Vermont officials seek clarity on what OneCare does, plans for the future

  • OneCare CEO Vicki Loner in an undated photograph. (Courtesy photograph)

  • Vermont State Auditor Doug Hoffer at his office in Montpelier, Vt., on Aug. 14, 2019. (VtDigger - Glenn Russell) GLENN RUSSELL

  • Dan Bennett

  • Jill Lord

Valley News Staff Writer
Published: 11/2/2019 10:29:04 PM
Modified: 11/2/2019 10:29:01 PM

MONTPELIER — As an accountable care organization formed by Dartmouth-Hitchcock Health and the University of Vermont Health Network adds patients and increases its budget, Vermont’s state auditor wants more clarity about what it is and what it’s doing. State regulators also would like the public to better understand the way health care in Vermont is changing.

The two health systems formed OneCare Vermont in an effort to slow the rate of increase of health care costs while also keeping people healthy. The Colchester, Vt.-based ACO now contracts with insurance companies to pay a growing network of health care providers across the state based on their success in preventing their patients from needing expensive care — such as hospital stays or emergency room visits — rather than based on the services they perform.

OneCare, which appeared before state regulators last Wednesday to present a 2020 budget, aims to support providers in activities such as analyzing data and coordinating the care of patients, especially those with complex needs.

“Health care costs are rising and they need to be curbed,” said Vicki Loner, OneCare’s CEO, during Wednesday’s four-hour hearing in Montpelier.

The state aims to keep the rate of inflation in health care costs at 3.5% annually or less, as well as to increase Vermonters’ access to primary care, reduce deaths by suicide and drug overdose, and prevent and better manage chronic diseases.

Some, including State Auditor Doug Hoffer, want to know more about OneCare as it plays a larger and larger role in the way people in Vermont receive their health care.

ACOs were established as part of the Affordable Care Act to bring together doctors, hospitals and other health care providers to improve the way health care is coordinated, avoid duplication of services and reduce medical errors.

In 2020, OneCare expects to play a role in managing the spending of $1.43 billion to care for 250,000 people across Vermont. That’s up almost 60% from the $895.8 million total spending for the care of 160,000 people regulators approved for 2019.

There’s an “awful lot of people who don’t understand this as well as we should,” Hoffer said in a Thursday phone interview.

The state entered into a contract with the U.S. Centers for Medicare and Medicaid Services in 2016 for an “all-payer model” using the ACO, and it is slated to run through 2022. It allows insurers to reimburse providers in this value-based way and allows investments in community services.

OneCare began the initiative in 2017 with just 29,100 Vermonters covered by contracts managed by the ACO. By 2022, the state aims to have 70% of Vermonters, or about 438,000 people, in the OneCare program. The expansion is happening both by adding geographic areas and by adding Vermonters’ insurers, also known as payers. In addition to Medicare, Medicaid and BlueCross BlueShield, MVP will be participating in 2020, OneCare officials told the board.

Hoffer’s office recently completed one investigative report on OneCare’s community-based initiatives and is in the midst of a broader audit of the organization aimed at answering the questions: “What is OneCare?” and “How is the Green Mountain Care Board authorized and expected to oversee OneCare?”

Hoffer said he expects the first audit to be completed in February and it will be followed by another aimed at analyzing OneCare’s performance both financially and in terms of health outcomes, which he said he hopes will be completed by the end of 2020. Hoffer said he also hopes to take a closer look at the 3.5% rate of inflation that the Green Mountain Care Board and OneCare use as a limit for the state’s annual increase in health care spending.

Kevin Mullin, chairman of the Green Mountain Care Board — the regulatory body tasked with reviewing OneCare’s budget, as well as hospital budgets, insurance rates and certificates of need — also expressed concern about the general public’s lack of understanding of OneCare and the state’s health reform efforts at the beginning of the board’s Wednesday hearing.

“Despite all the good work being done, most Vermonters don’t seem to know what an all-payer model is or what we are doing in health care,” Mullin said.

The budget OneCare officials presented last week showed total spending of $62 million, with $43.1 million of that being payments to support care coordination and primary care.

The remaining $19.28 million would cover OneCare’s operating costs. The bulk of that money, $11.78 million would go to salaries and benefits for the more than 70 employees who work for the ACO. (A filing with Vermont regulators indicates the top salary paid to a OneCare official in 2018 was $392,375.)

