The Accountable Care Organization: Hype versus reality

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"What if there was a prolonged illness in the family? Should I be pacified by the fact that I only have to come up with $15,000 out of my own pocket to pay for it, before insurance contributes (on top of the $9,000 I'm paying in premiums)?"

This quote is included in a recently released report from the Vermont Health Care Advocate's Office aptly entitled, "Health Care Doesn't Work if You Can't Afford It." The report echoes similar national findings that with rising out of pockets, people are avoiding trips to the doctor, especially to their primary care providers.

Shouldn't our legislators and policymakers take notice when Vermonters cannot afford their health care? They should, yet the focus this session seems to be on propping up OneCare Vermont, a large, for-profit entity (an Accountable Care Organization) whose ostensible purpose is to coordinate care and control costs. Chances are that the vast majority of Vermonters struggling with out-of-pocket costs, and potentially delaying needed care, have never heard of OneCare.

Most worrisome, the more we learn about OneCare, the more it looks like it is just creating yet another layer of administrative expenses, not the greater access to health care that Vermonters need.

This year Governor Scott proposes sending $5.5 million dollars of Delivery System Reform funds to OneCare. Yet, OneCare is not even transparent. State Auditor Doug Hoffer has tried to audit it, but because it is a private for-profit entity he cannot examine all its records. So where is the evidence that OneCare's array of very well-paid administrators (and lobbyists) are doing anything to address the problem of access? Has it made a dent in the problems of Vermonters who defer care due to cost?

I've made a list of the most commonly advanced claims for investing our resources into OneCare followed by some serious questions. Our legislators should ask these questions and more before they shell out taxpayers' hard-earned money to OneCare.

Claim: OneCare and the All Payer Model (APM) will provide more preventative care for patients.

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Reality check: Can people receive better care when they don't see their provider in the first place due to out of pockets costs? OneCare and the APM do not address the issue of underinsurance or no insurance that deter people from seeking care. Let's remember that primary care is more than a once-a-year physical; it's even more than continuous follow up on chronic conditions. It is the gateway we need whenever we have a health care problem. If the cost keeps us from walking through the clinic door, we don't get care.

Claim: OneCare is a Vermont success story. We outperform all other states engaged in similar experiments with Accountable Care Organizations.

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Reality check: OneCare keeps asking for more money to make up for its shortfall and just received almost $5 million for last year (2019) in the budget adjustment (H.760). In what universe do you save the system money if the payers have to infuse more money just to keep it afloat?

Claim: Optimism is justifiable. As the governor recently said in a WCAX story on OneCare and the All Payer Model: "I'm cautiously optimistic We just need to understand that we all know what we're doing."

Reality check: Is this a plea to believe in something or a claim based on evidence? Even the governor admits evidence is lacking because OneCare is not transparent. We have yet to be able to track how even one Medicaid dollar is spent once it enters OneCare. We are asked to just trust that OneCare is spending our tax dollars wisely.

Claim: Fee for service is to blame for rising costs and by devising new payment systems OneCare and the All Payer Model will control costs.

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Reality check: This assumption fails to recognize that many other industrialized countries with much lower per capita costs and better outcomes (Canada, France, Germany and more) use fee for service to pay their providers. Why would it be different here? What makes health care systems in other wealthy countries more cost effective is that they are publicly financed systems where everyone has uniform benefits. This simplifies administration, thus lowering administrative costs and also allowing for some price control. These systems also have a greater focus on prevention and primary care (see recent article in The Lancet on national savings with Medicare for All). In universal systems, because everyone is covered with limited out of pocket costs, people do not delay care until their conditions are more serious (and expensive). Fee for service is not the villain or the hero in these systems, it's just one possible way of reimbursing providers.

If the claims cited above on behalf of the ACO experiment are more hype than reality, what might be a better focus for our health care dollars?

Let's get back to the ACT 48 roadmap, health care for all Vermonters as a publicly financed public good. We could start by creating a universal primary care system (H.129). If primary care were a universal public good with no out-of-pockets for all Vermonters, we really would see the uptick in preventative and primary care that everyone says is so important to improving public health.

Greater access to primary care would help control system costs too. Vermonters would no longer defer care until their conditions landed them into the expensive emergency room. Universal Primary Care (as a first step in Act 48) would actually accomplish what the proponents of the ACO claim it will do - making sure Vermonters can access the care they need.

Wishful thinking and lofty goals are not the same as actual results. There's no evidence nationally that ACOs achieve improvements in health care quality and costs. On the other hand there's solid evidence all over the world of the success of publicly financed universal health care. Let's follow the evidence and start now by implementing Universal Primary Care.

Ellen Oxfeld is a board member of the health care for all advocacy group, Vermont Health Care for All. She lives in Middlebury.


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