Editor’s note: This commentary is by Susan Aranoff, senior planner and policy analyst for the Vermont Developmental Disabilities Council. The Council is a federally funded public board that supports the advocacy of people with developmental disabilities and their family members.
One of the most promising features of Vermont’s health care reform effort has been the commitment by policy makers, providers and payers to look beyond traditional clinical care in order to address the underlying causes of disease. Termed “the social determinants of health,” factors like early trauma, poverty and housing instability are now thought to have an even greater impact on your health status than visits to the doctor or hospital.
Therefore, it came as a surprise when the Green Mountain Care Board unanimously voted March 13 to approve amendments to OneCare Vermont’s 2018 budget. This decision reduces OneCare’s obligation to spend money on improving population health by over $3 million, or 20 percent. Was this just a temporary course correction or a change in direction?
As an advocacy group concerned for the needs of Vermonters with disabilities, this vote was one more piece of troubling news in an already confusing story. As we move closer to 2022 – the date by which Vermont must renew its All Payer Accountable Care Organization Model Agreement with the federal government — it’s important to ask if health care reform in Vermont is moving in the right direction. OneCare Vermont, the state’s only accountable care organization, is a private for-profit corporation owned by the University of Vermont Health Network and Dartmouth Hitchcock Medical Center. OneCare Vermont is part of a state experiment, sanctioned by the federal government, to change the way health care is paid for and provided. It’s also the recipient of millions in public funds allocated to help OneCare develop the administrative apparatus of payment reform and quality oversight across the three major payers: Medicaid, Medicare and participating commercial insurers.
There are other troubling signs that health care reform is not moving in the right direction. OneCare’s Medicare quality scores are sinking, and the trend should be setting off alarm bells. Instead, it’s the best kept secret in the Statehouse. However, a cursory review reveals that in 2017, the most recent results available, OneCare’s Medicare quality measures dropped 9.26 percent from the previous year. OneCare’s 2017 Blue Cross/Blue Shield Quality Measure was also quite low at 73.07 percent.
Still more concerning is OneCare’s Medicaid program, which received the lowest possible score in the key measure related to substance use disorder. OneCare received zero points for the initiation of alcohol and other drug dependence treatment, signifying its performance fell below the 25th percentile nationally for that measure. Given Vermont’s opioid crisis, this is not the direction we want to go. Champions of the All-Payer Accountable Care Organization Model sometimes argue that OneCare is new and can’t be expected to operate at peak performance yet. The reality is that OneCare is one of the oldest ACOs in the country. OneCare has been receiving ACO quality scores from Medicare since 2012 and from Vermont Medicaid since 2014.
Disability advocates – and others who support the Medicaid safety net – have good reason to worry. OneCare’s scope is slated to expand considerably. When the All-Payer Accountable Care Organization Model Agreement is renewed in 2022, it is supposed to include all of Vermont’s Medicaid-funded services, including the disability long term services and supports that are provided by Vermont’s designated mental health and specialized services agencies.
In order to ensure the sustained health of Vermont’s successful home and community-based services, a broad coalition of disability advocates recommended to the chairs of the House Health Care and Senate Health and Welfare Committees that the Legislature commission an independent evaluation to measure the course we are on. At a minimum, this review should include an accounting of all public funds and assets that support the ACO model and an assessment of the return on that investment. The benefits of health reform should be measured across multiple categories, including: the quality of care as measured by the All Payer – ACO model metrics; the health status of Vermonters, including medically underserved groups such as people with disabilities, people living in public housing, and/or people living in rural communities; access to care, especially access to primary care, and the affordability of that care; the ability of the All Payer – ACO model to generate a predictable, sustainable rate of cost growth in health care; and how any annual savings in health care costs compare with annual administrative costs for the All Payer – ACO Model.
Disability advocates want to ensure Vermont’s integrated health care system works optimally for all Vermonters, especially those who rely on Medicaid for health care and for long-term services, to meet their complex needs. Asking these basic questions now is the best way to ensure Vermont’s comprehensive approach to health works for the people who depend on it most.