Health Reform WK-EDGE Vermont’s community-driven approach to care coordination offers lessons
Tuesday, May 22, 2018

Vermont’s community-driven approach to care coordination offers lessons

By Sheila Lynch-Afryl, J.D., M.A.

A community-driven approach to care coordination, which was piloted in 2017 among 29,000 of Vermont’s Medicaid beneficiaries, resulted in beneficiaries making greater use of primary care and behavioral health services and pharmacy benefits, as compared to other beneficiaries. However, noted a report by the Commonwealth Fund, the accountable care organization (ACO) responsible for the pilot will not likely achieve savings in the first year of the contract.

Pilot. During the pilot, OneCare Vermont—a statewide ACO, a creature of Sec. 3022 of the Patient Protection and Affordable Care Act (P.L. 111-148)—took responsibility for providing most medical and behavioral health services for the beneficiaries, with a budget of $90 million. Similar to Medicare’s Next Generation ACO Model, the state’s Medicaid program offered the ACO capitated payments: if actual expenditures fell below the budgeted amount, OneCare would keep the first 3 percent of savings, but if expenditures exceeded it, the ACO would make up the first 3 percent.

Instead of hiring its own staff, OneCare relied on care coordinators, employees at partner organizations, who helped patients manage their medical conditions and addressed their social, financial, and psychological challenges. Care coordinators, frequently nurses or social workers, offered support to patients who identified as being at high or rising risk—16 percent of patients in 2017.

Results. Over the first nine months of the contract, the percentage of beneficiaries with early- to late-stage disease who lacked a primary-care visit fell to from 4 to 2 percent. Those who were at high or rising risk had substantially fewer hospitalizations and emergency department visits during the first nine months of 2017. In addition, Medicaid beneficiaries deemed to be at highest risk are, the report found, a relatively stable group, which supports the ACO’s approach of targeting services to the subset of patients who might benefit the most. However, the total cost of care for 2017 was forecasted to be 1.5 percent above budget, which means the ACO would owe money to the state.

The future. OneCare faces "significant hurdles," said the report. Much of the ACO’s early focus was on community-led care coordination, but more extensive institutional reforms may be harder to accomplish.

In 2018 the ACO is accountable for 42,000 Medicaid beneficiaries and 72,000 Medicare and Blue Cross and Blue Shield members, by 2022, Vermont expects to have nearly 70 percent of its 624,000 residents attributed to an ACO.

Companies: OneCare Vermont

IndustryNews: StateNews AccountableCareNews AccessNews DemonstrationProjectNews MedicaidNews NewsFeed

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