November 11, 2016

What works best in your Chapter for member/patient benefit?

This week's BOG Update is brought to you by Governor of the Vermont Chapter, Prospero Gogo, MD, FACC.

The Vermont All-Payer ACO Payment Model

Unique conditions on the ground in Vermont have lowered the threshold to attempt more advanced health care reform compared to most of the United States. These factors include: a small population with a per capita income very slightly above the national average, an all Democratic and progressive state government since 2011, and a rural landscape with the majority of the health care spent by one large hospital system which is the core institution of the largest accountable care organization (ACO) in the state.

Governor Peter Shumlin (D) on Oct. 28 signed an agreement with the Centers for Medicare and Medicaid (CMS) to form the nation's second all-payer model and to be the first to bring all-payer transformation beyond the hospital. The first all-payer model in the nation was in Maryland and focused on hospital reimbursement beginning in 2014.

The Vermont All-Payer ACO Model is the CMS' new test of an alternative payment model in which the most significant payers throughout the entire state – Medicare, Medicaid, and commercial health care payers – incentivize health care value and quality, with a focus on health outcomes, under the same payment structure for the majority of providers throughout the state's care delivery system and transform health care for the entire state and its population. The Vermont All-Payer ACO qualifies as an Advanced Alternative Payment Model. The initial Vermont-based ACO participating in the All-Payer model will be OneCare Vermont.

Participation is voluntary. There are three ACO systems in the state, and the model's attributed lives are based on the primary care provider's affiliation with a participating ACO. Although largest by spend, the OneCare ACO only has 30 percent of the attributed lives in the state. The OneCare ACO is affiliated with the University of Vermont Health Network, and most cardiology services in the state are provided by cardiologists affiliated with the OneCare ACO. Services provided to a patient who is not from a primary care practice participating in the all-payer structure will remain fee-for-service and evolve into other value-based payment models under other parts of upcoming Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rules.

The expectation is that at least one or both of the other ACO systems in the state join by the midpoint of the six year program. Most Vermont cardiologists are salaried hospital/health system-based employees.

The risks for Vermont cardiologists are in line with any theoretical global payments model. Will there be enough resources for a "bad year" with a more-than-expected volume of expensive procedures? Will the model be able to adequately accommodate the introduction of new but expensive technology? Most of the model's language concerns the structure of primary care services and attributions.

The model may also be an opportunity for cardiologists in the approach to chronic disease such as heart failure. The ACO is planning to take advantage of the opportunity to offer more comprehensive post-inpatient stay programs and programs to address patients with high health resource use. Cardiologists have been involved on the backbone of an existing post-discharge congestive heart failure model to reduce 30 day readmissions, for example.