1. FletcherAllen.org Successful Switch Hitting in a Combined Volume and Value Environment J. Churchill Hindes PhD (Iowa 1977) Chief Operating Officer, OneCare Vermont ACO Vice President for Accountable Care, Fletcher Allen Health Care Clinical Associate Professor of Medicine, University of Vermont

2. HEALTH CARE IN VERMONT Vermont superlatives: Small, pretty, rural & healthy First or second “Healthiest State” in the USA 625,000 population (equals Denver or Milwaukee) Low number of uninsured—6.8% (before exchange) Low to average health care spend per person Health care is nearly 20% of state economy 2

3. HEALTH CARE IN VERMONT 2 academic health systems (University of Vermont and nearby Dartmouth) 14 hospitals (8 are Critical Access) 1,900 physicians (65% are hospital employed) Two commercial health insurers dominate market All major players are non-profits Largely non-competitive provider model 3

4. HEALTH CARE IN VERMONT Aggressive state reform agenda Committed to “Single Payer” by 2017 Fueled by SIM funding—Most per capita in USA Exchange required for individuals and business <100 One dominant, liberal political party Closely regulated health care system Providers and public sector closely engaged

5. HEALTH CARE IN VERMONT University of Vermont (UVM, in Burlington) is: 90 minutes south of Montreal Canada 6 hours north of New York 4 hours north of Boston Dartmouth and UVM on opposite state borders VT & NH among smallest states with Med Schools

6. FletcherAllen.org 6 Top 10 University Hospital University HealthSystem Consortium (UHC) ranked University of Vermont / Fletcher Allen Health Care:  1 st in the nation for patient safety for 2014  7 th for overall quality of care

7. Vermont’s Reform Legacy Northern New England Medical Compact (1958) Cooperative Health Information Center of Vermont (1970) John Wennberg’s small area variations (1970) CON controls (since 1979); Hospital budget reviews (since 1983) State public controls after Reagan era relaxation (1987) Vermont Program for Quality in Health Care (1988) Medicaid expansion (1987…) Health insurance reforms (1991…) Creation of statewide Health Care Authority (1992) Howard Dean’s unsuccessful universal access attempt (1992-94) 7

8. Vermont’s Reform Legacy Blueprint for Health—Chronic disease and PCMH’s (2003) Choices for Care long term care reforms (2004) Statewide HIE mandate (2005) Catamount Health Plan (2007) Contribution to and capitalization on PPACA (2010 to present) William Hsiao Report on 3 Single Payer opportunities (2011) “Single Payer” mandate (2011) Green Mountain Care Board (2011) OneCare Vermont first statewide Medicare ACO (2013) Medicaid and Commercial ACO programs (2014) Physician Assisted Dying legislation (2014) 8

9. FletcherAllen.org 9 Health Care Reform Path 2011-2017 2010-2011 Legislative Action National: PPACA Vermont: Act 48 2011-2012 Early Implementation National: MSSP ACO Program; Age 26; Exchange Planning Vermont: GMCB seated; VT exchange legislation; Hospital NR growth limits, payment reform pilots 2012-2014 Becoming Real National: ACA benefit plans, exchanges, Medicaid expansion Vermont: SIM Grant, VT Health Connect, Multi- Payer ACOs; population- based SSP on top of FFS 2014-2016 Redesign and Results National: MSSP ACO risk; stabilize ACA and national exchange Vermont: ACO Multi-Payer; GMC Funding design; continued provider consolidation; Start move to non-FFS 20102011201420132012201720152016 2017+ Future Model National: Refined national model and/or state innovation; Medicare/Medicaid funding challenges Vermont: GMC as right of citizenship; new funding and provider revenue model(s)

10. onecarevt.org 10 Vermont Public Reforms  Primary public agenda elements “Act 48” >Commitment to “Single Payer” reforms >Public financing of system (taxes replace premiums) State Innovation Model grant program (SIM) >Payment reforms away from fee-for-service Vermont Health Connect (PPACA insurance exchange) > To become single payer enrollment tool > To access to federal exchange premium subsidies Insurance market changes >Individuals, most employers must purchase via exchange 10

11. FletcherAllen.org 11 Key Public Priorities

12. onecarevt.org 12 Vermont’s Private Reforms  Primary private elements include Capitalize on federal and state legislative opportunities Explore payment reform alternatives to fee for service >shared savings> bundled payments >global budgets> pay for performance Explore Accountable Care Organizations and ACO programs (Medicare, Medicaid, Commercial) Integrate Vermont Blueprint for Health PCMH initiative Structural changes (UVM Network, OneCare Vermont ACO) Eliminate cost shift Eliminate premium hikes at multiples of GDP rates 12

13. FletcherAllen.org 13 Key Provider Priorities

14. FletcherAllen.org 14 Vermont’s Reform Landscape

15. FletcherAllen.org 15 Who Should Focus on What?

16. FletcherAllen.org 16 Both Pulling Together

17. FletcherAllen.org 17 Filling the Funnel

18. FletcherAllen.org 18 Filling the Funnel (detail)

19. FletcherAllen.org 19 Flowing to Providers

20. FletcherAllen.org 20 Flowing to Providers (detail)

22. FletcherAllen.org 22 Enter the OneCare Vermont ACO OneCare Vermont ACO  Began in 2012 as joint venture between Dartmouth and University of Vermont’s Academic Health System to: Explore potential for further collaboration Attempt a broad statewide population health strategy Present a unified front in politics of Vermont reforms  Structured as a Medicare SSP track one ACO

