Vermont's 'all-payer' model aims for patient accountability

Published: Dec. 19, 2019 at 4:10 PM EST
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Democratic presidential hopefuls on the campaign trail have had a lot to say this fall about "Medicare for all," the single-payer health care plan championed by Bernie Sanders. But Vermont abandoned single-payer a few years ago and is now working toward an "all-payer" model which maintains the commercial insurance market and fundamentally changes how doctors and hospitals get paid, and how people receive care and interact with their doctors.

D.J. Redmond lives alone in Winooski. Over the years he's dealt with a laundry list of chronic medical conditions from Parkinson's disease to diabetes to arthritis.

"I had my gall bladder out in my late 20s, then they found out I was bipolar in the early 80s, and I also had post-traumatic stress syndrome. And they have thrown just about every medication in the book at me, and nothing stuck," Redmond said.

He's just one of many patients in Vermont who manages severe, chronic conditions that require frequent visits to the doctor. Vermonters with conditions like these utilize time and resources in the health care system, driving up costs for everyone.

In the traditional fee-for-service health care system, patients like Redmond visit the doctor's office and are often referred to hospitals for acute care. He might take an ambulance there, stay overnight and use resources at the hospital which are expensive. For each of the services the hospital provides, they bill Medicaid, Medicare, or private insurance. They're the "payers" in this model. Those payers get their money from taxpayers or premiums paid by employers and employees. Under this fee-for-service system, the rising demand for care has led to unsustainable costs.

"If you look at overall health and health care, people are getting sicker, their health is less well managed as it was in the past. You're seeing more uses of things like patient services and emergency room services. I think here in Vermont we have challenges in mental health and substance use," said Vicki Loner, The CEO of OneCare Vermont, the for-profit accountable care organization set up to facilitate the state's all-payer system.

The all-payer model was signed into law by Governor Shumlin in 2016. It looks to make the state's health care system financially sustainable by changing the way patients get care and providers get paid. In the all-payer model, Medicare, Medicaid and private insurance funnel their money into a single entity, which then pays the doctors and hospitals.

But instead of reimbursement for each treatment, the providers get a flat fee for each patient. The providers then invest that money into preventative care and regular checkups so patients like Redmond can catch his acute conditions before he has to go to the hospital.

"We catch things before they get balled out of shape. Like I said, the diseases, they're not going to go away. You can control the symptoms. With telehealth, that's what you can do. With them, with the doctors, you are your own decisions," Redmond said.

Under the all-payer model, Redmond checks his blood pressure weight and vitals at home through UVM Health Network-Home Health & Hospice. Joe Haller, a nurse complex care coordinator from UVM Health Network-Home Health & Hospice, also visits him at home to check in on his progress.

"We live our lives at home. We don't want to live our lives in the hospital. Our goals are set as personal goals and our health is one way to attain those goals," Haller said.

Our Calvin Cutler on Friday will take a closer look at OneCare Vermont, the organization tasked with rolling out these sweeping reforms. We'll also hear from a woman in St. Albans who says the new model is making her accountable for her health.