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

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

Tue, 12/26/2017 - 7:24am -- Anonymous

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 receiving timely care, with a goal of fewer avoidable emergency 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 through December 31, 2018.

OneCare Vermont network  

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

Organization Name

Participating In

Addison County Community Trust

CNSSA

Addison County Home Health and Hospice, Inc.

MSSP; VMNG; XSSP

Addison County Transit Resources, Inc.

CNSSA

Affiliates in Obstetrical and Gynecological Care Inc

VMNG

Alder Brook Family Health, P.C.

VMNG

Allan Eisemann, MD

MSSP

Andrew Minkin, MD

MSSP; XSSP

Anesthesiology Associates of Bennington, PC

XSSP

Angela Wingate, MD

MSSP

Angela Wingate, MD

MSSP; XSSP

Arthritis & Rheumatology Center, PLC

MSSP; XSSP

Avery Wood

MSSP; XSSP

Barre Housing Authority

CNSSA

Bayada Home Health Care, Inc.

MSSP; XSSP

Bennington Project Independence Inc.

CNSSA

Brattleboro Area Adult Day Services

CNSSA

Brattleboro Crossings

MSSP

Brattleboro Housing Authority

CNSSA

Brattleboro Memorial Hospital, Inc.

MSSP; XSSP

Brattleboro Mutual Aid Association Inc. dba Thompson House Rehabilitation and Nursing Center

MSSP

Brattleboro Retreat

MSSP; XSSP

Burlington Housing Authority

CNSSA

Carl Petri

VMNG

Cathedral Square Corporation

CNSSA

Cedar Hill Health Care Corporation

MSSP

Central Vermont Council on Aging Inc

CNSSA

Central Vermont Home Health and Hospice, Inc.

MSSP; VMNG; XSSP

Central Vermont Medical Center, Inc

MSSP; VMNG; XSSP

Champlain Center for Natural Medicine

VMNG; XSSP

Champlain Housing Trust, Inc.

CNSSA

Champlain Imaging

MSSP; XSSP

Champlain Valley Area Agency on Aging

CNSSA

Champlain Valley Area Health Education Center Inc.

CNSSA

Charlotte Family Health Center Inc.

VMNG

Cheshire Medical Center

XSSP

Christopher J. Hebert, PC

VMNG

Clara Martin Center

MSSP; XSSP

Cold Hollow Family Practice, P.C.

MSSP; VMNG; XSSP

Connecticut Peer Review Organization, Inc.

CNSSA

Copley Hospital, Inc.

MSSP; XSSP

Copley Professional Services Group Inc.

MSSP

Council on Aging for Southeastern Vermont, Incorporated

CNSSA

Counseling Service of Addison County Inc.

MSSP; VMNG; XSSP

Craig E. Goldberg, DO

MSSP

Dartmouth-Hitchcock Clinic

XSSP

David M. Gorson, MD

MSSP

David W. Butsch MD PC

XSSP

DH Specialty Services, LLC

MSSP

Dorothy A. Brodmann

MSSP

Downstreet Housing & Community Development Inc

CNSSA

Dr. Robert C Bauman PLLC

MSSP

DTGC, PC

VMNG

Elderly Services Inc

CNSSA

Eric Asnis MD

MSSP

Eric S. Seyferth

MSSP; XSSP

Essex Pediatrics, PC

VMNG

Evergreen Family Health Partners, LLP

VMNG

Eye Vermont

MSSP

Fairfax Associates in Medicine PLLC

MSSP; XSSP

Five Ninety Six Sheldon Road Operations LLC dba Saint Albans Healthcare and Rehabilitation Center

MSSP; XSSP

Forty Six Nichols Street Operations LLC dba Rutland Healthcare and Rehabilitation Center

MSSP; XSSP

Franklin County Home Health Agency, Inc.

MSSP; VMNG; XSSP

Franklin County Rehab Center, LLC

MSSP; VMNG; XSSP

Franklin County Surgical Associates PC

MSSP

Gene Moore MD, PLC

VMNG

Gilman Housing Trust, Inc.

CNSSA

Green Mountain Wellness Solutions, Inc.

VMNG; XSSP

Hagan, Rinehart & Connolly Pediatricians, PLLC

VMNG; XSSP

Health Care and Rehabilitation Services of Southeastern Vermont Inc

MSSP; XSSP

Helen Porter Healthcare and Rehabilitation Center

MSSP; XSSP

Hillemann & Kirwan MDS PC

VMNG

Housing Authority of the Town of Springfield

CNSSA

HowardCenter, Inc.

MSSP; VMNG; XSSP

HPDP Consulting LLC

CNSSA

Joel Silverstein MD

MSSP

Joshua D. Green

XSSP

Kindred Transitional Care and Rehabilitation - Birchwood Terrace

XSSP

Kingdom Rehab Center LLC

MSSP

Lamoille County Mental Health Services

XSSP

Lamoille Family Center, Inc.

CNSSA

Lamoille Home Health Agency, Inc.

