Health Care: All-Payer will change how you get health care

Dr Fred Kniffin, CEO of Porter Medical, and PMC Auxiliary President Jan Bark in June 2016. Porter photo.

by Timothy McQuiston, Vermont Business Magazine Beginning with this new year, an estimated 120,000 Vermonters, or about 20 percent of the population, will find out what the All-Payer health care model is all about. All-Payer begins January 1, 2018, as an effort to make people healthier while ultimately making health care cheaper. All-Payer is where capitalism meets socialized medicine. Health care providers are paid a flat fee to keep patients healthy. OneCare Vermont, based in Colchester, will coordinate the process with payers and providers. If the health care providers manage the care well, they get to keep any left over money as a profit.

In the world of American health care, the only way to make it cheaper is for people to be healthier.

Todd Moore, CEO of OneCare, described it like this: An over-weight middle-aged man, who’s a smoker with high blood pressure, goes to his primary care physician. Instead of just telling him to lose weight and stop smoking and giving him lisinopril for the blood pressure, he sets him up with several preventative specialists, perhaps even a trainer and a psychologist, whatever seems appropriate – including the usual medical interventions and medications as needed – to try and prevent what would be the inevitable outcomes: Diabetes, heart and lung disease, hip, leg and foot issues, etc.

Those escalated health problems are not only more deleterious to the patient; they are also much more expensive to treat.

The patients in this new model, which is a five-year test here in Vermont, primarily will come from Medicare, but also will include those on Medicaid and some with commercial insurance. OneCare’s budget is $600 million. Medicare will be the biggest chunk because Vermont is a relatively old state and older people utilize more health care than younger people.

In all, the Green Mountain Care Board projection released in January 2017 estimated that Vermont spent $5.54 billion on health care in 2014 (the most recent data available). Of that, Medicare accounted for $1.2 billion, Medicaid was $1.5 billion and private insurance was $1.9 billion.

The goal by the end of 2022 is to have 70 percent of Vermonters involved in the All-Payer model and 90 percent of Medicare recipients.

While five years will not provide a lifetime of results to judge the success of this program, “We can’t afford to dig the hole any longer,” Moore said.

If this plan of using preventative care to make for a healthier population and reduce costs sounds familiar, it should. Back in the 1990s, Health Maintenance Organizations (HMOs) were expected to do the same thing. Remember CHP (Community Health Plan)?

HMOs are still the primary insurance model for commercial health insurance policies, but now they cost more than a mortgage on a four-bedroom home in the suburbs.

Utilization rates along with premiums continue to rise. All-Payer will attempt to “bend-the-curve” on both, while limiting cost growth to 3.5 percent, rather than the current 6-7 percent.

“There’s no better time to start this than now,” Moore said.

Moore said this All-Payer plan is different, and better, than the previous HMO model because it is driven by the health care providers themselves. The HMOs were set up by the health insurance companies and was based on the traditional fee-for-service model, with the insurers setting up the benefits.

Moore called the payer deciding on things like denial of care a “blunt instrument.”

All-Payer is a fixed-revenue system with that dual motive of healthier outcomes for patients and profit for the provider. Moore said OneCare will help providers avoid waste to further save money.

In Vermont, nine Vermont hospitals have chosen to partner with OneCare Vermont in 2018, according to a provider submission made with both the Centers for Medicare and Medicaid Services (CMS) and the Department of Vermont Health Access (DVHA).

Hospitals, independent physician practices, specialists, skilled nursing facilities, designated mental health and substance use agencies, Federally Qualified Health Centers (FQHCs), home health providers and area agencies on aging are among those who are participating in population health programs in the coming year.

With providers being paid differently, there will be increased support for providers to engage with patients to improve quality and patient experience.Benefits to patients will not change.

Moore said the 2018 participant agreements are a key milestone in Vermont’s efforts to keep people healthy rather than treating them only when they are sick.

“This shows real buy-in by health practitioners across the state,’’ said Moore. “We are on our way to a statewide network that focuses on primary care and population health for all Vermonters. It means doctors and hospitals are agreeing to treat patients in a holistic way across the spectrum of their lives. It is an exciting change.”

Moore said the difference is that this new model should be called a “health system” rather than just “health care,” which suggests just treating the sick.

OneCare is the state’s largest Accountable Care Organization, or ACO, which was created by the University of Vermont Medical Center and Dartmouth-Hitchcock Health to improve quality of care, improve patient satisfaction and better manage cost of care in Vermont.

OneCare's provider network shares savings and losses against population-based spending targets. Monies are distributed through OneCare to providers if total expenditures to deliver care are less than expected, and collected from providers for repayment if the target is exceeded. OneCare itself represents the operational infrastructure required to participate in the ACO programs, implement reformed payment mechanisms, and provide the tools and support necessary for success. OneCare operations are funded at cost with no planned margin from financial resources contributed by its participating hospitals and contracted health plans and payers.

