One Care: Profiting Off Patients?

November 18, 2012

Valley News

By Chris Fleisher
Valley News Staff Writer

Burlington — At a recent health care conference in Burlington, Church Hindes wanted to make something clear to the audience of physicians and hospital administrators in the audience.

There’d been a lot of questions lately over the new accountable care organization that Fletcher Allen Health Care and Dartmouth-Hitchcock were proposing to form. Specifically, around its tax status.

“I assure you, we made OneCare Vermont as non-profit as it could legally be made,” said Hindes, Fletcher Allen’s vice president of accountable care and Vermont managed care.

Which is to say that it is a for-profit in name only, Hindes said. Due to conflicting state and federal laws, the Twin State’s largest health care providers had their hand forced, in essence, to check a box they didn’t want to check.

What they are hoping to do is simply provide more efficient, coordinated care to Vermonters, Hindes said.

OneCare’s application to the Centers for Medicare & Medicaid Services is still pending, but if approved, it would provide a framework for a vast swath of the state’s health care providers to work together in treating patients.

The ACO could be up and running by January.

For more on ACOs, see related story, "Taking Accountability: DHMC Explores ACOs"

Although there are some differences from Dartmouth-Hitchcock’s Pioneer ACO — namely, that there’s less financial risk in OneCare — it would essentially work the same. Any provider that participates would get to share in the savings realized from treatment that cost less, as long as it met standards for high-quality care.

The ACO would include 13 of the state’s 14 hospitals — Porter Medical Center in Middlebury was the only one to opt out — as well as a slew of rural health centers and private practices. Mt. Ascutney Hospital and Health Center, Gifford Medical Center and Springfield Hospital have all signed on.

It could include more than a third of the state’s Medicare beneficiaries — 40,000 people.

But if Dawn Griffis has anything to say about it, she won’t be one of them.

“I am totally opposed to this OneCare,” said the 72-year-old Hartford resident.

The reason, she said, is because the corporate structure that will oversee these disparate providers is technically a for-profit. And anytime she hears that word in health care, she fears the results.

A native of England, where there has long been a nationalized system of care, Griffis has practiced as a nurse since 1956. And wherever she’s gone, she’s been disgusted by what she’s seen when care givers are motivated by money.

The consequences include unnecessary tests, physicians abusing the system and people rushed out the door before they were ready, she said.

The kind of coordinated care that OneCare is proposing to deliver could be a good thing, she said. But she can’t come to terms with its for-profit status.

“Their idea is good,” she said. “But whenever they have for-profit, corruption comes in. It never fails.”

The reason OneCare is a for-profit is because it has to be, Hindes said.

Federal regulations governing ACOs require that at least 75 percent of the governing body include providers participating in the network. By contrast, Vermont’s non-profit corporation law says that no more than 49 percent of the individuals serving on the board can have a personal financial stake.

And so, they set up OneCare as a for-profit, Hindes said, confident that the two founders — both non-profit entities — as well as the array of non-profit providers who would be participating, would govern it with the public interest in mind.

“This is not some scheme to get into the for-profit business,” Hindes said in a recent interview.

Almost all of the “profits,” or savings, that Medicare would pass on to the hospitals goes to the providers in the network, with the remaining 10 percent going toward the ACO’s infrastructure, according to the application to the Centers for Medicare & Medicaid Services.

The dustup created by the for-profit question back in September, when the news was made public, has since settled down, Hindes said. But it remains a problem for at least a few people, including Griffis and Ann Raynolds.

Raynolds is a psychologist with practices in Quechee and White River Junction. Like Griffis, Raynolds believes doctors should be working together on patient care. And also like Griffis, her hackles go up when she hears about for-profits in health care.

“I don’t get the for-profit motive in health care,” she said. “That’s what we’ve been fighting in health care.”

Both Griffis and Raynolds are not only health care professionals but also, due to their ages, Medicare beneficiaries. Neither woman knows whether she is part of an ACO, but they could make an educated guess based on where they get the bulk of their primary care.

Patients are usually assigned to ACOs according to their primary care physician, both for Medicare and commercial programs. If a Medicare beneficiary gets most of her primary care at Dartmouth-Hitchcock, for example, there’s a good chance she’s part of the Pioneer ACO.

Federal rules require ACOs set up under Medicare to notify anyone who’s been “attributed” to them, or included among the population of patients for which the ACO has agreed it will be accountable. The letter provides a description of what the ACO is about and gives patients the choice of opting out of having their information shared with the providers.

When Dartmouth-Hitchcock sent out 19,000 of those letters last December for its Pioneer ACO, only around 500 people decided against participating, according to Barbara Walters, executive medical director at Dartmouth-Hitchcock. It was one of the lowest opt-out rates among all of the 32 Pioneer ACOs, she said.

But then, there was no question about Dartmouth-Hitchcock’s tax status.

Hindes says that shouldn’t matter.

“Tax status does not determine behavior,” Hinds said. “Leadership determines behavior.”