Vermont is a national leader in healthcare delivery reforms and promoting overall population health. The Green Mountain Care Board, created in 2011, is charged with ensuring that changes in the state’s healthcare system improve quality while stabilizing costs. The board serves this function through a variety of activities related to regulation, innovation and evaluation. In 2013, Vermont was awarded a federal State Innovation Model Grant, which it used to fund the Vermont Health Care Innovation Project (VHCIP). The VHCIP has three main goals: improve care, improve population health and reduce healthcare costs.
Vermont has well-established integrated delivery systems, including 124 medical homes as part of the state's Blueprint for Health program. In 2014, the state launched three accountable care organizations (ACOs), which include a majority of the state's healthcare providers, including mental health providers and those specializing in long-term services and support. The state received federal approval to test an innovative all-payer ACO reimbursement system beginning in 2017.
Vermont ranked 3 out of 47 states plus DC, with a score of 57.1 out of 80 possible points in the Hub's 2021 Healthcare Affordability State Policy Scorecard.
Despite having health insurance, Vermont carpenter Rick McDowell incurred more than $7,000 in medical debt following a stroke, according to Vermont Public Radio. Even though about 96% of Vermont residents have health insurance, they often don’t have the means to pay out-of-pocket costs. Vermont hospitals have consistently reported between $62 million and $85 million annually in unforgiven medical debt, which can hurt Vermonters finances and credit scores. Through story gathering, Vermont officials have found that fear of worsening medical debt pushes people to forego care, causing health conditions to worsen and ultimately increase the overall cost of care in Vermont.
Vermont has spent $29.8 million supporting OneCare, the state’s only accountable care organization, and has yet to realize any healthcare savings as a result, reports the Burlington Free Press. These findings, from a final report from the state auditor, will influence the state’s decision by the end of 2021 whether to continue the program for another five years. OneCare Vermont is supposed to cut the cost of healthcare by keeping people healthier through more preventative care. Also, rather than receiving a fee for service, healthcare providers receive lump sum payments that should encourage them to be more efficient in providing care. However, there has been no complete analysis on the program from the Centers for Medicare and Medicaid Services, which oversees the program. The Agency of Human Services, however, believes that these early-years' operating costs should not be a leading factor in determining whether the state should enter into a subsequent agreement.
A blog in Health Affairs highlights five challenges facing Vermont’s all-payer model (APM): incentivizing participation among providers; properly attributing patients to providers; paying for value; determining how financial risk should be distributed among providers; and overcoming the disadvantages of fee-for-service benchmarks. The all-payer model allows accountable care organizations in the state to receive payments from Medicare, Medicaid and commercial insurers and then align payments and quality measures for providers. While the APM offers theoretical advantages such as economies of scale, aligned incentives and potentially reduced administrative costs, without tax increases or public provision of services, operationalizing the model has been difficult.
The Centers for Medicare and Medicaid Services issued a warning after Vermont failed to meet performance targets for the state’s all-payer model, reports the VTDigger. The experiment—which combines money from Medicare, Medicaid and commercial insurance to fund healthcare services on a per-patient basis, rather than a fee for services rendered—aims to incentivize preventive care and to lower the growth of healthcare spending, neither of which has been realized in the three years since the program began. OneCare Vermont, a for-profit hospital and provider group that manages the all-payer system, has also failed to meet enrollment targets. If the state is unable to provide a satisfactory response within 90 days, the federal government will draw up a corrective action plan. Vermont’s Agency of Human Services has asked state healthcare leaders to develop a “complete plan for rebooting the all-payer model” within 45 days.
Systems for Action hosted a webinar to present emerging evidence on the use of global budgets and multi-sector teams to align health and social service systems, increase access to needed services, control healthcare costs and create more equitable health outcomes in Vermont. This effort is part of Vermont’s Blueprint for Health initiative, which is among the most ambitious statewide health financing reforms underway in the U.S.
Ambulatory care providers receiving fee-for-service payments are struggling to stay afloat after a sharp decline in non-emergency patient visits in response to COVID-19. Prospective, value-based payment arrangements, like Vermont’s All-Payer Accountable Care Organization (ACO) model, provide more flexibility and predictability to help providers, states, and health plans respond to changing patient needs. This interview from Center for Health Care Strategies describes how the state’s largest ACO, OneCare Vermont, is addressing COVID-19, including rapid ramp-up of telehealth capacity, and how payment reforms in the state supported the ACO’s rapid response.
