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2024 Fund for Health Care Delivery Projects Using Waivers

Watch

Waiver Project Fund Webinar

Watch our recent March 6, 2024 webinar in which Linda Cohen, OneCare’s assistant general counsel and resident expert in maximizing waivers to improve health care delivery, provided a detailed overview of OneCare’s Waivers Project Fund. She also provided examples of how waivers have already been used by health care organizations and answered questions from attendees. Questions can also be directed to waivers@onecarevt.org or by calling 802-522-5621.

Watch this video on Vimeo

Funding Requirements for Waivers Project Fund Application

OneCare has allocated $100,000 to fund up to five delivery system projects intended to impact the key areas of quality focus and goals as described below. Minimum funding request: $10,000.

DEADLINE EXTENDED: Applications due March 28, 2024 by 5pm – application button is at bottom of page.

Applicants notified of decision no later than April 19, 2024 for a funding period of April 1, 2024-December 31, 2024.

Read the full description of funding requirements below for more information. Strong applications will describe projects that are designed to: 

  • Influence one or more of OneCare’s Population Health Model measures or goals

  • Potentially decrease total cost of care

  • Support transformation to a value-based delivery system

  • Identify key metrics to quantify results

Waivers Project Fund Background 

Health care providers are generally subject to a large body of federal and state regulations relating to the financial relationships between provider organizations and between providers and their patients. Most of these regulations originate in the fee-for-service healthcare system and seek to ensure that providers’ care delivery choices and financial interests do not cause federal health programs (Medicare and Medicaid) more costs in claims. These regulations can require that financial relationships between provider organizations meet detailed requirements—such as benchmarking to fair market value—or limit the value of items or services given to patients free to support their care. As payments move away from fee-for-service to value-based programs, regulators have recognized that regulatory requirements can be a barrier to innovative partnerships between unrelated provider organizations (like a hospital and a designated agency) that lead to higher value care, improved health outcomes, and shared savings in the healthcare system.

OneCare Vermont, as an accountable care organization (ACO) participating in Vermont’s All-Payer Model, has been provided waivers—known as “Fraud and Abuse Waivers”—that are specific to the Vermont All-Payer Model and have been adopted in OneCare’s program agreement with Medicaid. Arrangements that meet the limited criteria of these waivers are protected from enforcement under Anti-Kickback, Stark and Civil Monetary Penalties laws. The intention is to promote delivery system innovation amongst unrelated provider organizations working together on cost and quality of care as an ACO in Vermont’s All-Payer Model.

OneCare has long been using these “Fraud and Abuse Waivers,” which it has the unique ability to access as a certified ACO, to facilitate its financial model and clinical arrangements that seek to reform the way health care is paid for and delivered but might otherwise be considered an unacceptable regulatory risk. After implementing several successful unrelated provider organization arrangements using the waivers, the OneCare Board of Managers has committed funding to facilitate innovative arrangements and promote delivery system reform.

Two Waivers Available to Reduce Regulatory Barriers to Health Care Delivery Innovation: 

There are two “Fraud and Abuse Waivers” that can be utilized:  (1) the Participation Waiver and (2) the Waiver for Patient Engagement Incentives. 

Find a general outline and additional informational summaries here.

1. Participation Waiver

This generally relates to financial relationships between health care providers. Examples of using this waiver include the Brattleboro Retreat Transportation Waiver where the Brattleboro Retreat pays a capacity fee for Rescue Inc. ambulance company and contracts with OneCare to have Rescue Inc. transport patients from network hospital emergency departments to the Brattleboro Retreat for voluntary inpatient treatment. Other examples can be found at: https://www.onecarevt.org/fraud-and-abuse-waivers/ 

    Where the following conditions are met, unrelated provider organization arrangements granted a Participation Waiver are exempt from Anti-Kickback and Stark laws.

