The Fed proclaims Vermont’s enrollment target for all payer models ‘unattainable’

Phil Scott, Mike Smith and Ena Backus
From left Governor Phil Scott, Human Services Secretary Mike Smith and Director of Health Care Reform Ena Backus in 2019. File photo by Mike Dougherty / VTDigger

Federal regulators said they will not penalize Vermont for not reaching enrollment benchmarks in the state health care reform plan.

The Medicare and Medicaid Services Federal Centers called state-of-the-art payroll benchmarks for all payers “unattainable” and “unnecessary,” prompting the agency to suspend its enforcement of those targets until the agreement could be revised.

The agency will continue to enforce other standards, according to the October 12 letter.

Vermont has consistently not reached its enrollment goals, the letter said. Heads of state have committed to having 70% of all Vermonters participate in the all-payer model by the end of 2022, but only 57% have so far signed up, according to Vermont’s latest report to the Centers for Medicare and Medicaid Services.

“The federal government says it recognizes that it is not appropriate to enforce goals that are unattainable,” said Ena Backus, director of health care reform at the Vermont Agency of Human Services. “… They are not saying we should not work towards increased participation.”

Critics say, however, that the lack of enrollment benchmarks is the latest in a series of flaws in the approach to all payers and OneCare Vermont, the responsible care organization that has become almost synonymous with the model in the eyes of the public. OneCare sends hundreds of millions of Medicare and Medicaid payments to providers across the country.

Patrick Flood, who previously served as commissioner of the Department of Mental Health and the Department of Disabilities, Aging and Independent Living, called Vermont’s model with all payers “a failure from the start.”

“So they (the federal government) have to boost it by making it easier for (the state),” said Flood, who previously served as deputy secretary of the Agency for Human Services. “It lets them get off the hook because they are never going to reach those goals.”

Vermont and the federal government entered into an agreement in 2016 that would allow the state to experiment with a state-wide value-based care model. Under the state’s all-paying model, Vermont’s public and private insurance companies would pay providers to keep patients healthy, rather than for every blood test, checkup or x-ray. If enough patients participate, one thinks, health care in the state would be cheaper and better.

In its most recent letter to the state, federal regulators attributed the state’s enrollment challenges to Medicare enrollees either to getting care out of state or participating in Medicare Advantage plans that do not have an agreement with OneCare.

Vermont executives have also said commercial insurance companies were slow to move sign-ups to OneCare. As of 2020, about 20% of all commercially insured Vermonters were part of OneCare compared to more than 90% of the state’s Medicaid subscribers, the state said in its latest report to FB.

In addition to enrollment targets, the 2016 agreement sets quality standards, such as increasing access to care and reducing suicide, which the agency will continue to enforce, according to the letter.

Kevin Mullin, chairman of the Green Mountain Care Board, a regulatory body overseeing OneCare, said the letter from the Centers for Medicare and Medicaid Services “accepts the reality” that Vermont’s original goals were overambitious.

“Why has a cloud hanging over everyone’s head, including the state of Vermont, to come up with a corrective action plan to get to a place you can never get to?” said Mullin.

Mike Smith, secretary of the Vermont Agency of Human Services, is expected to go before the Green Mountain Care Board to discuss the agreement on all payers early next month. In conversations this week, both Mullin and Backus suggested that achieving Vermont’s enrollment goals may require a different approach.

“The goals are not OneCare goals in themselves,” Backus said. “But because OneCare is the only one doing it, the scales measure participation in OneCare.”

These discussions coincide with significant changes to OneCare. John Brumsted, longtime head of the University of Vermont Health Network, recently announced that he was stepping down from his leadership role on the board of the responsible care organization. Last month, the University of Vermont Health Network became the sole parent organization for OneCare.

The nonprofit was originally a joint venture of Dartmouth-Hitchcock Medical Center UVM Medical Center. Brumsted said the new governance structure was part of an attempt to correct the course after Centers for Medicare and Medicaid Services warned the state of the lack of enrollment benchmarks in 2018 and 2019.

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