare and its board of directors to be more independent from UVM Medical Center and Dartmouth-Hitchcock.
  8. replace key leadership positions within State, OneCare and the Green Mountain Care Board of Directors as necessary to successfully implement an agreed plan

I know that in response to a letter of concern from Medicare regarding the progress to date in implementing the All Payors Model Agreement, the Social Services Agency has developed an “improvement plan. implementation ”which addresses many of the concerns raised by Medicare. However, in my opinion, what is missing from the agency’s response is evidence of stakeholder engagement or buy-in from those who will ultimately be responsible for achieving the required results. . Without this buy-in from participating vendors, payers, advocates, etc., the chances of the ACO model achieving its goals are slim at best. For this reason, forming a group of stakeholders to address these issues is critical to the success of the plan.

  1. Participating Vermont hospitals and their medical staff need to restructure their business plans to be more aligned with the goals of the system as a whole. The question is not whether Vermont’s 14 hospitals should continue to exist. The question is, what is the best way to configure Vermont health care services in a way that best serves the people of Vermont.

    In my opinion, OneCare is not, as some have recently suggested, simply a way to transfer dollars from payers to hospitals and other providers. It is the only organization that can and must take responsibility, through its participating members, for the success, both financial and clinical, of the pay-as-you-go model. It is called a “responsible care organization” for a reason, and it should be held accountable for its accomplishments, or lack thereof. This would mean that OneCare’s role in the hospital budget process and determining changes in clinical services need to be increased, and Green Mountain Care’s board should rely on OneCare’s recommendations before making decisions. final regarding hospital budgets and / or clinical service changes.

    For that to happen, however, OneCare’s management and board will need to earn the trust of its participating vendors and many other Vermonters, which it currently does not have. This may require significant changes in both the management and structure of OneCare.

  1. In order to reduce costs and improve quality, the Green Mountain Care Board and administration must negotiate new agreements with Medicare, Medicaid and major commercial payers in Vermont to move the payment system faster and more universally. fee-for-service. capitation payments and other forms of value-based payments, as provided for in the standard agreement of all payers. This would change the focus of providers from increasing the volume of services they provide to increasing the value of their services to the people of Vermont.

OneCare and the ACO all-payer model will only gain the trust and support of Vermonters when people begin to see that the quality and accessibility of their health services have improved and that there is evidence. sufficient that health care costs (i.e. premiums) have been slowed or in fact reduced. Then Vermonters will understand what the COA All Payers Model is.

The question now is whether we have the leadership, the will and the time to make it 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, repeated to me over and over again, “So what’s up, Dad? Are we going to do this or what?

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