Blog#16- 2/14/20
THE ONE CARE MAZE
By Richard Davis
The public is not engaged enough in the process of health care reform. That is nothing new. Most people don’t get worked up about health care issues until they get sick and have to use their health insurance, if they have it, or when they find out about all the details of payment and coverage.
Yet, many polls indicate that health care is one of the most important issue for voters. What that means is that Americans who have to use their health insurance or who pay premiums are sick and tired of being used as pawns in a money game that should be focusing more on health and not as much on finances.
Voting for a candidate who connects with people on health care issues means that voters have to dig into the issues and figure out what plans mean and how they might affect their health and their pocketbook. But what happens when the course of health care reform cannot be controlled enough by voters?
Most health care issues, whether they relate to financing or the direct provision of services are controlled by administrators and policymakers. The state of Vermont laid the foundation for a new type of payment system for health care a few years ago called the All Payer Model. The basic concept is that eventually most Vermont health care providers would be paid a set fee based on a per person per month figure worked out among the state, insurers and providers.
In order to facilitate the use of that model Vermont created One Care, an accountable care organization. According to VTDigger reporter Katie Jickling in a December 2019 piece, ”About 160,000 Vermonters, roughly a quarter of the state’s population, have their health care funds pass through OneCare Vermont. For the most part, the company flies under the radar.
In fact, nearly a billion dollars of state health care funds go from insurance providers to the for-profit accountable care organization; OneCare then funnels the money to doctors and hospitals.
OneCare helps facilitate the state’s all-payer system, which prioritizes preventative care and aims to lower health care costs by keeping people healthy.”
That means that a lot of Vermont’s health care dollars are now being controlled by One Care, yet there have been a number of instances where the organization’s transparency and public accountability have been called into question.
In November I contacted One Care to find out about how to disenroll. If you a Medicare beneficiary you are automatically enrolled in Once Care unless you opt out. Opting out requires contacting Medicare directly but the people I contacted at One Care initially gave me incorrect information. They assured me that they would upgrade their web site to explain how to disenroll. As of today, those promised changes have not been made.
In January Mike Smith, Secretary of the Agency of Human Services, urged lawmakers not to give One Care a requested $5.7 million until they become a non-profit organization. Becoming a non-profit would provide more transparency, something that many people have been looking for.
The original hope for One Care was that it had the potential to transform Vermont’s health care system by becoming a model for comprehensive care. Many of the pieces of that framework are in place yet the overall organizational structure appears to be getting in the way of meaningful progress. When an organization controls so many health care dollars it needs to do a better job of being open and honest about what it is doing.
One Care, as well as the governor, are claiming that millions of dollars have been realized in savings because of the program. But is money really being saved? Patients may be using fewer services and the cost of their care may be decreasing in some instances.
The other side of that coin that you won’t readily hear about is the fact that providers whose patients use up less of their allotment can keep the money they save. That money goes back into the accounts of hospitals and health care organizations. We need more information about what happens to that money that is called savings.
Insurance vs health care
So much of our conversation about health care isn’t about health care at all… it is about insurance. Insurance isn’t health care. It’s insurance, and insurance companies. Last I checked, they provide no health care at all. They process payments.
When candidates talk about keeping existing health care, I hear “I promise to allow you to keep paying your insurance company, and deductibles, and current drug prices.” Gee, thanks for nothing, candidate.
I’m also getting a bit annoyed at folks who can’t see the value of increasing the number of people using Medicare. To me, Medicare for All is about the same as Fire Protection for All, or Police Protection for All. No one suggest that fire and police services should be doled out based on your employer, and I don’t hear the anti-Medicare For All folks arguing for privatizing police and fire services. But they do want health care to be that way. Weird.
Thanks for the information about One Care. I know I got a bit off topic here. : )
A for-profit middleman in health care?
