by Emma Lamberton Vermont Watchdog OneCare has contracted with Medicaid to transition providers into a global budget in 2017, and independent doctors have until November 4 to decide if they will participate in the agreement. “The Medicaid agreement moves away from fee-for-service to a global budget, consistent with the all-payer model,” Vermont Care Organization Chair and Rutland Regional Medical Center CEO Tom Huebner told Vermont Watchdog on Monday.
Vermont Care Organization, the newly-authorized statewide accountable care organization (ACO) overseeing Governor Peter Shumlin’s all-payer model, will act in an oversight capacity for the Medicaid agreement, even though it is contracted to OneCare.
“Medicaid has established a pilot program (for 2017), and we expect a small number of providers to participate in 2017 as a precursor to the much broader all-payer model which goes into effect in 2018,” Huebner said.
OneCare, an ACO owned by the University of Vermont Medical Center and Dartmouth-Hitchcock Medical Center, announced in July that it would be partnering with Medicaid to align with a Next Generation ACO model and payment system. Centers for Medicare and Medicaid Services is encouraging this type of ACO across the country as an experiment to see if stronger financial incentives for ACOs, combined with an integrated exchange of patient data, will improve patients’ health and lower the cost of care.
HealthFirst, an advocacy group for independent doctors, also must participate if the OneCare Medicaid agreement is to reach critical mass — the number of providers and patients active in the system to make it function properly. HealthFirst represents 160 independent physicians and about 90 physician assistants and nurses.
The Department of Vermont Health Access lists HealthFirst as responsible for between 70,000 and 120,000 patients. OneCare has approximately 95,000.
“We’re working with OneCare to make it attractive,” said HealthFirst Chief Medical Officer Dr Paul Reiss. “It’s come a long way.”
In the Medicaid agreement, OneCare will receive a payment of $6.50 per patient each month. Independent doctors would receive $3.25 per patient per month. These are bonuses separate from funds for patient care.
HealthFirst is also negotiating the removal of “prior authorization” from Medicaid practice. Reiss describes prior authorization as an “onerous” policy, where patients must seek approval from their insurance to see whether a provider-recommended procedure will be covered. Insurance companies will often resort to a “fail-first” method of treatment, authorizing alternatives that are less expensive than what a doctor originally recommends. This attempt to avoid spending can cost the system even more, and delays in doctor-recommended care can be detrimental to patients.
Independent physicians have historically been critical of global budgets, but Reiss calls the proposed partnership a “positive first step.” Because independent physicians are needed for the critical mass of the program, he sees the proposal as a way to negotiate improvements in the way hospital monopolies treat small private practices. This week, Reiss moved his own practice, Evergreen Family Health, under the OneCare agreement.
While Reiss is behind joining OneCare, he says the overall feeling of independent physicians is “extremely cautious.”
Opponents of global budgets say the system incentivizes doctors to limit patient care. If the money allotted at the beginning of the fiscal year runs out, providers will be responsible for a large portion of the overspending. Because of this, providers could sacrifice necessary care to stay within budget. OneCare is also responsible for overspending, and will work with providers under the program to meet health and spending requirements.
Huebner told Watchdog that HeathFirst practices would remain independent, and that “it is (OneCare’s) intention to make the program financially attractive for all primary care physicians.”
The exact financial allotment from Medicaid is still being negotiated, Huebner said.