    ALL of the following conditions must be met:   

    • The arrangement includes OneCare, one or more ACO Participants (an organization that includes attributing providers such as primary care practices), or a combination
      • Additional parties can also join
    • The Board of Managers makes a bona fide and documented determination that the arrangement is “reasonably related” to one or more of the following “ACO Activities:”
      • Promoting accountability for quality of care
      • Promoting accountability for cost of care
      • Promoting accountability for overall care
      • Managing and coordinating care
      • Encouraging infrastructure investment
      • Encouraging investment in re-designed care processes for high quality and efficient services delivery
      • Carrying out any obligation or duty under the Vermont ACO Initiative or the Vermont Medicaid NextGen Program (together “Programs”)
      • Direct patient care
      • Promoting evidence-based medicine
      • Promoting patient engagement
      • Reporting on quality and cost measures
      • Coordinating care with telehealth, remote monitoring and other technologies
      • Establishing and improving ACO clinical systems
      • Establishing and improving ACO administrative systems
      • Meeting programs’ quality standards
      • Evaluating patient health
      • Communicating clinical knowledge
      • Communicating evidence-based medicine
      • Developing standards for patient access and communication including to medical records
    • The arrangement is documented contemporaneously with its establishment
    • A description of the arrangement is disclosed publicly on OneCare’s website
    • Records are available to be audited

    2. Waiver for Patient Engagement Incentives

    This is generally related to health care providers giving services or items of value to patients for free. Examples of using this waiver include the University of Vermont Medical Center primary care practices providing medical nutrition therapy to Medicare outpatients at no charge. Where the conditions are met, arrangements granted a Waiver for Patient Engagements Incentives are exempt from Anti-Kickback and Civil Monetary Penalty laws.   

    ALL of the following conditions must be met:   

    • The arrangement includes OneCare and/or one or more ACO participants
    • There is a reasonable relationship between the item or service and the medical care of the patient
    • The items or services are in-kind, and the patient receives the actual item or service (example, no discounts, coupons or cash equivalents)
    • The items or services are:
      • Preventive care items or services, or advance one or more of the following clinical goals:
        • Adherence to a treatment regimen
        • Adherence to a drug regimen
        • Adherence to a follow-up care plan
        • Management of a chronic disease or condition
    • Records are available to be audited

    Areas of Interest 

    OneCare is particularly interested in projects that will produce measurable impacts on OneCare’s Population Health Model priority quality measures, as well as the delivery system goals selected to have the most impact on the health of the Vermont population. 

    2024 Population Health Model Quality Measures: 

    • Hypertension: Controlling High Blood Pressure 
    • Follow-up after ED Visit for Patients with Multiple Chronic Conditions 
    • Medicare Annual Wellness Visits 
    • Child and Adolescent Well-Care Visits 
    • Developmental Screening in the First Three Years of Life 
    • Initiation of Alcohol and Other Drug Dependencies Treatment 
    • Engagement of Alcohol and Other Drug Dependencies Treatment 
    • 30 Day Follow Up After ED Visit for Substance Use 
    • 30 Day Follow Up After ED Visit for Mental Illness 
    • 7 Day Follow Up After Hospitalization for Mental Illness 

    2024 Annual Priority Quality Measures: 

    • Reducing ED costs  
    • Preventing ED utilization 
    • Facilitating discharge from inpatient or ED 
    • Increasing access to primary care 
    • Increasing access to mental health care 

    Evaluation 

    Screening applications will be reviewed by OneCare’s Assistant Counsel for Contracting and Innovation. Follow up calls and additional information will be sought from applicants who pass through this initial screening process. The eligible projects will then be evaluated by OneCare’s Innovation Waivers Workgroup and OneCare’s Chief Medical Officer.

    Projects will be evaluated by:

    • Whether they fit the stated goals
    • Whether they provide benefit impact on costs of care
    • Quality impact
    • Uniqueness
    • Capability of measurement
    • Resources required
    • Viability of the plan and factors agreed to by the evaluators

    The Chief Medical Officer and the Innovation Waivers Workgroup will select a group of projects to be presented to the Board to request appropriate waivers. Participants in funded projects will be required to sign agreements with OneCare that encompass the requirements of the Fraud and Abuse Waivers and the funding program including quarterly and as-needed online reporting requirements primarily to track number of Vermonters impacted.

    Questions?

    Please direct any questions to: waivers@onecarevt.org or call 802-522-5621 

    Start Application