Having One Care act as for-profit middleman for health care payments in Vermont seems to be a recipe for allowing them to profit off of every Vermonter’s healthcare. If the goal is to save money, why would TPTB choose to run all that money through a for-profit? It should have been non-profit from the gitgo.
I’m also suspicious of the word “accountable” which almost never means what we think it means and rarely pertains to the people we think should be accountable. Who is accountable in accountable care?
Thanks for keeping us informed.
Maze is right
I read that VTDigger article a few weeks ago, and it left me as confused as when I started about what One Care actually does. That wasn’t the reporter’s fault; One Care is just a Rube-Goldberg attempt to paper over the continent-sized holes in the current system, while not actually doing anything about the root causes: the insurance companies.
Medicare For All would be cheaper (my family would save ~$300 a month, or ~$3600 a year with Bernie’s bill) and wouldn’t require endless explainer articles that still leave you scratching your head. You’d just go to the doctor, get treated, and leave. The only “problem” is that it would end a useless, predatory industry that took $812 *billion* (!!) in paperwork costs in 2017 alone.
Opting out?
I do not understand the pros and cons for a Medicare patient to stay on the OneCare system vs. to opt-out?
OneCare VT
Thanks for this informative post. I have a lot to say on this subject, maybe more than people here want to read. To answer Lise’s question, it’s not clear what they mean by “accountable.” Maybe it’s just a feel-good name. But the theory behind ACOs is that doctors be accountable to controlling costs and that giving them financial skin in the game (incentives) is the way to do that. Essentially they are turning medical practices into quasi-insurers. I think this is ethically questionable, to say the least.
OneCare VT is about payment reform, not healthcare reform. Once Shumlin bailed on the financing plan for a universal system in VT, the big hospital conglomerates pushed for the other road that was included in Act 48 (the healthcare law), which was to push for payment reform by pushing through the “All-Payer Waiver” (another misnomer since participation is voluntary, so it is not really all-payer) and then consolidating power (and money) in one ACO, OneCare VT. It receives huge amounts of public money in the form of Medicaid and Medicare payments. In the case of Medicaid, this drains money from the Medicaid pool that remains in the state’s coffers. This is particularly important for people with disabilities, since OneCare gets to choose who it “attributes” and they choose NOT to attribute people who are on both Medicare and Medicaid. Maybe you can guess why…. Hint: It’s all about risk pools and money.
At this point, OneCare is a huge roadblock to true healthcare reform in VT. It is sucking up all the air–and dollars–in the room. The Green Mountain Care Board, which is supposed to be regulating OneCare, is also party to the All-Payer Waiver, which means they are charged with promoting the organization they are supposed to be regulating. I would call that a conflict of interest.
The State Auditor’s office is doing an audit of OneCare, and I’m eager to see what they turn up. It is really hard to track where all that public money is going but maybe with special auditor skills they will be able to do that.
In addition to controlling costs, OneCare is supposed to be improving health outcomes. I went to their dog and pony show for the House and Senate Health Care Committees that was supposed to be about health outcomes. It lasted 1.5 hours and most of it wasn’t about outcomes at all. Then when they trotted out their shining example of a health outcome improvement, it was about how Berlin Medical Center had shown huge improvement in the number of people on Medicaid who got A1C testing. That is NOT a health outcome. The outcome would be that more people had their diabetes under control. Not one legislator even asked about that. Quite honestly, the whole presentation seemed like a lot of smoke and mirrors.
If you want to read more, search on VT Digger for articles by Julie Wasserman, Patrick Flood, or Susan Aranoff. They have all written in some detail about OneCare.
Finally, in terms of pros and cons of opting out, so far as I can tell it makes no difference in terms of patient care since you get attributed because your doctor is part of OneCare (not necessarily because they chose to be, but because they are part of a “medical system” that is in OneCare). There may be some data sharing that won’t happen, and maybe you won’t get certain surveys, but it’s actually not very clear to me what the difference is. Maybe Richard knows more about this.