Are Vermont’s Global Budgets, Community Health Teams Improving Outcomes?

The State of Vermont is engaged in an ambitious long-term plan to combine a global all-payer reimbursement model with community health teams responsible for coordinating care between the medical, social services and public health sectors. A research team from the University of Vermont has set out to study the impact of this combination on system alignment, health outcomes and equity, and healthcare financing.

“On paper, the combination of these community health teams with global payment mechanisms is sort of an ideal alignment mechanism,” said Adam Atherly, Ph.D., director of the Health Services Research Center and professor of medicine at the University of Vermont Larner College of Medicine, “but our question is: does it actually work as it is intended to work?”

Atherly was speaking during a June 10 webinar put on by Systems for Action, a national program office of the Robert Wood Johnson Foundation and a collaborative effort of the Colorado School of Public Health.

Researchers at the University of Vermont are collaborating with the Department of Vermont Health Access, OneCare Vermont, and the Green Mountain Care Board to conduct the study. Results will provide state and federal decision-makers with strategies for using global budgeting and multi-sector teams to achieve systems alignment.

Atherly called the community health teams the right structure to create linkages between these different environments, and he said the global payment model should make health systems want to work with community health teams and keep people healthy. “We want to study if this is working the way it is intended to,” he explained. “Does it create the system alignment? Does it change priority-setting to emphasize health vs. healthcare spending? Does it change financial outcomes? And ultimately does it improve health equity across the state?”

To set the table for the discussion, Atherly gave some background about Vermont’s journey. He noted that it was the top-ranked state overall in a Commonwealth Fund State Health System Performance Scorecard, and its uninsured rate is second-lowest in the country at around 4 percent. He said that made it a good place to try this type of statewide reform. The state’s “Blueprint for Health” journey began almost a decade ago.

In 2008, the state launched a patient-centered medical home transformation effort and community health teams were piloted in three hospital service areas supported through capitated payments. In 2011, there was a statewide expansion of community health teams to all hospital service areas. Patient-centered medical homes and community health teams continue as foundational elements of All-Payer ACO Model, he added.

The Green Mountain Care Board (GMCB) was originally created to oversee a publicly financed single-payer health care system, but that plan was dropped when the tax increases required to fund it were deemed too high.  But the GMCB continues to oversee hospital budgets, commercial payer rates, ACO budgets, and the financial impact of the All-Payer ACO Model agreement with CMS.

The state’s reform goals remain to control healthcare spending; move from a fee-for-service system to one that pays for volume; and to create a value-based system that allows for investments to keep the population healthier.

The all-payer model enables Medicaid, Medicare and commercial payers to pay an ACO (called OneCare Vermont) differently than through fee-for-service reimbursement. A CMS waiver allows Medicare’s participation. Hospitals are starting to receive a fixed, pre-determined all-payer fee for all necessary services, and currently all Vermont hospitals are voluntarily participating.

“This model is unique to Vermont,” Atherly said. “People may have heard about what Maryland did with an all-payer model with hospitals, but this is a big step beyond that. The fixed fee is not just for hospitals but for all necessary services. Hospitals now have a strong incentive to keep their covered population healthy and out of the hospital.”

“Once you get incentives aligned, the rest should flow out of it,” he said. Things like social determinants of health that were outside the health system’s purview are suddenly of interest because focusing on them could keep patients from needing expensive care.

He gave an example of how this could be having an impact. Burlington hospitals that treat homeless  people often would have discharged them back to the streets, where their outcomes were not good. Now they are starting to pay for hotels for the homeless discharged from the hospital. “They are thinking about keeping from needing more inpatient care,” he said.

Linchpins to Success

Atherly described the statewide network of regional community health teams (CHTs) as multidisciplinary teams regionally headquartered in each service area’s central hospital or federally-qualified health center. They support a series of activities connecting patients to community-based services. They are funded by Medicaid, Medicare, and commercial payers through the Vermont Blueprint for Health initiative since 2011.

They are relied upon to help achieve the goals of the ACO and also the public health goals of Vermont.

Little data has been gathered, however, about their effectiveness, other than positive anecdotal reports from patients and provider organizations they work with. Part of the problem, Atherly said, is the funding mechanism. Funds flow from payers to the Vermont Blueprint, then to hospitals, which then send funds to the community health teams. “It is an odd financing mechanism that creates questions about how they operate and who they answer to,” he said. “Despite the fact that they are the linchpin to success of this model, how they operate is relatively unknown. That is what we want to find out.”

Mary Kate Mohlman, Ph.D., a health services researcher in the Blueprint for Health program, spoke about the dearth of data on CHTs.  Because they are funded by a per-member, per-month capitated payment, no claims data are ever generated to capture their encounters. “One thing fee-for-service is great at is generating data through claims,” she said. One thing to think about is as we change how we pay, there may be unintended consequences in terms of data available. Early attempts to gather data on their work were frustrating, she said, because data was entered inconsistently, including the  number of services offered or the duration. “It was difficult to capture what the intervention was,” she said. “When we were able to capture who they interacted with and link it to claims data, it was difficult to draw any conclusions on health utilization or expenditures or outcomes.”

Atherly described three research aims:

• What is the impact of the alignment on formal system linkages between the healthcare sector and the social services and public health sectors in Vermont?

• How do CHTs set priorities for what social, public health and medical services to offer? What are the tradeoffs made between health, health equity and healthcare spending?

• What is the impact of Vermont’s CHTs and global payment alignment on changes in health risk, health outcome, health equity and access to care? Atherly noted that the researchers will have access to EHR and other data that will allow it to compare Vermont’s experience to that of upstate New York, and to all-payer claims databases from Vermont and New Hampshire to help compare outcomes between those states.

Both Atherly and Mohlman stressed that the description of the statewide transformation in this webinar is high level, and that there are lots of nuances and steps still in process. “It is really messy to change a healthcare system and the way everybody is paying,” Atherly said. It is not something that is suddenly happening. It is going to take years to implement.”