october 20, 2015 don ross oregon health authority operations policy and program mgr coordinated care...

October 20, 2015

Don Ross

Oregon Health Authority

Operations Policy and Program Mgr

Coordinated Care Organizations

Health System Transformation

Oregon Fast Facts

• Total Populations is 3.9 million (2012)• Urban, Rural and Frontier• Total Square Miles 99,000• Key Industries(Tourism, Fishing, Timber, Technology,

Agriculture)• Intel, Nike, Adidas Have Ties to Oregon• Current Medicaid Eligible Enrollment approx 1.1 million• 89 % managed care 11% FFS (Non-enrollables)• ACA Medicaid Expansion Population is nearly 350,000 since

1/1/14

How is Oregon Medicaid Organized?

• Single State Agency• Title 19 (Medicaid)• Title 21 (S-CHIP)• Multiple 1115 CMS Waivers(first was 1994)• http://www.oregon.gov/oha/OHPB/Documents/special-terms

-conditions-accountability-plan.pdf• Latest Waiver Created Coordinated Care Organizations

(July, 2012).• https://cco.health.oregon.gov/Pages/Home.aspx

How is Oregon Medicaid Organized?

• >50% of babies born in Oregon are Medicaid• 16% of all Oregonians are in Medicaid• 85% of Oregon providers participating• 11% percent of total state budget• Fastest growing portion of state budget

Why Transform?

• Recognition that health care costs were not sustainable and we do not get the health outcomes for the money that we spend.

• After 100s of hours of stakeholder meetings, tribal consultation and community meetings, a health transformation plan for Oregon’s Medicaid program was developed.

• Better Health, Better Care, Lower Costs!!

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Key Health System Transformation Components

• Coordinated Care Organizations (CCOs)– Community level accountability for better health, better

care and lower costs– New models of integrated care and that are patient

centered and team-focused; integrated across physical, behavioral and oral health.

– Governance by a partnership of providers of care, community members and stakeholders in the health system who have financial responsibility and risk

– A global budget that grows at a sustainable, *fixed rate with payment alternatives that incent positive health outcomes.

– Use of non-traditional health care workers (peer wellness specialists; community health workers; patient navigators)

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Transformation Contracting Process

• Request for Application (RFA)• Application Review and Certification Processes• Created Internal Workstreams for Planning and

Implementation(Inter-Agency)• Created improved communication models with Contractors

and Stakeholders• Implemented over 4 Months(August to November, 2012)• Established a Transformation Center

CCOs Governed Locally

State law says governance must include: •Major components of health care delivery system•Entities or organizations that share in financial risk•At least two health care providers in active practice

– Primary care physician or nurse practitioner– Mental health or chemical dependency treatment

provider•At least two community members•At least one member of Community Advisory Co

Community Advisory Council

• Majority of members must be consumers.• Must include representative from each county government

in service area.• Duties include Community Health Improvement Plan and

reporting on progress.

Oregon Medicaid Contracting Models

• Pre-Transformation (before August, 2012)• Heavy Managed Care (over 10 years)• Fully Capitated Health Plans (FCHP) 15• Mental Health Organizations (MHO) 10• Dental Care Organizations (DCO) 8• Physician Care Organizations (PCO) 1• Transportation Brokerages (NEMT) 8• Disease Management(FFS populations) 1

Oregon Medicaid Contracting Models

• Post-Transformation (August, 2012 to present)• Formed Coordinated Care Organizations (CCO) 16

Contracts with 15 Organizations• Merged Physical and Behavioral Health• Merged Dental• Merged NEMT• Transitioning Other Medicaid Services (per Waiver) to CCOs• Continued prior contracting models(FCHP,PCO,DCO,NEMT,

DM)valid until July, 2017, accounting for 6% of managed enrollment

Patient-Centered Medical Homes

– Patient-Centered Primary Care Homes (PCPCHs)• 2703 Health Home SPA

– More than 400 clinics have applied and been certified as PCPCHs in Oregon

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Safety Net Providers & Alternative Payment Model

• State Plan Amendment (SPA 12-08) submitted to CMS for FQHC & RHC Alternate Payment Methodology (APM)

• CMS approved the SPA August 13, 2012 • FQHC and RHCs can choose to use an APM under

Section 1902(bb)(6) of the SSA which requires the state to pay at least what the clinic would have received on PPS

• Purpose of APM is to allow clinics to innovate in managing the health of populations by engaging their patients in ways that do not currently qualify as billable medical visits

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CCO Incentive Measures • PCPCH enrollment percentage• Adolescent well-care visits• Developmental screenings in the first 36 months of

life• Depression screenings and follow up plan• Childhood immunization status• Mental, physical, and dental health assessments

within 60 days for children in DHS custody

Sparks of Innovation

• CCOs are making funding available to primary care practices to specifically to increase their mental health integration.

• We have a CCO that is working on information sharing between primary care, juvenile justice, and other social services.

• CCOs meet regularly in learning communities to share ideas just like these.

What Have We Learned?

• Transformation is really hard and it takes time• It costs money to transform (new infrastructure)• Healthcare integration is hard work and it takes time• Maintaining institutional knowledge is critical• Healthcare transformation includes cultural

transformation(Organizational Dynamics)• Flexibility spawns a variety of CCO organizational models

(Sub-contractors, delegation)• Writing an integrated contract doesn’t make you an

integrated system

What Have We Learned?

• Timing is Important (PPACA Impact) what else is on your plate?

• CMS is a great partner in this journey• Communicate, communicate, communicate• Be flexible - what we did yesterday may not be the

process tomorrow

Questions?

More Information

http://health.oregon.gov/

Don Ross: donald.ross@state.or.us

503.945.6084