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How is Vermont Doing - By Dr. Gene Lindsey

Past, Present, and Future of Health Care in Vermont

Here is an outline with references to time that I hope will augment your understanding of what has happened and hopefully will happen in Vermont in the very near future. The picture that I hope evolves in your mind’s eye will show how the continuing “Blueprint” efforts to improve primary care along the lines of medical homes fits nicely into the new finance through the ACO and the necessity of primary care to manage the resources that flow from payers through the Green Mountain Care Board as a single source of income to the merged ACO.


  • Independent primary care physicians, primary care physicians in federally qualified health centers, and primary care associated with academic medical centers all working in a traditional way with specialists in private practice, community hospitals and academic medical centers.
  • Care was provided in community hospital environments and in academic medical centers.
  • Where care occurred was more a function of circumstance and finance than a function of the coordination of care to insure that it would be delivered in the most appropriate site that was closest to the patient’s home.


  • Primary care practices in the private environment and the federally qualified health centers, are--in affiliation with hospitals--attempting to follow the path outlined in the Blueprint toward more robust medical homes that focus on a better use of resources through care coordination, population management tools and team based care.
  • Some patients from publicly funded sources, plus a minority of commercially funded patients, get their care from three ACOs:
    • OneCare (already qualified as a Next Generation ACO) includes Dartmouth and The University of Vermont Medical Center plus most of the community hospitals.
    • An IPA based ACO includes about 70 independent practitioners.
    • Another ACO serves federally qualified health centers (FQHC).
  • Specialty care and Primary care are FFS and the ACOs are upside sharing of savings with no risk.


  • Medicare, Medicaid, commercial insurance and out of pocket co-pays are blended into one revenue stream by the Green Mountain Care Board (GMCB). This requires a waiver from CMS and continued adequate funding from the state for Medicaid.
  • The IPA affiliated ACO and the FQHC ACO blend into the larger OneCare ACO. An MOU has been signed and discussions continue. There is optimism about a positive outcome.
  • The GMCB negotiates risk contracts, budgets and payment details with the ACO to cover all the willing physicians and hospitals in the state.
  • Most Vermonters get their care through the ACO. All patients are attributed to a PCP.
  • Hospitals and primary care are paid through the risk contracts.
  • Specialties are paid FFS. (Presumably units of care delivered by specialists are ordered by primary care through the referral process since all patients are attributed.)

I hope my outline of the past, present and future will help you appreciate the vision that is powering the Green Mountain Care Board’s strategy, which was in essence the subject of the conversation over the two days of the conference I attended in Stowe.