Lesser amounts would go to cover costs of software, contracted services and risk protection.

Revenues to support OneCare’s budget come from a mix of state and federal funds, as well as payments from hospitals and insurance companies.

In a phone interview on Thursday, Loner, who became CEO this summer, said OneCare officials aim to end each year with operating costs matching revenues. In years where they take in more from insurers than they spend because they’ve succeeded in keeping people healthy, those revenues will be reinvested into the system. In years where they take in less from insurers than they spend caring for patients, their member hospitals have to pick up the cost of that difference.

They won’t have actual numbers until early next year, so the numbers officials presented on Wednesday were estimates.

Though OneCare officials say it’s too early to evaluate the success of this model of payment, Sara Barry, OneCare’s chief operating officer, told the board that they are beginning to see some positive changes as a result of their work.

For example, Barry said that as high-risk Medicaid patients in the Brattleboro, Vt., area have begun working with care management teams to better address all of their needs — such as medical, mental health support and home care services — their hospital admissions have decreased.

It takes more than a phone call to create this change, Barry said. It “often takes months to establish trust” between a patient and a group of providers, she said. Together, they have to determine what is important to the patient and what resources are available to help address that particular patient’s needs.

In the Upper Valley, OneCare participants include Mt. Ascutney Hospital and Health Center in Windsor and Gifford Health Care in Randolph.

Jill Lord, Mt. Ascutney’s director of community health, said that participating in OneCare is helping the hospital and its community partners to better meet the needs of patients.

With support from OneCare, Lord said Mt. Ascutney is able to offer self-management courses for chronic diseases, as well as a range of programs to encourage people to exercise, reduce obesity and improve nutrition.

In addition, Lord said, OneCare helps to bring together teams of health care providers, mental health professionals, nursing home staff, visiting nurses and others who are involved in caring for patients’ sometimes-complex needs. Though they are still working through some kinks in the methods they use to communicate, Lord said they are working to develop “a process so that we can all communicate better.”

For example, Lord said the new process helps providers ensure that patients with diabetes regularly have their blood glucose levels checked and helps them to act quickly when a test comes back with troubling results, showing that the disease isn’t being well-managed.

The system also helps to better meet patients’ social needs so that if, for example, a patient is about to lose his housing, a social worker can get on the phone to help him get rental assistance or otherwise address the need, Lord said.

Through OneCare’s care coordination software, “we know what each other is doing so the right things are being done for the patient,” Lord said.

Gifford CEO Dan Bennett, who joined OneCare’s board earlier this year, said that whether or not the state’s all-payer model continues beyond 2022, the future of health care will involve paying health care providers based on the well-being of the people they serve, not on the amount of medical care provided.

“I don’t see that going away,” he said.

But as hospitals and other providers make the switch away from the traditional fee-for-service model, there are some challenges, Bennett said.

They haven’t quite figured out how to fund all of the projects they think might help to keep people healthy. For example, Bennett said, Gifford would like to expand a project that allows ambulance services to conduct preventive house calls to check on patients at home. Gifford is currently working with First Branch Ambulance in Chelsea but would like to offer the service in other communities, he said.

“There’s a lot of these kinds of ideas out there,” he said.

It was “community-based initiatives” such as these for which Hoffer, in his Oct. 23 memo, said OneCare didn’t provide enough information.

“OneCare did not satisfy the GMCB’s criteria concerning community-based initiatives because OneCare did not reliably monitor or accurately report these initiatives,” Hoffer wrote.

This was because OneCare contracted with a consultant to compile the list of initiatives. Hoffer recommended that the Care Board adopt more rigorous standards for OneCare’s reporting of these initiatives.

During the hearing on Wednesday, Tom Borys, OneCare’s director of ACO finance and analysis, said that, as the organization grows, “we need to make sure we have the right staff to manage those initiatives.”

Part of that will involve replacing some contracted work with full-time staff positions, he said. OneCare is proposing to add 20 new positions in 2020. Mullin asked OneCare officials what the right size is for OneCare relative to the size of the state’s health care system.

Borys said they didn’t know yet, but they regularly evaluate the needs of their members.

“I’m not sure there’s a set number,” Borys said.

The Green Mountain Care Board is expected to vote on OneCare’s budget in December and then review it again in March, once more information about the insurance contracts is available.

Nora Doyle-Burr can be reached at or 603-727-3213.

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