Burlington Free Press

Dan D’Ambrosio

The senior partner at one of the largest primary care practices in Vermont worries that reduced payments from OneCare Vermont, the state’s only accountable care organization, will make it even harder for his practice to survive the coronavirus pandemic.

“This is a tough time for everybody, especially when we have no reserves, or other sources of income,” said Dr. Paul Reiss of Evergreen Family Health in Williston. “Unfortunately (OneCare’s) plan, even with this downturn, is to cut our upfront money.”

Vicki Loner, chief executive officer of OneCare, has a very different understanding of what her organization is doing for primary care practices. She said Evergreen can make even more money as a result of the change.

Instead of paying a flat $3.25 per patient per month for primary care, Loner said, OneCare is offering to pay a range of $1.75 to $4.75 per patient per month, depending on how well a practice performs against quality and cost measures.

When OneCare launched in 2018, it paid Evergreen $3.25 per patient per month for so-called “attributed lives” — the patients in the practice who are part of the accountable care organization.

Cutting the minimum payment to $1.75 per patient per month, instead of $3.25, could cost Evergreen $200,000 annually, according to Reiss, at a time when the 18-practitioner private practice is already struggling to survive.

“You can’t make it up,” Reiss said of the reduced payment. “There’s no other source of revenue. We can’t raise rates. Other insurers aren’t paying more. We will likely have to cut staff, and the staff we’ll cut is our care management staff.”

The way Loner sees it, Evergreen Family Health has the opportunity to make an additional $70,000 annually, if it does well on quality and cost measures and is paid $4.75 per patient per month instead of $1.75.

“I don’t look at it as a cut, I look at it as an opportunity we never offered before to share (in the revenue) when the system does well,” Loner said.

But Reiss said the money his practice earns is dependent on the cost-saving performance not only of OneCare, but also of the University of Vermont Medical Center.

“You can … make up to $4.75 per patient, but it will be at least 18 months later, when they do the final analysis of whether there is savings for the whole state, including the hospitals,” Reiss said. “Everybody else has to do well for us to benefit.”

Goodbye, fee-for-service

The basic premise of OneCare is that it will save money by paying a fixed amount for the care of a group of patients, rather than paying for each test or procedure performed by a doctor — known as “fee-for-service.”

In order for the program to work, primary care doctors need to keep their patients healthy.

Care management staff at Evergreen closely monitor patients, making sure, for example, that a diabetic is maintaining a healthy blood sugar level so she doesn’t develop costly complications.

The cut in upfront payments has led Reiss and his partners to consider dropping out of OneCare, which would only add to the difficulty the organization is having reaching its targets for patients under its management.

About 4,000 of Evergreen’s 18,000 patients are enrolled in OneCare, according to Reiss.

In a recent report, State Auditor Doug Hoffer noted that “Vermont is significantly behind its attribution rates to date,” which could trigger a warning from the Centers for Medicaid and Medicare Services. The state and federal governments are partners in the OneCare program and are monitoring it closely.

OneCare missed its targets for the number of people it needed to enroll to make the program viable by nearly 200,000 patients in its first two years, according to Hoffer’s report. Hoffer estimates the accountable care organization will fall more than 50,000 patients short this year.

Amy Bodette, director of public affairs for OneCare, questions Hoffer’s contention that the program was 200,000 patients short in its first two years, but Hoffer said he stood by his numbers.

Bodette’s calculation is that the target for 2020 is to enroll 305,000 people out of a total universe of 570,000 Vermonters. She said OneCare currently has 223,000 people enrolled for 2020, which is 16% shy of the target, or approximately 82,000 people.

OneCare is jointly owned by the University of Vermont Medical Center and by Dartmouth-Hitchcock Medical Center in New Hampshire. Because of the way state and federal laws governing health care organizations work, OneCare is a for-profit company, despite the fact that both UVM Medical Center and Dartmouth-Hitchcock are nonprofit organizations.

Taking the art out of medicine?

OneCare has come under criticism not only for changing its payment structure, but also for changing the way primary care medicine is practiced. Dr. Louis Meyers, a hospital medicine specialist at Rutland Regional Medical Center, said OneCare creates a “centralized, top-down” approach that relies heavily on metrics.

Meyers is running for the Vermont Senate and spoke as a political candidate, not as a representative of the Rutland hospital. Claudio Fort, the president and chief executive officer of Rutland Regional Medical Center, declined to comment for this story.

“They want people treated in a certain way,” Meyers said. “For example if you have someone with diabetes they’re going to be looking at various metrics and reimbursing people, and/or withholding money, based on whether or not you hit certain metrics.”

Meyers compared the approach to No Child Left Behind in education, which resulted in teachers “teaching to the test,” rather than focusing on real learning.

“I see the same thing happening in medicine,” Meyers said. “People forced to reach metrics regardless of whether it’s appropriate for an individual patient. … It’s a recipe you have to follow. It changes the way you treat patients.”

Meyers also criticized OneCare for creating an unreasonable burden of electronic paperwork, much of it meaningless.

“In primary care doctors are spending two to three hours in the evening and much of the weekend doing it,” Meyers said. “It drives some of the best people out of primary care.”

Dr. Elizabeth Hunt, a pediatrician at Timber Lane Pediatrics in South Burlington, was one of OneCare’s first clinical advisory board members and now serves on a pediatric subcommittee for the organization. Unlike Meyers, Hunt said OneCare’s approach to paying for health care is innovative.

“We’re going to give you this amount of money for this blend of population and see how you do,” Hunt said of OneCare’s payment method. “That support has been extremely helpful in the pandemic.”

Hunt agrees with Meyers’ complaint about burdensome record keeping, but says “that ship has sailed.”

“There’s no going back to hanging a shingle and having vast independence to manage patients in primary care,” Hunt said. “If we’re going to save money, cut costs and provide care for a (population of patients) we do need these measures, and help reaching them.”

Is the fox guarding the hen house?

Dr. Meyers is also uncomfortable with OneCare’s ownership being in the hands of the University of Vermont Medical Center.

“My feeling has been, we’re a small state that values independent community-based health care and services,” Meyers said. “Having a central, top-down corporate, for-profit entity at UVM running health care in the state is not in keeping with the ethos of Vermont.”

Meyers contends the biggest driver of high health care costs in Vermont is the University of Vermont Medical Center itself.

“UVM has created a monopoly and used it in the way monopolies do,” he said. “If you go to a UVM lab, medical practice or radiology center you’re going to pay two to three times what you pay at an independent practice. That more than anything else has driven up health care (costs).”

Green Mountain Care Board Chair Kevin Mullin agrees that UVM Medical Center is expensive, but says it’s also necessary.

“There is a natural price you have to pay to have an academic medical center,” Mullin said. “If you didn’t have UVM here in Vermont, where would future doctors be coming from? Believe me, I see the numbers on procedures. Some are obscene.”

Mullin believes moving away from fee-for-service to the population-based payments OneCare is providing will help bring down the high cost of health care in Vermont, but he worries whether the organization is up to the task.

“I don’t have as much confidence in our one (accountable care organization) as I wish I had,” Mullin said. “I don’t feel warm and fuzzy that the one (accountable care organization) is meeting these huge tasks that have been assigned to them. Maybe we’ve been unrealistic thinking things can change overnight, but at some point you have to see results.”