Vermont is requiring commercial health insurers to waive cost-sharing requirements—such as co-payments, coinsurances or deductibles —for the diagnosis and treatment of COVID-19, according to an official press release. The emergency regulation applies to fully funded health insurance plans, such as plans sold on the exchange or to large-group employers. Consistent with existing Department of Financial Regulation rules, insurers will be required to cover out-of-network services for members if in-network providers are unavailable.
UVM Health Network’s system-wide consolidation has resulted in longer wait times for patients seeking diagnosis and treatment and could increase healthcare costs for Vermonters down the line, according to the VT Digger. This is becuse hospitals that dominate local healthcare markets have greater leverage in negotiations with insurance companies, which can ultimately lead to higher prices per procedure. These higher prices trickle down to patients in the form of higher deductibles, copays and premiums. Barriers to access have caused some Vermont residents to seek care across state lines.
Vermont is projected to exceed its target for healthcare spending growth in 2020, indicating that the state’s reform efforts may not be working as planned, reports the VTDigger. The state has projected 4.3% growth in Vermont’s total healthcare costs next year, exceeding the 3.5% benchmark. Green Mountain Care Board officials report that higher than expected costs in the Medicare program are partly to blame. Nevertheless, further growth could trigger “corrective action” from the federal government.
The governor of Vermont submitted a concept paper to the federal government outlining the state’s approach to implementing the first-in-the-nation drug importation law, according to NASHP. Unlike an earlier submission from Florida that proposes a wholesale importation plan to benefit public programs, Vermont’s plan includes all commercial health plans and is designed to benefit all state residents, not just those on public programs. Vermont proposes to assure consumer savings through a number of vehicles, including lowering premiums and deductibles, and reducing or eliminating copays on imported drugs.
Vermont’s hospitals are expected to collect $2.72 billion in revenue in 2020, exceeding a revenue growth target that officials set earlier this year, according to the VTDigger. The budgets, approved by the Green Mountain Care Board, authorize hospital revenues — and therefore the amount that Vermont spends on hospital care — to grow by about $100 million in fiscal year 2020. While hospitals argue that the increased revenue will improve access to care, consumer advocates fear that growing hospital budgets will increase consumers’ insurance premiums. Evaluation is needed to understand the impact of the decision on costs, quality and access.
Vermont’s 14 hospitals are requesting to increase patient revenue growth beyond the 3.5% limit set by state regulators, reports the VTDigger. The Green Mountain Care Board, which regulates healthcare spending in Vermont, will review the proposed budgets, which represent a 4.5% growth in revenue compared to budgets approved by the board last year. The hospitals argue that budget increases are necessary to improve solvency. The increased revenue would stem, in part, from rate increases for consumers and insurers.
Vermont is eyeing birth control, insulin and pricey medications for HIV and multiple sclerosis as possible candidates for the state's landmark program to import cheaper drugs from Canada, reports Politico. State officials determined that the importation program could save insurers up to $5 million annually, based on this list of drugs, which the state has yet to finalize. A potential barrier is that Vermont must prove that the importation program wouldn’t pose additional risks to patient safety and that consumers will pay less for drugs under the new model in order to receive approval from HHS. HHS set up a working group last summer to study importation, but many of the details have been kept secret.
Rutland Regional Medical Center was the only Vermont hospital to receive an ‘A’ rating from The Leapfrog Group’s Spring 2019 Hospital Safety Grade for its efforts to protect patients from harm and provide safer healthcare, according to Vermont Business Magazine. The Safety Grade assigns an ‘A’, ‘B’, ‘C’, ‘D’ or ‘F’ to hospitals across the country based on their performance in preventing medical errors, injuries, accidents, infections and other harms to patients in their care. Rutland Regional was one of only 832 hospitals to receive this rating, out of over 2600 nationwide.
Total spending on Vermonters’ healthcare surpassed the $6 billion mark in 2017, but the rate at which that number is growing slowed, reports the VTDigger. Expenditures for Vermont residents grew 1.7% from 2016-2017, a significant improvement from recent years, as spending grew an average of 3.2% annually from 2012-2017. Vermont’s 2017 spending growth was also far below the national growth of 3.8%. Nevertheless, out-of-pocket costs for Vermonters’ healthcare ($776 million in 2017) continues to rise, increasing 1.8% from 2016. Out-of-pocket expenses also were a concern raised in a recent state health insurance survey, which found a low number of uninsured but a rising number of “underinsured” residents. About 36% of Vermonters under age 65 don’t have insurance policies that can adequately cover their needs based on their income.
