Gov. Peter Shumlin's ambitious plan to have Vermont become the first single-payer health care state in the U.S. never materialized, but in a quieter way, the health care system in Vermont is changing.
Hospitals and health care providers in Vermont are already shifting toward a new approach to caring for patients – and, perhaps more challenging, a new approach to paying for that care.
Nearly all Vermont’s hospitals are part of what’s called an Accountable Care Organization (ACO), where if the health care providers are able to keep people healthy and avoid expensive tests, the hospital splits the savings with Medicare and Medicaid.
The basic idea is to move away from the traditional fee-for-service health care model, which puts an economic pressure on doctors and hospitals to administer more tests, and to instead health care providers a set fee for keeping people healthy.
UVM Medical Center has been proactively pushing to further develop this payment model and move toward a system where instead of simply splitting any savings with the federal government, the hospital would be paid a set rate for taking care of patients. Rates would be different for different patient populations.
“I think that there’s a real collective energy to want to make this change,” says Dr. John Brumsted, who heads the University of Vermont Medical Center.
“The reason I’ve been out there saying we want 80 percent of the reimbursements to come this way [via accountable care organizations] is … we as physicians and other providers can’t treat one patient or group of patients one way — that’s we’re taking this holistic approach to keeping you healthy and getting paid that way — and then the next minute deal with somebody whose care is being paid for on a per-encounter basis," Brumsted says.
“You can’t do that," he adds. "You need to move enough of your whole interaction to the new paradigm to really have that culture shift.”
The new paradigm in practice
UVM Medical Center's Colchester Family Practice currently receives about 30 percent of its funding through OneCare, an ACO in which all the Medicare patients here are enrolled.
If you asked Ken Petersen, a patient here, if he had any idea that his primary care was delivered through an ACO, he’d say no.
But Petersen has noticed a marked change in his own engagement in taking care of his health, and part of that change comes from the new team approach to his care at Colchester Family Practice.
“Dr. Jacobs recommended that I see the [dietitican], and I’m thinking, ‘Oh yeah, here goes another one,’" he says. "Sure enough, I went in there, and Chassidy made me so relaxed— I was back in school again, she was teaching me all about my diet, the carbs, what percentages, and eat this.”
Petersen says he was surprised, but this dietician coaching really helped him see how little changes could make a big difference in his health, like how cutting out cereal before bed helped reduce his sugar levels.
Seeing the patient as a person
Chassidy DesLauriers is a clinical dietitian who works with Petersen's physician, Dr. Alicia Jacobs, as part of a care team. This team approach is the crux of the ACO method: It emphasizes preventative care and working closely with patients before health issues become serious. The doctor works with a team that may include dietitians, social workers and specialists to personalize the patient’s care.
“[We’re] trying to meet people where they’re at, and we’re all trained now in what we call motivational interviewing," says Jacobs. "So we do active listening … and try to create a goal that they can make on their own that feels achievable."
“[Dr. Jacobs] puts it back on my shoulders and says, ‘Ken, if this is going to work, it’s going to be up to you to make it work. I can only advise you,'” says Petersen.
Petersen says his former doctor interactions were rote and impersonal:
“Most medical people are, you’re in for two seconds: ‘Hi, how are you doing? Goodbye. Take two of these a day and everything else.’ You know, they don’t take time to communicate with you.”
UVM Medical Center's Colchester Family Practice moved to an ACO model in 2009. The practice is making major changes to become more proactive about preventative health care measures — especially for people with chronic illnesses.
“If the goal in health care ... is to make health care cost less, then we have to do better at taking care of chronic health issues," says Jacobs. "Because that’s where the bulk of money is spent."
Jacobs says her office actively tracks down at-risk patients and urges them to come in for a check-up before they have health complications. Her office has registries so they can find patients who aren’t coming in, say for a mammogram or a diabetes check-in.
“Patients with diabetes have lots of care they need, above and beyond — yearly eye exams, foot exams, special urine testing, lab testing, etetera, etcetera," she says. "So we now can do that population health management. We can find our patients who aren’t here.”
A team approach to personalized care
For Petersen, who was already scheduling his own appointments in a timely manner, the extra prompting came in the form of coaching. With that help, he started actually using the tools he had.
“These are things I didn’t do every day before," he says. "With the finger prick thing you could see, ‘OK, this particular food isn’t really doing me any good, or, I gotta cut down amount of this food.’”
Petersen says he feels more energetic then he has in long time.
Many doctors support the team approach that’s centered around the patient, regardless of whether it comes with a change in the payment model.
Can the team care approach save money?
As UVM Medical Center and other state hospitals try out the accountable care approach, the lingering question is: Can it actually save money?
Dr. Brumsted, who runs the UVM Medical Center, thinks it can. He’d like to see the hospital move to having 80 percent of its patients paid for under the ACO model by 2018.
“Right now, we’re rewarded for doing more tests, more procedures, and heaven forbid if someone gets a complication, financially that is in some ways beneficial to the health care delivery system,” says Brumsted.
“If we could change, so that for a population of individuals, a set of health care providers are given dollars up front to pay for your health care for a period of time, to cover everything, then the incentives are totally aligned to keep you as an individual, your family, your community, healthy," he says.
Brumsted says the model forces health care providers to work together and find innovative ways to keep patients healthy. He says a key part of the equation is that ACO needs to have rigorous quality standards to be reimbursed for care.
“We have confidence that we have built into the system the ability to live within a budget,” he says.
Better communication is key
Brumsted says it’s critical that when people leave the doctor’s office or the hospital, they have a clear understanding of the instructions and strategies necessary for their care.
“We’re going to be even more incented to make certain that the hand-off to home care and other support services in the community are really smooth to reduce re-admissions, to reduce people needing to come to the emergency room," he says.
For the past three years, UVM Medical Center and nearly all the hospitals in Vermont have been trying out a cost-share ACO model, where any savings are shared with federal programs like Medicaid and Medicare.
Brumsted wants to go even further and have the Legislature and federal government give the providers those dollars up front: a pool of money carefully calculated to care for the specific needs of a given population.
But it’s unclear if the state would switch to such a model any time soon, because the big unanswered question remains: What happens if – especially in its early years—more money than is available in the pool is needed to take care of patients? Who would end up paying the extra costs if the pool gets drained too quickly?
That’s a gamble that the state hasn’t been willing to make yet.