[S]tate regulators have released more details on a major health care reform deal that would change significantly the way the health care industry runs in Vermont.
Al Gobeille, the chair of the Green Mountain Care Board, told the House Health Care Committee on Monday that he expects to have the terms for an all-payer model agreement with the federal government in December.
The terms sheet would be the framework for an agreement that the Green Mountain Care Board would continue to negotiate with the U.S. Centers for Medicare and Medicaid Services to create a first-in-the-nation statewide all-payer system.
The term all-payer carries different definitions, and the only other state with something similar is Maryland, which uses an agreement with the federal government to regulate how much hospitals charge to government programs and insurance companies.
Vermont’s would be more comprehensive and very different. Among its many goals, the state is seeking the power to control Medicare, a federal program, and maintain its current control over Medicaid, commercial insurance companies, and self-insured health plans.
Once the state has the contract terms sheet, Gobeille said his staff would work with key individuals in the industry to set up a more complete all-payer model by May 2016. The all-payer system could then be implemented by Jan. 1, 2017 — the same date that the abandoned single-payer effort was scheduled to come into play.
The most clear part of the deal right now is this: The Green Mountain Care Board wants to agree with the federal government to limit the growth rate in health care spending for all Vermont residents to 3.5 percent each year. The parties would set a 4.3 percent maximum growth rate.
The U.S. Centers for Medicare and Medicaid Services would also relinquish its control over Vermont’s Medicare program during the contract term; the Green Mountain Care Board says it would “stand in the shoes” of federal regulators.
The other major parts of the all-payer plan come down to details of a so-called transformative health care model: The Green Mountain Care Board would make it attractive for Vermont doctors to join a single accountable care organization, or ACO.
The board would also maintain legal authority to use the ACO to set payment rates to doctors and hospitals, establish how payments are calculated, determine which doctors are responsible for which patients, and implement quality measures, among other things. However, regulators might not use all of that legal authority.
The board has been holding regular meetings with stakeholders for nine months as they work to set up the transformative care model. Gobeille said he wants to encourage joining the single ACO as opposed to penalizing doctors for not joining.
He said the details of the transformative care model would be worked out over time. And as discussions move forward, lawmakers and advocates are pressing regulators to implement parity for mental health care and substance abuse treatment.
Mental health and substance abuse
Rep. Kiah Morris, D-Bennington, who sits on the House Health Care Committee, was one of several lawmakers asking Gobeille for answers on mental health parity. She said mental health and substance abuse treatment are underfunded, and those need to be addressed as part of health care reform.
“I didn’t feel that an all-payer model was going to accurately and efficiently cover mental health and substance abuse,” Morris said. “There are growing mental health and substance abuse issues that aren’t as straightforward as ‘Did you take this diabetes education class?’”
She said mental health and substance abuse are not “afterthoughts” and that lawmakers need to be assured that designated agencies and substance abuse treatment centers will have the tools they need to support patients so that the duty doesn’t fall on primary care physicians.
Rep. Chris Pearson, P-Burlington, said it’s not clear how mental health will be addressed in the all-payer model. He said it’s more about uncertainty than fear that mental health will be handled poorly.
“I think they (mental health and physical health) should be integrated,” Pearson said. “I think they deserve an equal seat at the table. We have long tried to build parity between mental health and physical health, and that principle needs to be honored here with payment reform as well.”
Trinka Kerr, the chief health advocate at Vermont Legal Aid, pointed to concerns about mental health and substance abuse as part of a report on Consumer Principles for Vermont’s All-payer Model.
The 11-page report calls for the all-payer model to “improve access to care”; measure access in a way that’s more robust than determining who has insurance and who has a primary care physician; and give patients the opportunity to appeal their case if an ACO denies services.
Gobeille, the chair of the Green Mountain Care Board, said he has been bringing feedback from lawmakers and advocates to the team meeting regularly to set up a transformative care model. He said that feedback is crucial to setting up a model that doctors want to participate in.
Gobeille referenced recent testimony at a Green Mountain Care Board meeting that discussed primary care providers. He said Vermont Legal Aid’s presentation was also helpful because it gives regulators written goals to address.
“How do you work as a primary care doctor or nurse practitioner with a mental health professional so that you keep your folks healthier?” Gobeille said. “How does that work? That’s working surface stuff that it just doesn’t happen overnight.”
Rep. Anne Donahue, R-Northfield, sits on House Health Care and is a mental health advocate who works for the Vermont Psychiatric Survivors. Donahue said she’s been encouraged by her conversations with Gobeille.
“I am relatively confident that (the model) will be set up to enable (mental health parity) to be phased in,” she said. “I’m not confident that it will be from the get go, but I think that’s a work in progress.”
