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Should Doctors Get Paid For Keeping Patients Healthy? Vermont Officials Say Yes

Al Gobeille, chairman of the Green Mountain Care Board
Tony Talbot
Associated Press

State officials say they're hopeful that a new health care payment system can be in place at the beginning of next year. The proposal is designed to reimburse providers to keep their patients healthy and to encourage the expansion of primary care practices.

It's known as the "all payer" system, and it represents a dramatic change in the way that health care is paid for in Vermont.

Currently, under the "fee for service" system, providers are paid for every office visit, procedure or test that's done. Under all payer, providers would receive a set amount of money each month based on the number of patients they have and would be encouraged to work with their patients on prevention programs.


This story was produced by Vermont Public Radio.

Al Gobeille is the chairman of the Green Mountain Care Board, a group that oversees virtually all aspects of health care in Vermont. He argues that "fee for service" might have worked in the past, when patients were more likely to present with problems that could be addressed with a few doctors’ visits or procedures.

“Today the world is very different,” Gobeille explains. “Eighty-six percent of health care spending is currently spent on chronic conditions in the United States and that changes the whole game. Meaning, folks have something in their personal health that requires constant monitoring and constant intervention from the health care system."

Gobeille says the state's health care system is financially unsustainable unless steps are taken to proactively reduce chronic illness in Vermont.

"Whenever anything goes wrong [people] end up basically in an emergency room and that's not the best way to care for them,” says Gobeille. “And so the idea behind this is, if we can get the incentives right in health care that we can incent doctors to take care of people before they need those interventions."

Gobeille says the all payer model needs the support of physicians and the state's hospitals to be successful. The program would be optional for doctors and patients – those who do not opt in would continue operating under the fee-for-service model. Government payers like Medicare and Medicaid, as well as private insurance companies would be involved.

Bea Grause, the executive director of the Vermont Association of Hospitals and Health Systems, says her members are taking a close look.

“How are they going to determine whether or not they will provide access,” says Grause. “How will the delivery of care be recognized? What's the impact on their physicians, their nursing community? There are a lot of different questions each hospital has to consider and every hospital is different."

Gobeille acknowledges that getting that support is now more difficult because of the poor performance of Vermont Health Connect, the state's health care exchange.

“It's a factor that has affected other things that government wants to do that don't have to do with health care,” Gobeille says. “It's a big deal and I'm not going to shrink from that, but I'll also say it's a really big deal how much health care costs families today, and I don't think we should stop moving forward."

Gobeille hopes to spend the next few months encouraging health care providers across the state to consider this new payment system. But if a lot of them don't like it, he's prepared to drop it.

He says the federal government also needs to sign off on this new payment system and he hopes to receive federal approval by the spring.