A Consumer Advocate’s Perspective on Vermont’s All-Payer Model Presented by Kaili Kuiper Staff Attorney Office of the Health Care Advocate How to add new slide layouts: 1. In the Slides group, click the drop-down area next to New Slide 2. Click on the layout you want to use for your next slide. 3. Delete this note when you're finished. How to change the date in the footer of your presentation: 1. Choose “View” in the task bar at the top of your screen 2. In the “Presentation Views” group, choose “Slide Master.” 3. Click on the top, slightly larger slide – this is your Master slide. 4. Highlight the date that is listed, and change to the date you want to use. 5. Save the document, making sure that you name it so that you’ll know what it is. 6. Delete this note when you’re finished. Questions or problems? Call Sandra at x-222. February 16, 2017

Agenda Introduction to the Office of the Health Care Advocate Vermont’s All-Payer Model Background Structure Regulation Risks HCA Advocacy

The HCA: Who We Are A special project within Vermont Legal Aid Created by the Vermont Legislature in 1998 Mission: To help Vermonters with problems involving access to health care and insurance/coverage To be a voice for health care consumers Staff: Chief Health Care Advocate, 7 Advocates, 4 Attorneys, 1 Policy Analyst, 1 Communications/Web Manager

Background Based on Accountable Care Organizations and Shared Savings Programs What is an Accountable Care Organization (ACO)? ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their patients. (CMS’s definition) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html What is a shared-savings program? Payment reform initiatives developed by health care payers. Allow providers to share a percentage of savings.

Goals What are the goals of the All-Payer Model (APM)? Limit health care cost growth to no more than 3.5% Increase access to primary care Improve health outcomes for Vermonters How does the model attempt to achieve these goals? Move from fee for service to capitated payment model Align across Medicaid, Medicare, and commercial payers Increase opportunity for coordination in the health care system

Structure Three levels of agreement: between CMS and VT between Vermont Care Organization and payers Medicaid Medicare Commercial between Vermont Care Organization and providers Accountability needed at each level

Structure Capitated Payments and global hospital budgets Which services are included in capitated payment? Include traditional Medicare Part A and B services and equivalent services under Medicaid and commercial insurance. Which continue to be fee for service? Pharmacy services Home health Substance use disorder treatment Mental Health treatment These may be phased in over time.

Timeline Five years All-Payer ACO patient attribution targets End of 2018: 36% End of 2019: 50% End of 2020: 58% End of 2021: 62% End of 2022: 70% By end of performance year 3 (2020), state shall submit a plan to CMS “to coordinate financing and delivery of Medicaid Behavioral Health Services and Medicaid Home and Community-based Services with the All-Payer Financial Target Services.”

Regulation Population Health Measures Regulatory Processes Reduction of substance abuse deaths Reduction in suicide deaths Reduction in chronic disease Access to a primary care physician Regulatory Processes ACO Certification Annual ACO Budget Approval Annual Hospital Budget Approval (pre-existing) Health Insurance Rate Review (pre-existing) Certificate of Need Process (pre-existing)

Risks What are the risks? Limiting or rationing care to reduce costs Will physicians avoid expensive test or treatments? Will physicians or ACOs “cherry pick” patients? How can patients know their physician is limiting their care? Increased consolidation of hospitals and practices Reduced competition can drive up costs Increased administrative costs Duplication? Measures may not reflect actual savings or ensure quality

HCA Advocacy How has the HCA been involved? Medicaid and Commercial Shared Savings Programs HCA advocated for Standards to include consumer engagement requirements for Accountable Care Organizations (ACOs) Beneficiaries on governing boards Consumer advisory groups HCA advocated for increased accountability of ACOs Stronger sets of quality measures Measures for more populations (i.e., not just Medicare) Higher performance thresholds for earning shared savings

HCA Advocacy Act 113: Implementing an All-Payer Model and Oversight of ACOs Passed in 2016 legislative session APM must meet a set of criteria Consistent with principles of health care reform in VT law, preserves Medicare consumer protections and provider choice, allows providers to choose whether to participate in ACOs, includes outcome measures for population health, payments from Medicare go directly to health care providers or ACOs Requires certification of ACOs by GMCB based on a set of criteria Grievance process, quality & utilization measures, transparency & consumer engagement in governance, provider choice, etc. Requires GMCB to review ACO budgets and gives HCA a role

Vermont’s All Payer Model Resources All-Payer Model documents Available at http://gmcboard.vermont.gov/payment-reform/APM Act 113: An act relating to implementing an all-payer model and oversight of accountable care organizations Available at http://legislature.vermont.gov/assets/Documents/2016/Docs/ACTS/ACT113/ACT113%20As%20Enacted.pdf HCA White Paper: Consumer Principles for Vermont’s All-Payer Model Available at http://www.vtlawhelp.org/health-care-policy

Questions? Contact Information: Kaili Kuiper, Staff Attorney Office of the Health Care Advocate kkuiper@vtlegalaid.org www.vtlawhelp.org/health HCA HelpLine: 1-800-917-7787