Burlington Free Press 

Dan D’Ambrosio

The prognosis for OneCare, Vermont’s latest effort to bring down the cost and improve the quality of health care, is being called into question lately by both doctors and patients.

OneCare’s mission is to end traditional fee-for-service health care, which is thought to incentivize doctors and hospitals to perform more tests and procedures, and move to a “capitated” system in which providers are paid a fixed amount to take care of a group of patients.

The organization is in the third year of a five-year pilot that includes ambitious targets for enrolling Vermonters in the program. It’s not hitting those targets, which prompted a response from the Centers for Medicare and Medicaid Services (CMS). CMS partnered with the state to work with OneCare.

On Sept. 14, CMS sent a notice to the Green Mountain Care Board, which oversees all aspects of health care in Vermont, warning that the state failed to meet its targets for enrolling patients in OneCare for two consecutive years in 2018 and 2019 — the first two years of the program. This constituted a so-called “triggering event,” which requires the state to explain how it’s going to get on track.

The state has 90 days to respond to the warning notice. Depending on how it views the response, CMS can ask for modifications to the agreement, or it can shut the program down, unilaterally. The state also has the right to end the program on its own, but would lose certain benefits from the federal government it currently enjoys as part of the agreement.

Kevin Mullin, chairman of the Green Mountain Care Board, wants to stay the course. But he knows the clock is ticking.

“Hopefully we can all make improvements and build success. People aren’t going to wait forever for success on this program,” he said.

Ena Backus, director of health care reform for the Agency of Human Services, also continues to back OneCare — sort of. She said everybody knows there will be bumps in the road when trying to make major changes to the way health care is delivered.

“Health care reform is not an easy task. It certainly takes some tenacity to continue with reform efforts, especially when it feels like there isn’t agreement across all the factions, if you will, of health care providers and the stakeholder community,” Backus said.

You can say that again.


Criticism from all sides

OneCare found itself embattled on a number of fronts as it struggled to meet its goals for signing up patients.

  • On Aug. 11, a group of 14 independent medical practices announced they were leaving OneCare after it refused to roll back a change in its payment policy the primary care doctors said reduced their income.
  • On Sept. 28, five nonprofit organizations issued a news release calling for the state to immediately end its affiliation with OneCare, or let the agreement that formed the organization expire in 2022, and spend the money instead on “basic health care needs.”
  • On Oct. 2, marchers from Vermont Workers’ Center picketed the UVM Health Network offices in Burlington, calling on Gov. Phil Scott to end the state’s contract with OneCare and expand Medicaid to all Vermonters. There were simultaneous pickets in Barre and St. Johnsbury.

The five nonprofit organizations calling for an end to OneCare are Justice for All, VT; League of Women Voters of Vermont; Physicians for a National Health Program, Vermont Chapter; Vermont Health Care for All and Vermont Workers’ Center.

Dr. Deborah Richter, president of Vermont Health Care for All and a primary care doctor, said there’s no evidence OneCare has reduced costs or improved quality, a point State Auditor Doug Hoffer also made in a recent audit.

Dr. Deborah Richter (Photo: COURTESY)

Richter, together with the heads of the other nonprofit organizations, pointed out OneCare had $17.4 million in Medicaid cost overruns last year, and that health insurance rates grew by double digits in 2020.

The organizations also called out the administrative costs of OneCare, with the 2019 salaries of the top five administrators adding up to nearly $1.5 million.


An extraordinary reform effort

Despite the criticisms and the warning notice from the Centers for Medicare and Medicaid Services, OneCare’s chief executive officer Vicki Loner said her organization represents the direction both state and federal governments are taking on health care.

“We have the responsibility to do our part of the deal, which is to bring providers together to operate differently, improve outcomes and drive down the cost of care over time,” Loner said. “This is the direction that we’re moving in right now. Is it hard and is it perfect? Yes, it’s very hard and no, it’s not perfect.”

OneCare represents an “extraordinary reform effort,” Loner said, that “doesn’t happen overnight.”