MSSP; XSSP

Lamoille Housing Partnership, Inc.

CNSSA

Lorilee Schoenbeck N.D., P.C. DBA Mountain View Natural Medicine

VMNG; XSSP

Martin Brutus

XSSP

Mary Ann Yeatts-Peterson MD LLC

MSSP

Mary Hitchcock Memorial Hospital

XSSP

Matrix Health Systems P.C.

MSSP; XSSP

Mayo Healthcare Inc

MSSP

Michael J. Corrigan, MD PC

MSSP; VMNG; XSSP

Middlebury Family Health

VMNG; XSSP

Mount Anthony Housing Corporation dba The Centers for Living and Rehabilitation Center (CLR)

MSSP; XSSP

National Church Residences of Pittsford, Vermont

CNSSA

National Church Residences of Rutland, VT

CNSSA

Natural Family Health, P.C.

XSSP

Neurological Associates of VT

MSSP

NFI Vermont, Inc.

XSSP

Nine Haywood Avenue Operations LLC dba Mountain View Center

MSSP; XSSP

North Country Hospital and Health Center Inc.

MSSP; XSSP

Northeast Kingdom Council on Aging

CNSSA

Northeast Kingdom Human Services, Inc.

MSSP; XSSP

Northeast Washington County Community Health Inc

VMNG

Northwestern Counseling and Support Services

MSSP; VMNG; XSSP

Northwestern Medical Center

MSSP; VMNG; XSSP

Northwestern Occupational Health, LLC

MSSP; XSSP

Orleans Essex VNA & Hospice Inc

MSSP

Paul Kenworthy, DMD, PC

XSSP

Pediatric Medicine PLC

VMNG

Pine Knoll Nursing Home Inc.

MSSP; XSSP

Pioneer Spine and Sports Physicians, PC

XSSP

Planned Parenthood of Northern New England

MSSP; XSSP

Porter Hospital, Inc

MSSP; VMNG; XSSP

Primary Care Health Partners - Vermont LLP

MSSP; VMNG; XSSP

Pulmonary Internists, Inc.

MSSP

Radiology Associates of Bennington, Inc.

XSSP

Rainbow Pediatrics

VMNG; XSSP

Richard C Lyons MD

MSSP; VMNG; XSSP

Richmond Family Medicine PLLC

VMNG

Richmond Pediatrics and Adolescent Medicine LLC

VMNG

Roger B. Kellogg, MD

MSSP; XSSP

Rutland Crossings, LLC dba The Pines at Rutland Center for Nursing and Rehabilitation

MSSP; XSSP

Rutland Eye Physicians LLC

MSSP; XSSP

Rutland Hospital Inc.

XSSP

Rutland Housing Authority

CNSSA

Rutland Mental Health Services, Inc.

MSSP; XSSP

Shaftsbury Medical Associates, Inc.

MSSP; XSSP

Sheridan Healthcare of Vermont, Inc.

MSSP; XSSP

Shires Housing, Inc.

CNSSA

Southwestern Vermont Council on Aging, Inc.

CNSSA

Southwestern Vermont Medical Center, Inc.

MSSP; XSSP

Starr Farm Partnership

MSSP; VMNG; XSSP

Sunrise Family Resource Center, Inc.

CNSSA

The Manor Inc

MSSP

The Richford Health Center, Inc.

VMNG

Thirty Five Bel-Aire Drive SNF Operations LLC dba Bel-Aire Center

MSSP; XSSP

Thomas Chittenden Health Center, PLC

VMNG

Turning Point Center of Addison County, Inc.

CNSSA

Twin Pines Housing Trust

CNSSA

Union House Nursing Home Inc

MSSP

United Counseling Service of Bennington County Inc

MSSP; XSSP

University of Vermont Medical Center Inc.

MSSP; VMNG; XSSP

UVM Nursing and Health Sciences Practice Group

XSSP

Valley Cares, Inc.

CNSSA

Valley Radiologist, PA

XSSP

Vermont Center For Dental Implants

XSSP

Vermont Gynecology, PC

VMNG

Vermont Interventional Spine Center

VMNG

Vermont Medical Society

CNSSA

Vermont Orofacial Pain Associates PC

MSSP

Vermont Spine Works and Rehabilitation

XSSP

Vermont State Housing Authority

CNSSA

Vernon Advent Christian Home, Inc.

MSSP; XSSP

Visiting Nurse Association & Hospice of VT & NH

MSSP; XSSP

Visiting Nurse Association of Chittenden and Grand Isle Counties Inc

MSSP; VMNG; XSSP

VNA & Hospice of the Southwest Region, Inc.

MSSP; XSSP

Washington County Mental Health Services, Inc.

MSSP; VMNG; XSSP

Wilcox Medical Inc.

XSSP

William J. Sarchino

MSSP; XSSP

Windham & Windsor Housing Trust Inc

CNSSA

Windsor Hospital Corporation

MSSP; XSSP

Winooski Housing Authority

CNSSA

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