State of Vermont Reports Scale Target Performance for Year 3 (2020) of All-Payer Model
Last Wednesday, the Green Mountain Care Board (GMCB), in consultation with Vermont’s Agency of Human Services, submitted the Annual ACO Scale Target and Alignment Report for Performance Year 3 (2020), as required by the Vermont All-Payer Accountable Care Organization Model (“All-Payer ACO Model” or “APM”) Agreement with the federal Center for Medicare and Medicaid Innovation (CMMI).
The 2020 (PY3) scale report demonstrates that Vermont, despite falling short of APM Agreement scale targets, has made strides toward increasing Model scale:
- All-payer participation grew by over 67,000 lives compared to 2019 (PY2), an increase of over 40%.
- The number of Medicaid beneficiaries attributed under the Vermont Medicaid Next Generation ACO Program (114,000 in 2020) has grown by 45% since 2020, and by nearly 300% since the program launched in 2017.
- Commercial participation more than doubled in 2020, from 30,000 in PY2 to 62,500 in PY3.
- The number of participating Medicare beneficiaries remained static from 2019 to 2020.
Looking ahead, Vermont expects continued improvement in 2021 (PY4; data is preliminary), with the addition of an estimated 40,000 lives, including approximately 8,000 Medicare beneficiaries. Despite increasing growth in scale year-over-year, it is no surprise that Vermont remains shy of the scale targets set forth in the APM agreement. The Medicare scale targets included in the Agreement are unattainable because some beneficiaries are ineligible to participate or receive the majority of their care out-of-state. All-Payer scale represents a significant stretch goal, and includes populations for which the state has no data or regulatory leverage, for example, self-funded groups that do not report data to the State and Medicare Advantage plans. Vermont’s Agency of Human Services laid out strategies for improving scale in the Agency’s APM Implementation Improvement Plan published in November 2020.
CMS Releases Surprise Medical Billing Interim Final Rule
Last week, the U.S. Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury (Tri-Agencies), along with the Office of Personnel Management (OPM) released an interim final rule with comment period (IFR) entitled the Requirements Related to Surprise Billing; Part I implementing many of the provisions of the No Surprises Act (NSA) signed into law as part of the Consolidated Appropriations Act, 2021 COVID-19 relief bill. The NSA addresses surprise medical billing at the federal level by holding patients harmless from the costs of out-of-network care in certain situations and creating an Independent Dispute Resolution process for determining provider payments. These situations include emergency services, air ambulance services provided by out-of-network providers, and non-emergency services provided by out-of-network providers at in-network facilities in certain circumstances. The law also addresses price transparency, provider directories, and other patient protections.
The IFR clarifies the Qualified Payment Amount (QPA) by specifying cost sharing calculations for emergency services provided by out-of-network emergency facilities and out-of-network providers, and certain non-emergency services furnished by out-of-network providers at certain in-network facilities. In addition, the IFR clarifies certain notice and consent requirements for health care providers and facilities. The American Medical Association (AMA) is closely reviewing the IFR after submitting comments to the Tri-Agencies on the implementation and calculation of the QPA and the QPA audit process, amongst other provisions, as well as comments on the Independent Dispute Resolution Process and will provide a detailed summary in the coming days. For more information, see CMS’ interim final rule fact sheet.
Drug Utilization Review Board is Currently Seeking Board Members
The Department of Vermont Health Access (DVHA) manages the publicly-funded benefit programs for the State of Vermont including the pharmacy benefit programs and oversees the activities of the DUR Board. The DURB is composed of prescribers and pharmacists that meet approximately every six weeks with a total of seven meetings per year. Materials for the meeting are sent via email ahead of time to allow DUR Board members to review before the meeting. The agenda typically consists of:
- Drug utilization review and analyses
- Review of new drugs, new indications and dosage forms
- Therapeutic class review including recently published treatment guidelines and best practices that may influence clinical criteria
- Safety information
- Drug information pertinent to managing the drug benefit programs of DVHA
You can find the DURB description, meeting schedule and location, meeting agenda’s, meeting minutes, current members, and contact information on our website at Drug Utilization Review Board | Department of Vermont Health Access
Please reach out to Lisa Hurteau if interested: Lisa.Hurteau@Vermont.gov.
Medicaid COVID-19 Billing Update
Since the announcement that COVID-19 restrictions have been lifted in VT there has been an increase in questions about COVID-19 related billing. Although the state of emergency has been lifted for VT, the federal state of emergency and waivers related to the COVID-19 public health emergency are still in place. Medicaid prior authorizations that are currently waived continue to be waived under the federal public health emergency. The DVHA COVID-19 web page is regularly updated, and DVHA will send additional information when those restrictions will be re-implemented.