A survey of Vermont households revealed that cost is the primary barrier to health insurance coverage for Vermonters without insurance. More than half of uninsured respondents rated costs as the only reason they do not have insurance, an additional quarter say cost is one of the main reasons they do not have insurance and 11% said it is one reason among many for being uninsured. Vermont residents without health insurance are more likely than those with insurance coverage to delay healthcare due to cost, regardless of the type of healthcare.
Medicare rules dictate that patients must stay at a hospital for at least three consecutive days before the program will cover treatment at a skilled nursing facility. However, OneCare Vermont, a statewide network of insurers and medical facilities, granted Brattleboro Memorial Hospital and three local facilities a waiver that reduces that requirement to one day, reports the Sentinel Source. The waiver is expected to decrease unnecessary hospital stays, cut costs and potentially improve quality by protecting patients from hospital-borne infections.
Vermont has dedicated $5 million in its fiscal 2019 budget to expand efforts to find and retain clinicians to help address the state's mental health crisis and opioid addiction epidemic, according to the Battleboro Reformer. The legislation outlined some potential solutions for combatting provider shortages, including new scholarships, stronger loan-repayment programs and "strategic bonuses" for professionals in Vermont's existing workforce. Funding for the initiative will be spread over four years "to ensure successful and sustainable implementation" of the new workforce programs.
Vermont is one of several states that have recently enacted drug cost transparency laws, designed to make drug pricing information accessible so states can eventually take action on price gouging, reports NASHP. The new Vermont law requires state officials to identify 15 drugs whose wholesale acquisition costs rose by 50 percent or more over the last five years, and 15 drugs whose costs rose 15 percent or more over a 12-month period. Drug makers must justify the price increases to the state’s attorney general and the information will be made public, with proprietary information withheld.
Vermont is the first state in the nation to approve importation of less-costly prescription drugs from Canada, according to NASHP. The new law creates a wholesale importation program to purchase high cost drugs through authorized wholesalers, who will purchase the drugs in Canada and make them available to consumers through an existing supply chain that includes local pharmacies. The law requires the Vermont's Agency for Human Services to work with stakeholders and the federal government to design and submit an importation proposal to the state legislature by Jan. 1, 2019. The agency must also submit its proposal to the federal government for final approval by July 1, 2019. The program must be operational within six months of approval of the financing strategy, certification and federal government sign-off.
Social workers, nurses and others coordinating care for high-need patients often work independently and with limited funding. Vermont’s three largest payers have committed to providing these individuals with additional financial support, and OneCare -- the state's largest ACO -- provides training and technology to help care coordinators collaborate. This report by the Commonwealth Fund highlights the Vermont ACO’s community-driven approach to care coordination, which may offer lessons about wringing greater value out of a fragmented health care system.
Vermont is setting an ambitious goal of taking its alternative payment model – which reimburses doctors and hospitals lump sums and financially rewards them for keeping people healthy – statewide, reports The Washington Post. By 2022, the state plans to apply the reimbursement strategy to 70 percent of insured residents, in an effort to limit the growth in overall annual healthcare spending to 3.5 percent each year. The current initiative is Vermont’s second attempt to revolutionize healthcare; it was the first state in the country to embrace a government-financed universal healthcare system, but abandoned the plan in late 2014 because of concerns over costs.
Last year, Vermont passed Act 165, the nation’s first drug price transparency law, which has spawned similar legislation across the country, according to NASHP. Act 165 requires the Green Mountain Care Board to identify “drugs on which the state spends significant health care dollars and for which the wholesale acquisition price has increased by 50 percent or more over the past five years or by 15 percent or more over the past 12 months.” The board reports to the state’s Attorney General (AG), who may require manufacturers to submit information and documentation justifying the price. In assessing the impact of the legislation, observers have noted that the law addresses only Medicaid expenditures and does not affect other large purchasers. Also, manufacturer data the law required was not highly detailed, which has made it difficult to gauge if the prices and increases are justified or not.
