Report by Lee Mercer, President Health Care for All-Oregon
December 4, 2014
Speaking to 1300 plus attendees at the Coordinated Care Organization Summit in Portland, Susan Johnson, Regional Director, US Department of Health and Human Services (Region 10) said Oregon is “leading the nation like a North Star” towards creating a sustainable model of health care for the future. Nichole Maher, President of the North West Health Foundation sees the key to health in our communities and health outcomes being now defined by zip code, race, income and other social determinants. She thanked Governor Kitzhaber for a budget reflecting dedication to health equity.
Kitzhaber outlined some of the successes of Oregon’s recent initiatives— 95% of Oregonians have health insurance and a million have enrolled in a new health care model. As the CCO’s start covering public employees we are moving towards savings that culminate in a structural budget surplus in 2123.
Building on this theme, keynote speaker Don Berwick, MD, former administrator, Centers for Medicare and Medicaid Services, and Founding CEO, Institute for Healthcare Improvement, praised Oregon and the attendees of the conference. “Bravo! You’re doing something amazing—there is a bright light here.”
But, he noted, there is “a burden of leadership for Oregonians as pioneers.” Pioneers are bound to experience uncertainties. He said Oregon should sense the importance of what we are doing and maintain cooperation—unprecedented levels of cooperation. Everyone must be willing to give up something as we stay focused on the triple aim of better care, better health and lower cost. The cost of health care is inhibiting us from being what we want to be as a nation.
His thesis, illustrated by graphs showing escalating costs, is that health care is “confiscating” opportunity in terms of eating up public finance. As premiums rise faster or through taxes), it is all, sooner or later, coming out of the pockets of the workers. And it means that health care is stealing from all the other programs that government might be providing.
He sees the health care system metaphorically like the Choluteca Bridge, in Honduras. Built well by US engineers, it has weathered every storm for generation, but, over the years, the river has moved and the bridge is no longer relevant.
To make health care relevant and effective, Berwick noted, we must begin treating it as a human right and build a system which is cost effective and sustainable. He sees a need for developing a cooperation index in our work. A focus on transformation and not the finances. He concluded by congratulating Oregon again on its successes, adding “the country needs you!”
Numerous Health Care for All Oregon advocates, proudly wearing their red t-shirts proclaiming health care as a human right, were disappointed that Berwick, an outspoken supporter of single payer as a candidate for Governor in Massachusetts, didn’t mention this needed systemic reform. He probably didn’t want to steal the thunder of the progress in reducing health care costs by Oregon’s CCO system.
Then a series of speakers outlined how they have organized their CCO’s in communities throughout Oregon. Much emphasis was on building the Community Advisory Councils that guide CCO’s. A number of moving personal stories illustrated the partnering of behavioral, physical and dental health specialties throughout the state. Also, stories emphasized partnership with early childhood education.
Kevin Campbell, a former business man and now CEO of Greater Oregon Behavioral Health, Inc. noted that, in Eastern Oregon, it was less about talking health care transformation and more emphasizing community strengths and local control. A big piece was doing Community Health Improvement Plans. In their vast region, 12 counties developed 12 independent plans and then found a unifying consensus. Not only did they serve Medicaid/OHP users, but philanthropic support was forthcoming which meant many of the facilities and services are available for all in the communities. One grant was given for each county, and the OHSU Center for Evidence Based Policy helped assess the grant projects.
Judy Mohr Peterson, Director of Division of Medical Assistance Programs (Medicaid) at OHA, spoke in a break out group providing an overview of the Coordinated Care Organization system. She started by outlining the reasons for the need for transformation:
Health care costs are unsustainable
Health outcomes are not what they should be
Lack of coordination between physical, behavior and dental health
Previously, during a budget crisis, there were three ways to deal with a shortfall of Medicaid dollars. One was to cut people, and thus began the lottery for OHP participation. Another was to cut benefits- this often meant cutting mental health, dental health or prescription drugs, all of which are optional under Medicaid. Finally, they could cut provider rates.
Under Kitzhaber’s vision of the triple aim, the goal was better health, better care and lower costs. Not just one or two, but all three. So Oregon set out to reduce waste, improve health and take steps to build a more sustainable model.
There are now 16 CCO’s, and 95% of 1,000,000 folks on Medicaid are enrolled. Mental, physical and dental health are all in one budget. Incentives are in place for quality and achieving growth limited to 3.4% (a cut of 2%).
Mimi Haley (Columbia Pacific CCO) and Coco Yackley, Operations Manager, Columbia Gorge Health Council, outlined more of the nuts and bolts of putting CCO’s together. In the Gorge the CCO was embedded in an existing organization (Pacific Source). The Community Advisory Council was formed, giving Pacific Source one vote, with 50% consumers and 50% “at risk” (financially) organizations. The Clinical Advisory Panel (optional) was also formed.
The Columbia Pacific CCO was formed in the coastal counties of Clatsop, Columbia, Tillamook and Douglas. It operates under a global budget as a wholly owned LLC of Care Oregon in partnership with Greater Oregon Behavioral Health. There are 15-20 directors. One seat each is held by Care Oregon and GOBH. There are 4 Community Advisory Councils, one for each county. They have grown from 7,000 to 25,000 members. Some of the health strategies include Health Home Assessments (discovered a woman who used oxygen has carbon monoxide leaking from her furnace—after repairing, she no longer required oxygen) and Health Resiliency (trauma informed support to “high utilization” patients).
Among challenges cited by the CCO’s include billing issues, different payment models and provider shortages. They couldn’t give metrics on provider shortages, but noted that most dentists in the area do not take Medicaid. Coco Yackley quipped that she could “see why single payer would help” due to the complexity of the various payment systems. Well child visits paid for by Medicaid, may, in a private insurance plan, be on a different annual calculation, so those patients may have to pay out of pocket.
Appreciating the opportunity to learn about the cost savings and system improvements being pioneered in Oregon’s Community CCO transformation, a nagging question remains. If this system is indeed more patient centered, why are all the metrics cited for its success, cost saving outcomes, not health outcomes?
In the Executive Summary of the 2013 Performance Report large improvements cited are:
Decreased emergency department visits. Emergency department visits by people served by CCOs have decreased 17% since 2011 baseline data. The corresponding cost of providing services in emergency departments decreased by 19% over the same time period.
Decreased hospitalization for chronic conditions. Hospital admissions for congestive heart failure have been reduced by 27%, chronic pulmonary disease by 32% and adult asthma by 18%.
Developmental screening during the first 36 months of life. The percentage of children who were screened for the risk of developmental, behavioral and social delays increased from a 2011 baseline of 21% to 33% in 2013, an increase of 58%.
Increased primary are. Outpatient primary care visits for CCO members increased by 11% and spending for primary care and preventive services are up over 20%. Enrollment in patient centered primary care homes has also increased by 52% since 2012, the baseline year for that program.
So cost savings are great and more screenings and primary and preventative services are wonderful.
But where are the patient health outcomes? How is the health of the folks not doing emergency room visits? Are they managing their congestive heart failure, chronic pulmonary disease and adult asthma? And how is the health of the kids being screened and patients getting primary care services?
At some point beyond cost savings and increased services, health outcomes need to be the final measure of a sustainable health system. When we have metrics which say that, in Oregon, we have achieved the lower infant mortality and higher life expectancy rates, the lowered rate of disease and the other health outcomes achieved by all industrialized countries which have in common universal, publicly funded health systems, we can say we are fully succeeding in transforming our health system.