In a recent article in VTDigger, the question was posed: “What happens if OneCare fails”? I would submit that this is the wrong question. The real question is: “What needs to be done to ensure the success of health care reform in Vermont?”  

Vermont’s health care reform initiatives did not begin with the creation of OneCare in 2012. For nearly 40 years, going back to the creation of the Hospital Data Council in 1983, Vermont has implemented a number of programs to improve access to health care services and to make health care more affordable for many lower income Vermonters. Initiatives such as hospital budget review, Green Mountain Care, premium assistance, pharmacy assistance, wellness and prevention programs, expansion and integration of health information technology, support for the expansion of Federally Qualified Health Centers and the Blueprint for Health have earned Vermont the reputation of being a national leader in health care reform.

In 2011, the Vermont Legislature passed Act 48, which established the Green Mountain Care Board and charged it with changing the way health care services are paid for, and controlling the growth of health care costs. One of Act 48’s specific goals was to change how care is paid for by moving away from fee-for-service payments toward value-based payments that reward access, quality and outcomes as opposed to the volume of services provided. The Legislature also encouraged collaboration among health care providers over competition in order to achieve the state’s health reform goals.

In February 2015, the Green Mountain Care Board convened and facilitated an ACO Payment Reform Subcommittee to discuss and outline the governance structure, provider payment policies and related parameters for an all-payer accountable care organization model for Vermont. Participants on the subcommittee included representatives from Vermont’s three existing ACOs at the time, physician groups, Blue Cross/Blue Shield of Vermont, the Department of Vermont Health Access, MVP Health Care, the Vermont Association of Hospitals and Health Systems, Bi-State Primary Care Association, Healthfirst, the Vermont Medical Society, the Office of the Health Care Advocates, home health agencies, and mental health organizations. Under GMCB leadership, this group met for two or three hours every other Monday morning for nearly nine months to develop its recommendations.

In December 2015, the subcommittee issued a detailed report to the board outlining the reasons to pursue an all-payer model in Vermont, and specific recommendations regarding the core functions of an ACO, the ACO governance structure, the principles of payment models for a variety of providers, performance incentives, and options for risk models.  This document became the “Framework” for an all-payer ACO model agreement with Medicare. 

In 2016, the state and the GMCB entered into the all-payer ACO model agreement with CMS/CMMI (Medicare) to implement a five-year plan to reduce the growth in health care costs, and to improve access to and the quality of health care services for all Vermonters. OneCare Vermont was selected to be the accountable care organization to convene the providers and to provide the administration necessary to implement the goals of the all-payer model. The ACO does not provide any health care services. That remains the responsibility of Vermont’s health care providers.

The all-payer model agreement is now in its third year of operation, and, as the VTDigger article noted, the ACO has “faced pushback from doctors, hospitals, the federal government, and the public.” There are many questions regarding the approach and the sufficiency of the ACO’s investment in primary care, how enrollment targets will be met, whether or not to implement global budgets for hospitals, and how financial risk should best be shared among the providers. Without going into all the criticism, I think it’s fair to say that although the ACO and its provider and payer partners have made progress toward achieving the all-payer model agreement’s goals, there is much left to be done, and the success of health care reform in Vermont is far from certain.

Today, the possibility of the ACO and the all-payer model failing seems to be real unless decisions are made soon regarding its future, and the future of health care reform in Vermont. I would suggest that now is the time for the GMCB and the Agency of Human Services to convene a group similar in composition to the 2015 ACO Payment Reform Subcommittee to meet regularly over the next several months to address many of the issues that have been raised, to consider alternatives, and to recommend a detailed consensus plan for how to move forward to ensure the success of health care reform in Vermont.


We have come too far over too many years to simply abandon the ACO model agreement or allow it to die for lack of leadership and attention. It is the responsibility of those who entered into and are responsible for the success of the all-payer model agreement (the governor, the secretary of AHS, the GMCB, and the board of OneCare) to establish and oversee an inclusive process to address the problems, consider alternatives, and seek solutions to ensure that all Vermonters have access to affordable and quality health care services.

Richard Slusky was CEO at Mt. Ascutney Hospital and Health Center in Windsor, from 1982-2010. After retirement, he became director of payment reform for the Green Mountain Care Board, Vermont’s healthcare regulatory authority until 2016.

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