Todd Moore is also CEO of Adirondacks ACO in northern New York, a partnership with the University of Vermont Health Network, Champlain Valley Physicians Hospital and Hudson Headwaters Health Networks, which operates FQHCs. Moore plans to continue the close partnership OneCare has had with Adirondacks ACO to bring greater coordination across the region.

Moore said he was especially pleased that so many independent practices have agreed to take part, including the Thomas Chittenden Health Center, Primary Care Health Partners practices, and others in Richmond, Middlebury and Charlotte.

OneCare anticipates that approximately 120,000 Vermonters will be covered, spanning the length of the state from Newport to Brattleboro, through a partnership between their health care providers and OneCare. Provider participation is diverse and includes:

9 Vermont hospitals

1 New Hampshire hospital

2 Federally Qualified Health Centers

24 Independent physician practices

30 Independent specialist practices

19 Skilled nursing facilities (SNFs)

8 Home health agencies

6 Designated Agencies for mental health and substance use

9 Other specialty providers

2 Area Agencies on Aging

“This is absolutely the direction we need to take to improve care and reduce cost for Vermonters,” said Jill Mazza Olson, executive director of the VNAs of Vermont, the trade association representing Vermont’s not-for-profit home health agencies. “Reducing costs and keeping Vermonters healthier means bringing more care and support to people in their homes and their communities, where they want to be. We are proud to be part of this health care transformation and appreciate the good work OneCare has done to get us to where we are today.”

As part of this more holistic approach to providing health care with an emphasis on prevention, OneCare Vermont has invested in a pilot program to improve the quality of mental health and substance use treatment services for residents of two Burlington area housing communities specializing in the coordination of care and services for older adults and those with special needs.

Working in collaboration with the Howard Center and SASH (Supports and Services at Home) at Cathedral Square, the program will deliver an improved health care experience to residents of two affordable housing sites by placing a Howard Center clinician there full time.

“We are pleased to collaborate with OneCare and SASH to provide mental health services for seniors and individuals with special needs who wish to receive services in their homes. The embedded clinical care that Howard Center will provide at two Cathedral Square communities will ensure residents are receivingtimely care, with a goal of fewer avoidableemergency room visits,"said Catherine Simonson, Chief Client Services Officer at the Howard Center.

The role of this SASH Community Based Clinician located in affordable housing sites will be to promote emotional wellness to all participants and residents while having the flexibility to provide more intensive individual therapeutic supports to individuals in need.

The clinician will play a role in enhancing already existing services provided by the SASH staff with providing both individual and group therapeutic support as well as participate in care coordination and treatment planning.

“The pilot program will provide easy access to flexible team-based supports,including direct one-on-one support and group-based programming,” said Molly Dugan, director of SASH.

“This is a natural next step for OneCare, and for Vermont,” said Sara Barry, director of Clinical and Quality Improvement at OneCare Vermont. “We know that one way to achieve population health is to focus on people in their homes and communities.We are meeting people who need our help where they are. We know this is where people are spending their time, so what we are now addressing is, how do we increase the knowledge of staff on site, and the quality of counseling and mental health services?”

The pilot, for older adults with disabilities who experience mental health and substance use conditions, will test the effectiveness of locating mental health practitioners and prevention resources on site, bringing care to the patients.

“This pilot program will enhance the existing community partner based SASH model,” said Deborah Bouton, Director of Outreach and Marketing at Cathedral Square. “The existing SASH model already provides comprehensive team-based care and prevention programs to help participants stay healthy in their homes. We are looking to build on this program and make it even better.”

Nearly 5,000 people in Vermont rely on the SASH program, which uses the state’s affordable-housing network as a platform to support healthy aging at home through services coordinated with nonprofit housing organizations, Area Agencies on Aging, Home Health organizations, community mental health and developmental services organizations and primary care health providers. Formal partnerships among these organizations provide for efficient sharing of information and regular team meetings.

OneCare Vermont will establish a standard process for soliciting and evaluating initiatives for funding that improve the health of the patients of the entire provider network. OneCare will also partner with Vermont communities to support activities that meet the needs of their specific patient populations.

This pilot program, with an initial investment from OneCare of $97,000, intends to serve up to 200 residents and seeks to achieve a number of outcomes including shortened timeframes to access mental health services, reduced avoidable emergency room visits, improved patient experiences, and enhanced inter-agency team coordination. The pilot began on November 1 and will continue throughDecember 31, 2018.

OneCare Vermont network

CNSSA = Collaborator
MSSP = Medicare Shared Savings Program
VMNG = Vermont Medicaid Next Generation Program
XSSP = Commercial Shared Savings Program

Source: Colchester, VT --www.onecarevt.com