23. FletcherAllen.org 23 Enter the OneCare Vermont ACO OneCare Vermont ACO  “Discovered” by Vermont public reform authority Adopted as a SIM program payment reform pilot Asked to co-design Medicaid and Commercial ACO deals  Agnostic to revenue sources including tax funding  Now providers’ lead vehicle in Vermont reform efforts  Commissioned to design “flow from bottom of the funnel”  Goal is a design that is Collaborative, cohesive and consistent Sustainable with reasonable growth rates

24. FletcherAllen.org 24 Center Place in the Landscape

25. FletcherAllen.org 25 Vermont is a bit different…  Across the nation, ACO’s are typically business arrangements between groups of providers and one or more payers. Providers see ACO as a way to maybe make a little extra money.  In Vermont, ACOs are business arrangements between groups of providers and multiple payers. Providers see ACO as a way to maybe make a little extra money…  AND, the ACOs (particularly the OneCare ACO) are high profile leaders for statewide health care reform—private provider led efforts that complement the public sector led initiatives

26. FletcherAllen.org 26 ACOs as a “platform” for reform ACOs as a “Health Care Reform Trifecta”  Structure a broad network of linked providers  Contract voluntarily to mutual performance agreements  Commit to better understand community status & needs  Commit to test and add new ideas into daily practice  Strive to achieve slower cost growth (While improving clinical quality and patient satisfaction)  Collaborate with insurers (Medicare, Medicaid, Blue’s)  Willing to be paid differently  Willing to assume more financial risk

27. onecarevt.org 27 Provider-Led, Population-Based Coordination, Alignment, and Support Forum for Delivery System Design/Optimization Payment Reform Leadership Revenue Model Design Incentive Programs Care Management Design and Support Primary Care/PCMH Alignment HIE Facilitation Population-Based Clinical and Analytic Systems Quality Measurement ACO Regulator(s) Payer(s) Legislators Physicians Hospitals Other Providers OneCare Vermont Roles

28. FletcherAllen.org 28 OneCare Vermont Multi-payer, private/public collaboration Credentialed by Vermont reform authority as a SIM payment reform program 100,000 attributed beneficiaries (16% of statewide population) $750,000,000 accountable spend (17% of statewide health care spending) MSSP began January 2013 Medicaid (VMSSP) began January 2014 Commercial (XSSP) began January 2014 Quality measures: CMS-33 plus others for Medicaid and Commercial ACO programs Preparing for two-sided risk starting in 2016

29. OneCare Vermont Statewide ACO Provider Network Two Academic Medical Centers (University of Vermont and Dartmouth) Every hospital in the state 550 Primary Care clinicians 90% are NCQA medical home practices 1,400 Specialist physicians 4 Federally Qualified Health Centers 5 Rural Health Clinics Broad network model: Nearly every VNA, Hospice, SNF and Community Mental Health and Substance Abuse agency statewide Links to other large ACOs in upstate New York, New Hampshire and Maine Hospitals with Employed Attributing Physicians Significant Attribution from Community Physicians 29

30. Some OneCare Notable Notes Central role in Vermont statewide health care system reform Credentialed by state regulators as payment reform program One of very few statewide ACOs in nation One of few ACOs sponsored by two academic health centers One of largest rural ACO’s—now at over100,000 attributed lives Now accountable for $750,000,000 in health care costs and growing One of relatively few multi-payer ACOs Unusually broad-spectrum provider network strategy Linked to ACOs from St Lawrence valley in New York to coastal Maine Close collaboration with Vermont ‘s statewide medical home model Designed to be compatible with Vermont’s plans for “Single Payer”

31. FletcherAllen.org 31 The Future of Vermont Reforms  Opportunities Providers are engaged and collaborative >Population-based approach is being widely embraced Broad physician alignment >65% of MDs work for hospitals or FQHCs >All hospitals and FQHCs are in multipayer ACOs Data infrastructure is approaching maturity >Statewide HIE >All-payer claims databases >Northern New England Accountable Care Collaborative OneCare provides statewide framework for real change

32. FletcherAllen.org 32 The Future of Vermont Reforms  Challenges How do you improve on our high-performing system? Ongoing tension about who should lead reform >Best public-private balance? >Best locus for public leadership—political or policy centric >Best roles for providers / payers / ACOs / state agencies? Providers’ concerns about their future sustainability Wariness about Vermont state intensions Wariness about Dartmouth and UVM intensions The heaviest lifting has yet to come

33. FletcherAllen.org 33 Some Key Unknowns  Will Vermont receive its required federal waivers?  Will the Vermont legislature approve public financing? “The largest tax increase in state history” “Substituting payroll taxes for private insurer premiums”  Where will “Single Payer” risk be held?  Will state or providers control key reform infrastructure?  What role will commercial payers continue to play?  Will ERISA plan employers successfully sue Vermont?

34. FletcherAllen.org 34 Some Key Unknowns  How will Vermont reforms impact out of state providers? (Dartmouth Hitchcock, Boston Children’s…)  Will the reforms adversely impact the state economy?  Will Vermont’s high performing system be maintained?  What will the changes mean for Vermont providers?  Will changes result from the Nov 4 Vermont elections?  Will changes result from the Nov 4 federal elections?

35. FletcherAllen.org 35 A Closing note— Then…and now! Then: C. Rufus Rorem visited us at Iowa and spoke about his work on the CCMC 1969 -1925 = It was 44 years ago! “None of us were born then!” “What an old codger!” Now: J. Churchill Hindes came to Iowa in 1969, back speaking today 2014 -1969 = It’s been 45 years! “None of us were born then!” “OMG! Who? Me? Old?!”

36. Questions and Discussion churchill.hindes@onecarevt.org 802-847-6249 churchill.hindes@onecarevt.org 36

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