“You can’t flick the light switch and see change,” she said. “I know that not everybody believes this is the right path to be on. It’s the path we’re on right now. There will be good and bad years. This is about the long game, it’s not about looking at things year-to-year.”

Primary care doctors form the foundation of the new system, which relies on them to keep patients healthy and out of emergency rooms and hospitals, where costs are the highest.

Ena Backus said OneCare is designed to help primary care practices with additional resources, such as fixed payments that give them predictable income and flexibility in how they practice.

“We can benefit from a system where providers can spend as much time as they need with patients and are alleviated from the burden of finding the next dollar,” Backus said.


Reducing the burden on hospitals

The 14 private practices that announced their intention to leave OneCare in August felt the organization was doing the opposite of providing them with additional resources.

OneCare offers primary care doctors two choices: they can continue working fee-for-service and receive supplemental payments per patient per month; or they can switch to a capitated system, receiving a set amount to care for a certain group of patients.

The practices that threatened to leave were getting supplemental payments of $3.25 per patient per month, when OneCare announced it was going to drop that minimum payment to $1.75 per patient per month.

By dropping the payment amount, OneCare is trying to reduce the financial burden on hospitals, which cover many of the organization’s expenses like the supplemental payments, according to Jon Asselin, chief operating officer of Primary Care Health Partners, a private group of seven practices in Vermont and one in Plattsburgh, New York.

“We know OneCare is under tremendous financial pressure,” Asselin said. “They’re clearly trying to ease the burden on the hospitals to convince them to remain part of this organization.”

Loner agreed with Asselin’s assessment, but added that the goal is to broaden accountability for the system beyond the hospitals, which currently bear the brunt of the investments and financial risks required by the program.

Asselin, who is the independent primary care representative on OneCare’s finance committee, said the program is working for Primary Health Care Partners, which chose the capitated payment option, known as Comprehensive Payment Reform, or CPR.

With CPR, Asselin said, the group’s practices would never go into a financial freefall because of the regular monthly payments, regardless of how many patients were seen or procedures were done. When COVID-19 hit, patient visits to the office fell off a cliff, Asselin said.

“We knew there was something we could fall down on to,” he said. “We at least knew where the bottom was on a monthly basis dealing with COVID-19.”

Dr. Joe Hagan, whose Lakeside Pediatrics in Burlington is also in OneCare’s CPR program, was more blunt.

“The per member per month money that our practice got in March, April and May of 2020 kept us alive when the patients weren’t there,” Hagan said.


You may have to give the money back

Loner reached a compromise with the mutinous primary care practices threatening to leave OneCare by offering to continue to pay them $3.25 per patient per month instead of dropping the payment to $1.75 per month. The compromise came with the understanding, however, that they might have to give the difference of $1.50 per patient per month back in 18 months, if the organization didn’t meet its financial goals.

The offer lured all but two of the 14 practices back, according to Loner. One of the holdouts is Evergreen Family Health in Williston, which led the charge to leave OneCare.

Dr. Mike Johnson, Evergreen’s managing partner, said the compromise is empty if OneCare can take the money back.

“My fear for my colleagues who are staying in OneCare is that it’s awful hard to take money and not to spend it,” Johnson said. “OneCare has never been profitable in the past. To think that now in this crazy pandemic year they’re going to become a profitable entity doesn’t make sense to me.”

Instead, Evergreen is jumping into a private Medicare Advantage plan called Clover, which also offers supplemental payments. Johnson hopes Clover will make up for some of the losses the practice will incur from leaving OneCare, but he still expects to face a budget gap in the hundreds of thousands of dollars at the start of the new year.

“It’s a really large amount of money, but we’re not planning to cut any staff,” Johnson said.

The hope is that staff, freed from the burdensome data collection required by OneCare, will be able to spend their time reaching out to patients instead, making sure, for example, those who missed follow-up visits for diabetes are seen and tested.

“Stuff that generates revenue, but also improves the quality of patients’ care,” Johnson said.