Vermont regulators close-in on all-payer health care system
Al Gobeille, the chair of the Green Mountain Care Board, told the House Health Care Committee on Monday that he expects to have the terms for an all-payer model agreement with the federal government in December. The terms sheet would be the framework for an agreement that the Green Mountain Care Board would continue to negotiate with the US Centers for Medicare and Medicaid services to create a first-in-the-nation statewide all-payer system....
Trinka Kerr, the chief health advocate at Vermont Legal Aid, pointed to concerns about mental health and substance abuse as part of a report on Consumer Principles for Vermont’s All-payer Model. The 11-page Vermont Legal Aid report calls for the all-payer model to “improve access to care”; measure access in a way that’s more robust than determining who has insurance and who has a primary care physician; and give patients the opportunity to appeal their case if an ACO denies services.
Vermont Legal Aid report author Julia Shaw, MPH, writes in the introduction:
"Health care costs in Vermont have increased dramatically over the past few decades and are projected to continue to rise at an unsustainable rate without reform of the existing health care system. A recent report sponsored by Vermont’s Legislative Joint Fiscal Office estimates that Vermont residents spent $5.1 billion on health care in 2012, more than double the $2.3 billion spent on health care in 2000. This figure is projected to grow to $6.8 billion by 2017. Vermont Governor Peter Shumlin championed legislation, enacted in 2011, to establish a single-payer health care system in the state. However, in 2014 the governor withdrew his support for such a system citing lack of a viable finance plan.
"With a single-payer system off the table for the foreseeable future, the governor and his administration are exploring other health care reform options that aim to reduce costs and move toward value-based care. One of these options is an all-payer model. Act 54 of 2015 directs the Agency of Administration and the Green Mountain Care Board to “jointly explore an all-payer model, which may be achieved through a waiver from the Centers for Medicare and Medicaid Services” (CMS). Under such a waiver the state would agree to restrict the growth of health care spending for a defined set of services by all health insurance carriers (Medicare, Medicaid, and commercial insurers) to a trend rate negotiated with CMS. CMS would agree to waive some of its rules to allow the state to implement payment methodologies such as global hospital budgets and capitated (per-person) or population-based payments to some health care providers. To implement the model, the state’s three Accountable Care Organizations (ACOs) are planning to merge into a single statewide ACO that would be responsible for managing the cost of care and care delivery for the population attributed to the model.
"The goal of implementing an all-payer model would be to bring Vermont closer to achieving the triple aim: improve the patient experience of care including quality of care and satisfaction; improve population health; and reduce the per capita cost of health care. The model would aim to change the financial incentives in the health care system, which currently reward high-volume care, to reward lower-volume higher-value care. An all-payer model would cause a drastic shift in the state’s health care system and would require robust regulatory processes to ensure that cost reduction is not achieved at the expense of access to services, quality of care, population health, or patient experience.
"The types of payment under consideration within the all-payer model, including global hospital budgets and capitated or population-based payments implemented by a single statewide ACO, carry a number of risks as well as potential benefits. Cited risks of these models include rationing care, cherry-picking or dumping patients, and sacrificing quality of care in favor of cost savings. An all-payer model could benefit Vermonters if these and other risks are sufficiently addressed in the model design."