House lawmakers get refresher course on the all-payer model

MONTPELIER — A group of lawmakers in the House were given a refresher course Wednesday on the state’s efforts to reform the state’s health care payment system, and were assured that Medicare benefits will not be changed as part of that process.

Al Gobeille

Al Gobeille

Green Mountain Care Board Chairman Al Gobeille walked the House Committees on Health Care and Human Services through the efforts to nix the current fee-for-service model in favor of an all-payer model. The Shumlin administration is working with the GMCB, the state’s health care regulatory body, to negotiate terms with the federal government on what the new model will look like.

Under the current system, health care providers are paid for each medical service they provide. That means doctors are incentivized to order more tests and procedures in order to get paid more. Under the all-payer model, health care providers would be paid based on health outcomes and work under a global budget that caps total payments. The system, according to proponents, would be more cost-effective and incentivize providers to perform only medically necessary procedures to achieve a positive outcome.

An all-payer model would be based on the Accountable Care Organization model, which are groups of doctors, hospitals and other health care providers that come together to provide coordinated care. The concept is intended to provide better information about a patient’s medical history among providers. The all-payer model would include private insurance as well as government programs like Medicaid and Medicare as payers. The state is in the process of negotiating terms and waivers that would allow it to include those government programs.

Detractors have claimed it would alter the health care benefits seniors and those with disabilities receive from Medicare. But Gobeille told the committees Wednesday that the claim is false. The federal Centers for Medicare and Medicaid Services, in fact, is encouraging a transition away from the fee-for-service model, he said.

“CMS, the federal government, is creating programs and has a stated intent to move way from fee-for-service over time,” Gobeille said. “It is doing that by creating programs.”

One of those programs, known as Next Generation, already exists and would be the foundation for the state’s all-payer model, according to Gobeille. It would maintain existing benefits for Medicare recipients, he said.

“They are all the same program for the beneficiary. There can be no change to the benefits,” he said. “The whole platform that the conversation has been based on is Next Generation models from CMS.”

Gobeille told the Vermont Press Bureau after the hearing with lawmakers that the state is “real close to having something to present.”

“I’ve been clear with the administration that it shouldn’t take any longer than it should, but it shouldn’t take shorter than it should. It’s a complicated process,” he said. “We may be able to present what we’re proposing soon, like, the governor may mention some things in the budget address. I don’t know what he’s going to say.”

Shumlin spokesman Scott Coriell said Wednesday the governor does include to discuss the all-payer model in his budget address slated for Jan. 21.

Gobeille said the most difficult negotiations with the federal government have centered on how to determine quality and performance measures in determining payments to providers.

“How do we measure the system to make sure that Medicare is getting what they want but make sure that our providers can actually perform what it is they’re asking. It’s really an issue of don’t sign up for something you don’t agree with, and that takes time,” Gobeille said, explaining the importance of making sure all parties are satisfied with the agreement.

The state is also learning which hospitals and providers are interested in the all-payer model.

“Some hospitals may say, ‘Hey, I want to stay in the world that is today,’ and others may want to try the new model. I don’t think we should get all wrapped up in the friction of that. I think we should focus on how we move forward with a coalition of the willing,” Gobeille said.

Shumlin, in an interview with the Rutland Herald and the Barre-Montpelier Times Argus on Monday, called the all-payer model “the biggest transformation in the way we pay for health care in the history of any state if we can pull it off.”

He said he expects to know next month if the state can come to an agreement with the federal government.

“We’re very advanced in these conversations and I would say by the end of next month we should have a good idea of whether we succeed or fail — whether we can come to terms with them,” the governor said. “[U.S. Department of Health and Human Services] Secretary [Sylvia] Burwell and President [Barack] Obama really want to see us succeed and they agree that change is likely to come from a small, rural state where the laboratory for change is smaller.”

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