1. A Consumer Advocate’s Perspective on Vermont’s All-Payer Model
Presented by
Kaili Kuiper
Staff Attorney
Office of the Health Care Advocate
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February 16, 2017

2. Agenda Introduction to the Office of the Health Care Advocate
Vermont’s All-Payer Model
Background
Structure
Regulation
Risks
HCA Advocacy

3. The HCA: Who We Are A special project within Vermont Legal Aid
Created by the Vermont Legislature in 1998
Mission:
To help Vermonters with problems involving access to health care and insurance/coverage
To be a voice for health care consumers
Staff:
Chief Health Care Advocate, 7 Advocates, 4 Attorneys, 1 Policy Analyst, 1 Communications/Web Manager

4. Background
Based on Accountable Care Organizations and Shared Savings Programs
What is an Accountable Care Organization (ACO)?
ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their patients. (CMS’s definition)
What is a shared-savings program?
Payment reform initiatives developed by health care payers.
Allow providers to share a percentage of savings.

5. Goals What are the goals of the All-Payer Model (APM)?
Limit health care cost growth to no more than 3.5%
Increase access to primary care
Improve health outcomes for Vermonters
How does the model attempt to achieve these goals?
Move from fee for service to capitated payment model
Align across Medicaid, Medicare, and commercial payers
Increase opportunity for coordination in the health care system

6. Structure Three levels of agreement:
between CMS and VT
between Vermont Care Organization and payers
Medicaid
Medicare
Commercial
between Vermont Care Organization and providers
Accountability needed at each level

7. Structure Capitated Payments and global hospital budgets
Which services are included in capitated payment?
Include traditional Medicare Part A and B services and equivalent services under Medicaid and commercial insurance.
Which continue to be fee for service?
Pharmacy services
Home health
Substance use disorder treatment
Mental Health treatment
These may be phased in over time.

8. Timeline Five years All-Payer ACO patient attribution targets
End of 2018: 36%
End of 2019: 50%
End of 2020: 58%
End of 2021: 62%
End of 2022: 70%
By end of performance year 3 (2020), state shall submit a plan to CMS “to coordinate financing and delivery of Medicaid Behavioral Health Services and Medicaid Home and Community-based Services with the All-Payer Financial Target Services.”

9. Regulation Population Health Measures Regulatory Processes
Reduction of substance abuse deaths
Reduction in suicide deaths
Reduction in chronic disease
Access to a primary care physician
Regulatory Processes
ACO Certification
Annual ACO Budget Approval
Annual Hospital Budget Approval (pre-existing)
Health Insurance Rate Review (pre-existing)
Certificate of Need Process (pre-existing)

10. Risks What are the risks? Limiting or rationing care to reduce costs
Will physicians avoid expensive test or treatments?
Will physicians or ACOs “cherry pick” patients?
How can patients know their physician is limiting their care?
Increased consolidation of hospitals and practices
Reduced competition can drive up costs
Increased administrative costs
Duplication?
Measures may not reflect actual savings or ensure quality

11. HCA Advocacy How has the HCA been involved?
Medicaid and Commercial Shared Savings Programs
HCA advocated for Standards to include consumer engagement requirements for Accountable Care Organizations (ACOs)
Beneficiaries on governing boards
Consumer advisory groups
HCA advocated for increased accountability of ACOs
Stronger sets of quality measures
Measures for more populations (i.e., not just Medicare)
Higher performance thresholds for earning shared savings

12. HCA Advocacy
Act 113: Implementing an All-Payer Model and Oversight of ACOs
Passed in 2016 legislative session
APM must meet a set of criteria
Consistent with principles of health care reform in VT law, preserves Medicare consumer protections and provider choice, allows providers to choose whether to participate in ACOs, includes outcome measures for population health, payments from Medicare go directly to health care providers or ACOs
Requires certification of ACOs by GMCB based on a set of criteria
Grievance process, quality & utilization measures, transparency & consumer engagement in governance, provider choice, etc.
Requires GMCB to review ACO budgets and gives HCA a role

13. Vermont’s All Payer Model
Resources
All-Payer Model documents
Available at
Act 113: An act relating to implementing an all-payer model and oversight of accountable care organizations
Available at
HCA White Paper: Consumer Principles for Vermont’s All-Payer Model
Available at

14. Questions?
Contact Information:
Kaili Kuiper, Staff Attorney
Office of the Health Care Advocate
HCA HelpLine: