Hester: Vermont’s Three-Pronged Approach to Reform Centers on Communities

One of a series of reports on the October 21 MMS forum, “Toward a Shared Vision of Payment Reform.”

Hester_James_60x70Massachusetts wasn’t the only New England state that passed health care reform in 2006. So did Vermont, as James Hester, Ph.D., explained to attendees of the October 21 payment reform conference. Hester is director of the Vermont Health Care Reform Commission, but he spent 14 years working in Massachusetts, qualifying him to compare and contrast.

Vermont’s 2006 health reform law (Act 191) legislated a three-pronged balance between reducing the number of uninsured citizens, deploying health IT, and transforming the health care delivery system.  “Massachusetts tackled covering the uninsured first,” Hester noted. “We were able to do all three concurrently.”

Stressing the need for “building ‘system-ness,’” Hester explained that Vermont’s foundation of system-ness is the patient-centered medical home. The state’s three medical home pilot projects currently cover 10 percent of its 600,000 residents.

Vermont’s version of accountable care organizations are “neighborhoods” of medical homes called community health systems. “Patients change health plans more often than they change communities,” observed Hester, citing the stability of the community as “the focal point of Vermont’s delivery-system reforms.”

At the heart of each community health system is the community health team (CHT), which links medical homes to a broader range of health care services. Staffed by five full-time professionals (nurses, community health workers, mental health professionals, and others) per 20,000 patients, each CHT is funded by all of Vermont’s three commercial and two public payers. Any provider can refer any patient to a CHT.

The payment reform aspect of Vermont’s reforms, said Hester, is a “necessary but not sufficient condition” for success. Vermont’s community-centric pilots rely on a state-mandated single system of aligned incentives through which providers receive sliding-scale “management fees” linked to their performance on 10 medical home criteria from the National Committee for Quality Assurance.

Hester reports that he frequently hears from participating doctors that the medical home pilots “have revitalized their love of primary care.”

Video excerpts of his presentation:

Download his slide presentation. (.pdf, 14 pages)

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