Brattleboro Reformer

OneCare, Vermont’s “Accountable Care Organization” (ACO), operates the “All Payer” (AP) system that Vermont adopted a few years ago. It is frequently in the news these days, but even people who are heavily involved in health care issues don’t fully understand what it is, how it works, and why it supposedly benefits the people of the state. Someone who understands health care pretty well recently described the AP system as an impenetrable “black box.” [For background, you can check out the Green Mountain Care Board’s “frequently asked questions” about it:]

There’s a reason that OneCare and the All Payer system itself seem impenetrable: If you did a flow chart of the relationships and transactions involved in the All Payer system in Vermont, it would resemble the scribblings of an asylum inmate.

The system is run by OneCare, overseen by the Green Mountain Care Board (GMCB), the governor and the Office of Health Care Reform. It operates within the parameters of agreements between the state, OneCare and the federal government’s Centers for Medicare & Medicaid Services (CMS).

OneCare negotiates and administers a variety of contracts with providers (doctors, hospitals) and payers (Medicare, Medicaid, and a commercial insurer or two). Not all payers participate to the same extent, and not all providers participate to the same extent.

All of this activity requires time and effort by every person, place and thing involved in the system, including the state, payers and providers. That’s an enormous amount of complexity and an unknown amount of cost. It’s so complicated that explaining it is a major challenge. This is exacerbated by the fact that OneCare, the central player in the system, appears incapable of explaining anything in terms that mere mortals can comprehend.

It’s extremely important to understand what this experimental health care reform does and does not do. The ACO — OneCare — serves as a middleman between insurers (the “payers”) and providers. It simply distributes funds from the payers to the providers in a new way, and works with providers to hopefully improve the quality of the care they provide.

None of the activities directly involve patients (indirectly is another matter), who remain subject to the terms of the contracts between them and their insurers as to premiums, deductibles, co-pays, “networks,” and the like.

None of the activities relieve insurers of the need to administer the patient’s contract and approve or reject providers’ bills.

None of these activities relieve providers of the need to bill the insurers and track payments, denials, etc.

None of the activities allow people without a “payer” to get health care. None of the activities make it any easier for people who do have a “payer” to pay their premiums and meet their deductibles and co-pays.

None of the activities reduce the administrative burden on insurers, providers, or patients; in fact it adds another layer of administration for providers and payers.

It’s worth noting that the first steps toward the All Payer system were made in 2013. At that time, Vermont was on the road to implementing the Green Mountain Care single payer program. Presumably, the intent was for the two programs to work together, but with Gov. Shumlin having unilaterally killed Green Mountain Care in December of 2014, All Payer functions on its own.

Supporters of All Payer claim that it will eventually produce cost savings but the system currently focuses on coordinating care, and there isn’t much if any evidence that this has improved quality of care. Any eventual cost savings, assuming that they ever exceed the added costs of administering the All Payer system, are too far off to help Vermonters now.

Although All Payer isn’t even designed to provide “coverage” for people who have no “payer,” and does not produce any reduction in premiums, deductibles or co-pays for people who do have a “payer,” many people (including politicians) point to it as the reason for not exploring or implementing other programs, like Universal Primary Care or a full single payer system, which would/could achieve those things. Whether you favor or oppose the All Payer system, it is indefensible to use that program’s existence as an excuse for not pursuing other reforms that immediately address the immediate need of Vermont’s people: access to health care they can afford.

The “lost opportunity” costs of that approach translate to lost lives, lost health, and lost security for thousands upon thousands of Vermonters.