Payment Reform

OneCare contracts with health insurers to reward providers for efficient and high quality care delivery rather than for the number of services they perform or order.

By working with OneCare, insurance companies like Medicare, Medicaid, and commercial payers make a decision to pay for results instead of service transactions. We call this value based care. This model ties quality measures to payments to promote care excellence.

Value-based care encourages investments in primary care, health prevention, early identification of disease, and treatment. A volume-based or service transaction model, commonly referred to as fee-for-service, rewards providers for seeing as many people as possible and ordering as many tests as possible. By moving from volume to value with a focus on quality, we have the opportunity to lower costs while delivering better health care.

The vision for value-based care is better health outcomes and a flattened cost curve for health care spending. When providers are reimbursed for value instead of volume, over time, they can change the way they deliver health care and invest in activities that are designed to lead to better health outcomes. Savings earned by providers in the network can be invested in primary prevention efforts and additional care coordination services to support people with chronic illness.

Larger version - Illustration - OneCare Core Business Area - Payment Reform. An accountant is looking at her computer and working with a doctor who is standing in front of a large clipboard with quality check marks on it. On the ground behind them are symbols representing money and payment.

How Payment Reform Works

To shift provider focus from volume-based reimbursement (i.e. fee-for-service), OneCare pays monthly fixed amounts to providers who choose to participate. These fixed amounts are based on historical fee-for-service spending to smooth the transition to value-based payments.

Hospitals

Hospital payment reform is important because hospital care is often the most expensive care. OneCare works with Vermont hospitals to provide predictable, fixed monthly payments for the patients they serve. The conversion to a monthly payment model aims to stabilize hospital revenues and incentivize investment in preventative care and care coordination for those with chronic illnesses. If this transition is successful, it will result in a healthier population and fewer costly hospital stays. Eventually, more Vermonters will receive preventative care and benefit from health promotion and wellness, preventing chronic disease and resulting in fewer expensive hospital stays.

Had we not been in CPR and relied solely on fee-for-service, we would have seen greater losses during the state of emergency [the COVID-19 pandemic] given the reduction in the number of in-person office visits. The fixed payments helped provide a safety net during these extraordinarily difficult times.

Jon Asselin

COO and CFO, Primary Care Health Partners

Independent Primary Care

OneCare works with independent primary care providers to support the transition to value-based care. Independent primary care practices receive financial resources that aim to shift focus to the care that’s right for their patients rather than billable services. OneCare offers a fixed payment to independent primary care practices, much like the hospital fixed payments, that are not part of a hospital or health system through its Comprehensive Payment Reform (CPR) program.

Contracting

Because of its designation as an Accountable Care Organization, OneCare can work directly with insurance companies to pay for health care in new ways. OneCare contracts with insurance companies to pay for value instead of volume. By representing providers in OneCare and with the goal of health care system change in mind, OneCare and insurance companies evolve payment models over time to support better health for Vermonters.

Quote card. On the left side is a quote from Eilidh J. Pederson, MPH who is the Chief Operating Officer of Brattleboro Memorial Hospital in Brattleboro, Vermont. The quote says: "By partnering with OneCare, we were able to use data that helped us shape how we deliver care. Our diabetic community had A1C levels which is a type of blood sugar measure, that were not well controlled. The data showed to us that we needed to do something different. Together, our team decided the best approach would be to embed a nurse practitioner who was focused on diabetes and lifestyle medicine, within BMH, to serve as a resource for our primary care practices. As a result, we have seen A1C levels go down dramatically. It’s important that we continue with this work." On the right side of the quote card is a photograph of Eilidh J. Pederson in a circle on a white background showing a woman with red hair and a green dress against a blurred sky background.