Vermont’s all-payer health care system assumes preventive medicine will help reduce spending, but health experts worry the state may not have the primary care infrastructure to turn that hope into reality.
“I’m concerned that we don’t have the right mix of physicians … to achieve the goal of the model,” Dr. Allan Ramsay, former member of the Green Mountain Care Board, told Watchdog.
“I feel we can be successful … only if we have an adequate foundation in primary care,” he said.
The newly-approved all-payer model is the Shumlin administration’s swan song, directing Vermont health care into management under the Vermont Care Organization. That accountable care organization will distribute funds from Medicaid, Medicare and private insurers to health care providers using global budgets, rather than paying based on individual services and procedures.
Not only does the model change the way payments are made, it also includes a list of targets that Vermont Care Organization providers must meet to qualify the model for renewal with the Centers for Medicare and Medicaid Services.
These targets identify specific numbers for the decline in substance abuse, suicide and chronic conditions, as well as for increasing Vermonters’ access to care. The concept comes from a new focus on preventative medicine, where doctors attempt to change patients’ lifestyle choices to reduce health care costs down the road.
This type of care is performed largely by primary care doctors, however, not specialists or emergency facilities. As a result, Ramsay said many physicians can expect “the demand for time will go up.”
In 2013, Vermont had 826 primary care practitioners — including certified physicians, assistants and nurse midwives — registered to practice primary care in Vermont. That resulted in about one primary care practitioner for every 759 patients, or about one primary care doctor for every 1,121 patients.
Those providers aren’t evenly distributed, however. The majority of primary care providers are clustered in urban areas, such as around Burlington or Rutland, meaning patients in rural areas may have to drive long distances to get primary care. Essex County, for example, has only two primary care facilities, and both are located on the county’s western border.
Dr. Paul Rogers, an independent primary care physician in Johnson, said targets of the all-payer model will provide an additional regulatory burden on his practice and take time away from seeing patients. He’s also concerned they lead to unnecessary spending, which could be a problem for his practice under a global budget.
“I get fed up with having to do meaningless things to get paid,” Rogers told Watchdog. “[The Green Mountain Care Board] has good intentions, but common sense has been eliminated from the formula. There are no exceptions.”
Rogers said patient screening may become unmanageable if new preventive medicine targets will require new screening. Currently, due to certain percentage requirements, he is required to screen some elderly patients who will not benefit from treatment and report to the state. Rogers expects such regulations to grow under the all-payer model.
Details about implementing targets will be decided in 2017, during the implementation phase of the all-payer model. The Green Mountain Care Board, which has power to set health care standards for the state, will determine whether doctors can meet targets using their own methods or through regulations set by the state.
Unless otherwise noted, the following targets set by the board in collaboration with CMS apply to all beneficiaries under the Vermont Care Organization, regardless of payer.
Substance Abuse Disorder Target
Reduce overdose related deaths by 10 percent. Vermont will increase its initiation and engagement of alcohol and other drug dependence treatment to the 50th percentile nationally on initiation, and the 75th percentile nationally on engagement and treatment.
The state must reduce the growth of emergency department visits in Vermont hospitals for all Vermonters, regardless of VCO participation. A specific target will be developed by June 30, 2017.
The state must increase the use of Vermont’s prescription drug monitoring program. A specific target will be developed by June 30, 2017.
The state must increase the number of Vermonters on medication-assisted treatment for substance use disorder to 150 per 10,000 Vermonters between the ages of 18 and 64, regardless of ACO participation.
Lower the suicide rate by 16 for every 100,000 beneficiaries, or reduce the state’s suicide percentile ranking from 7th highest in the nation to 20th highest.
A full 60 percent of discharges from a hospital emergency department for mental health must receive follow-up care within 30 days; 40 percent of discharges from a hospital emergency department due to alcohol or drug dependence must receive follow up care within 30 days.
The state must reach the 75th percentile for the percent of Vermont VCO-aligned beneficiaries who have been screened for clinical depression and received a follow-up plan if depression was detected.
Chronic Conditions Target
The prevalence of COPD, Diabetes, or hypertension must not increase.
The state must reach the 75th percentile for diabetes, hypertension and multiple chronic condition morbidity for Next Generation ACO-aligned Medicare beneficiaries.
The state must achieve the 75th percentile for beneficiaries screened for tobacco use, and if identified as a tobacco user, received cessation counseling.
Access to Care Target
Vermont wants 89 percent adult residents reporting they have a personal care doctor or provider.
The state must reach the 75th percentile for Next Generation-ACO aligned Medicare beneficiaries who state they receive timely care, appointments and information.
The state must reach the 50th percentile for the percentage of adolescents enrolled under Vermont Medicaid who receive a well-care visit.
Vermont must ensure that 35 percent of Vermont Medicare beneficiaries are under an ACO.