Vermont Governor Phil Scott signed legislation aimed at increasing the use of telemedicine technology in the state, according to VT Digger. The law goes into effect Oct. 1, 2017, and requires Medicaid and private insurers to reimburse doctors for services provided to patients through video conferencing technology. Previously, insurers only had to cover such services if they were provided through a medical facility such as a hospital.
State lawmakers have passed legislation aimed at expanding the use of telemedicine technology in the state, according to the VT Digger. The bill requires insurers to cover telemedicine services—defined as healthcare services delivered through live, interactive audio and video—at the same levels as in-person services.
A new report from the Commonwealth Fund ranked Vermont best in the nation for healthcare access and affordability, according to Vermont Business Magazine. The state has the smallest disparity in access among income levels and is the only state in which less than ten percent of low-income individuals have delayed care due to cost in the past year.
Vermont’s Green Mountain Care Board approved an all-payer waiver, according to the Burlington Free Press. Under an all-payer model, providers are paid set amounts for care, rather than being paid per test, service or procedure.Proponents believe the initiative will more effectively manage chronic diseases and save VT $10 billion over the next 10 years.
Vermont has received preliminary approval from the federal government for its plan to establish an all-payer reimbursement system for healthcare providers, according to Modern Healthcare. The system is modeled on Accountable Care Organizations and would replace traditional fee-for-service reimbursement with payments based on global rates that apply to Medicare, Medicaid, and private insurers.
The Vermont governor signed the prescription drug transparency bill that will make Vermont the first state to require pharmaceutical companies to justify why their drug prices go up, according to VTDigger. Vermont’s new law will require pharmaceutical manufacturers to justify why the “total wholesale cost” of specific prescription drugs go up in a given year. The data on the cost of the drug would come from the state’s Medicaid program.
The Vermont House of Representatives approved $310,000 in state and federal funding to study the potential expansion of the state’s Dr. Dynasaur Medicaid program to cover all individuals up to age 26. The funding was applauded by the Dr. Dynasaur 2.0 Coalition, comprised of 15 Vermont consumer advocacy organizations, labor unions, healthcare providers and small business groups. The study is to be presented to the legislature no later than January 15, 2017 and will examine the impacts the expansion would have on premiums, tax payers, employers, the health care system, and the economy.
The VT Digger: The Vermont House of Representatives passed a bill that expands oversight of the Shumlin administration’s healthcare reform plans. The bill tells state officials that they can only enter into an agreement with the federal government to set up a so-called all-payer model if the current Medicare system is protected. The legislation also includes dozens of consumer protection provisions.
Vermont has laid out the critical components of the state’s conception of an all-payer model, according to a report from the National Academy for State Health Policy. Vermont’s approach distinguishes itself by setting spending targets for almost all services – not just hospital care.
The Green Mountain Care Board has approved all 14 of Vermont’s private hospital budgets for 2016, with only minor changes. The approved 3.5 percent aggregate increase in hospital patient revenue is slightly below the aggregate request of 3.6 percent—which was the target set by the board. The increase is well below the average annual increase for the past 15 years of 6.8 percent, however, that the growth rate is a significant increase over the 1.5 percent increase approved two years ago.
The first report measured Medicare savings produced by Vermont’s Blueprint for Health and similar primary care reform efforts in seven other states. Of the eight states, Vermont’s savings were the most dramatic and the Blueprint was one of only two reform efforts that actually achieved slower growth in total Medicare spending. The savings in Vermont were driven mainly by better managed care that reduced the need for acute care such as hospitalizations, according to the study.
A second report focused on the Support and Services at Home (SASH) program, which is part of the Blueprint for Health. The report used two control groups, one in upstate New York and one in Vermont, and concluded that by the second year the SASH program resulted in an average $2,197 per member annual savings to Medicare compared to similar, non-SASH-enrolled New Yorkers, and an average $1,756 per member annual savings to Medicare compared to similar non-SASH-enrolled Vermonters.
Vermont was supposed to be the first state for a single-payer healthcare system in the United States. After the bill was defeated in 2014, Governor Peter Shulmin declared that it was not the right time for Vermont to become a single payer state, according to an article in Politico.
The Commonwealth Fund named Vermont as one of the top ranking states for improving healthcare access, quality, outcomes and lowering costs in the five years preceding implementation of the Affordable Care Act’s major coverage provisions, according to Vermont Biz.