As the health care system responds to COVID-19, there is a critical focus on caring for those severely affected by the virus. In the meantime, however, non-emergency patient visits have fallen significantly and revenues have collapsed for ambulatory care providers receiving fee-for-service payments, threatening their financial viability. Prospective, value-based payment arrangements provide more flexibility and predictability to help providers, states, and health plans respond to the pandemic. One example of this strategy is the All-Payer Accountable Care Organization (ACO) model in Vermont, which receives prospective payments and is using the flexibility inherent in these payments to respond to changing patient needs.

The Center for Health Care Strategies (CHCS) recently spoke with Vicki Loner, Chief Executive Officer of OneCare Vermont, about the organization’s response to COVID-19. OneCare is a provider-led, all-payer ACO in Vermont that works with Medicare, Medicaid, commercial, and self-funded insurance programs to improve the health of Vermonters. In our conversation, Ms. Loner discussed OneCare’s experience addressing COVID-19, including rapid ramp-up of telehealth capacity, and how payment reforms in the state supported the ACO’s rapid response to COVID-19.

Q: How has OneCare Vermont and its member organizations dealt with COVID-19? How has the coronavirus shifted the health care landscape in Vermont?

The fee-for-service revenue tied to telehealth codes is still insufficient in some cases, and it has required a lot of energy working to make sure that we could pivot to the new delivery system we needed in the moment.

A: There have been a lot of amazing ways that our provider networks and communities have ensured that access is available to those who need it and pivoted in terms of how we’re delivering care. A lot of our hospitals shut down elective procedures, and they along with our other providers made a huge change — it seemed overnight — toward telephone consultation and telemedicine in lieu of traditional face-to-face visits. The biggest part of the work in the first few weeks was to advocate with payers to ensure that the telehealth option was available to support Vermonters and make sure they had access. The fee-for-service (FFS) revenue tied to telehealth codes is still insufficient in some cases, and it has required a lot of energy working to make sure that we could pivot to the new delivery system we needed in the moment.

Q: OneCare Vermont is currently participating in the Vermont All-Payer ACO Model. How has this changed how providers are paid and how has this helped or hurt their involvement in the COVID-19 response?

A: Participation in the Vermont All-Payer ACO Model has allowed providers in prospective payment arrangements to be more agile in their response, particularly through the additional telehealth options, and has supported cooperation between health care providers and public health. For example, through our care coordination programs and outreach, we have been working to provide linkages to COVID-19 education and public health services (e.g. food and housing). Traditionally it has been difficult for the health care delivery system to put aside money for prevention efforts because it’s so dependent on fee-for-service payment. We have even heard discussions among our primary care practitioners that they would like to move toward a capitated type model because it offers more flexibility and predictability. The Milbank Memorial Fund just put out a paper about primary care moving more in line with capitated payments, so you see some momentum for it.

Q: You recently mentioned that Vermont would be better off if it had fully transitioned to a prospective payment model and that the current pandemic shows that FFS is not supporting providers now. Can you elaborate on what you meant?

If we were under a truly capitated prospective payment system, it would just be the fabric of the delivery system to be able to react and be more agile to meet changing needs.

A: If we were fully transitioned, we wouldn’t have had to spend time working with payers to make sure that the telehealth billing codes were sufficient to fund our providers’ work. If we were under a truly capitated prospective payment system, it would just be the fabric of the delivery system to be able to react and be more agile to meet changing needs. And more broadly, a fully prospective payment system would also create more predictability. It would allow providers to deliver the services people need without worrying about having to perform so many face-to-face visits in order to keep their doors open. There shouldn’t be a time where our health care delivery system is worrying about its solvency because they have to respond to a public health crisis.

Q: What do you think the post-COVID delivery system will look like? What is OneCare doing to prepare for this?

Most practitioners that we have spoken to like having these additional options for care delivery, and wouldn’t want to go back to exclusively seeing people through in-person visits, prior to the outbreak.

A: From where we are sitting, the biggest change will be an increase in telehealth. We’re currently not even 60 days into the pandemic, and in the conversations that we are having with our regulator, the Green Mountain Care Board, and our network of providers, we are recognizing a great desire to continue telehealth moving forward. Providers have found that there’s greater satisfaction among some patients who are receiving these visits, and primary care providers, in particular, find it valuable for reaching patients who they may not have been able to get into their offices. I would say that most practitioners that we have spoken to like having these additional options for care delivery and wouldn’t want to go back to exclusively seeing people through in-person visits, prior to the outbreak. They see the value in that.

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