Draft all-payer agreement reached between Vermont and feds - FEEDBACK SOUGHT

Governor Shumlin and the Green Mountain Care Board (GMCB) recently released the Draft Vermont Accountable Care Organization All-Payer Model Agreement.  You can find the draft agreement here: http://gmcboard.vermont.gov/sites/gmcb/files/documents/payment-reform/DRAFT_APM_Agreement_UNDER_LEGAL_REVIEW.pdf

You can find additional GMCB generated background materials here:

The GMCB is accepting public comments on the Vermont All-Payer Accountable Care Organization Model Draft Agreement until 4:00 pm on October 13, 2016.  In order to comment, please go here:  http://gmcboard.vermont.gov/board/comment

The GMCB plans to hold meetings on the issue at 9:00 am on Oct. 5 and 1:00 pm, Oct. 13 in their second floor hearing room, City Center, Montpelier. In addition, the Shumlin administration will hold public hearings on Oct. 3, 5:30-7:30 pm, Montshire Museum of Science, Norwich; Oct. 6, 4-6 pm, Chittenden County location TBA; and Oct. 11, 4-6 pm, Rutland Regional Medical Center, Rutland.

In brief, under the draft all-payer model agreement:

The Model begins on January 1, 2017 and concludes on December 31, 2022, and there are a total of 6 Performance Years, beginning with Performance Year 0 in 2017 and ending with Performance Year 5 in 2022.

Under the agreement, access to care, services, providers and suppliers for Medicare beneficiaries will not be limited.

$9.5M will be provided in one time funding in 2017 to fund care for Medicare FFS beneficiaries in support of the Blueprint for Health and the Support and Services at Home program (SASH).

The Model sets targets for the number of Vermonters attributed to an ACO:

Percent (%) By end of PY1 (2018) By end of PY2 (2019) By end of PY3 (2020) By end of PY4 (2021) By end of PY5 (2022)

All-Payer Beneficiaries

(Medicare, Medicaid, Commercial)

36% 50% 58% 62% 70%
Medicare Beneficiaries 60% 75% 79% 83% 90%

The model establishes targets for improvement by identifying 3 priority goals for improving the health of Vermonters within 3 “Measurement Domains.” These new targets are in addition to the separate ACO quality reporting measurements.


  1. Improve access to primary care
  2. Reduce deaths from suicide and drug overdose
  3. Reduce prevalence and morbidity of chronic disease (COPD, Diabetes, Hypertension)

Measurement Domains:

  1. Population Health Outcome Measures and Targets
  2. Health Care Delivery System Quality Measures and Targets
  3. Process Milestones

The all-payer model establishes the Vermont Medicare ACO Initiative and the agreement spells out CMS and GMCB duties in connection with the Vermont Medicare ACO Initiative.  

  • In 2018 the model will operate with a Modified Medicare Next Generation ACO, with the GMCB assuming regulatory authority. The full Vermont Medicare ACO Initiative will be launched in 2019 – PY 2 

The agreement Include the same benefit enhancements currently authorized under the Medicare Next Generation ACO: 

  • Telehealth
  • Post-discharge home visits
  • 3-day skilled nursing facility rule

A core responsibility of GMCB under the agreement is setting Medicare ACO growth benchmarks and monthly capitation amounts will be based on the benchmark target.

GMCB and CMS will work together to determine how the ACO Initiative should be modified to be considered an Advanced Alternative Payment Model under the MACRA Quality Payment Program. 

  • Providers in Advanced Alternative Payment Models will qualify for a 5% Medicare Part B incentive payment under the proposed rule.

The agreement set an All-Payer Total Cost of Care Target of 3.5% for statewide per capita spending growth. This applies to spending across all payers for Part A and Part B or their equivalent services under Medicare, Medicaid and Commercial plans.

  • The agreement also includes a separate Medicare Growth Target for per capita spending growth for Medicare beneficiaries for Part A and Part B services. The Medicare Target: 0.1%-0.2% below projected national Medicare growth.
  • Performance on these targets is calculated across Performance Years 1-5.
  • During the agreement term, failure to be “on track” to meet these targets could require the state to file a corrective action plan with CMS.
  • Vermont would be “on track” to meet the All-Payer Target if it remains below 4.3% growth

The Medicare Total Cost of Care per Beneficiary Growth Target limits Medicare growth and is intended to ensure that the model saves CMS money.

  • The exclusion of Medicare FFS spending in PY1-2, with ACO scale “trigger” in PY 3, is intended to protect Vermont from being accountable for spending it does not regulate, as the ACO program is ramping up and there are risk adjustments for age and specific high-need enrollees.

GMCB must submit a report on options to narrow reduce the Payer Differential between payers during and after the Performance Period by the end of Performance Year 3.

  • If the state chooses to increase Medicaid reimbursement rates to health care providers these rate increases will be excluded from the All-payer Total Cost of Care per Beneficiary Growth Target.

ACOs will be required to have a single network of providers for all payers by Performance Year 2 and AHS must ensure that at least 90% of all providers in the Vermont ACO’s network accept Vermont Medicaid beneficiaries.

The state may terminate the agreement at any time for any reason upon 180 calendar days written advance notice to CMS.

Current VMS Policy

During its November 7, 2015 annual meeting, the VMS adopted a policy resolution on Criteria for an All-payer ACO Model for Vermont.

The resolution included the following resolves:

Resolved, The Vermont Medical Society will urge State of Vermont not to enter into a  Medicare waiver that would further reduce Vermont’s already low predicted spending per Medicare enrollee and its already low predicted overall rate of growth compared to the New England region; and be it further

Resolved, The Vermont Medical Society will urge the State of Vermont to guarantee that the State of Vermont will increase Medicaid reimbursement to at least the negotiated or applicable Medicare level; and be it further

Resolved, The Vermont Medical Society will urge the State of Vermont to ensure physicians’ freedom of choice, so that physicians deciding not to join an ACO would be able to elect to continue to operate under traditional Medicare, Medicaid and commercial insurer payment policies;

To read the full resolution, please go to:


To help inform the VMS’ written comments, we are asking that members who provide written comments to the GMCB also share these comments with the VMS.

Thank you for your participation and feedback on this crucial issue. Please contact VMS if you have further questions: at pharrington@vtmd.org or  call 802-223-7898. 

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