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provides services through “managed care
organizations.” Similar to insurance
companies, managed care organizations
develop health plans it offers to patients on
the Oregon Health Plan, and contracts with
medical providers. Patients have separate
health plans for their physical, mental and
dental care. That means patients may g o to
three different places for their health care.
“None of those.
plans talk to each
other,” says Erin Fair,
the manager of state
and federal policy at
CareOregon, a
Portland-based
managed care
organization. “That
creates not only
siloed care and
administrative hassle”
but also leaves the
patient very confused.
“You could not create more convoluted
system,” says Mike Bonetto, Gov. John
Kitzhaber’s health policy advisor.
Solotaroff can ¿ay from experience that
the lack of communication among the silos
directly affects patients, I
One example she offers is a patient in
long-term dare with congestive heart failure,
whose weight must be checked every day to
determine whether fluid is building up in his
body. A staff person at the long-term care
facility might weigh him every day, but then
not call it in to his doctor, nor e-mail, but
rather send a fax.
“Two or three pounds could be a big
deal,” Solotafoff says. “And I might not see
it unless I’m running around saying, ‘where
is that piece of fax paper?’”
“The hope of a CCO is that they will be
able to deliver a much more integrated
package of sendees,” Greenlick says.
The way providers are paid has alsq
presented significant challenges to the
in August and September, and meet again in
October and November. They will give their
recommendations to the Oregon Health
Policy Board, which advises the Oregon
Healtii Authority.
The Oregon Health Policy Board will use
the recommendations to finalize a plan that
must be approved by the Legislature in
February in order for reform to move.
forward.
“We’re waiting with bated breath,” says
Rep Mitch Greenlick (D-Portland), another
legislator heavily involved in HB 3650’s
writing.
If the Legislature gives approval, the state
will work to have CCOs operationally July.
It is a fast timeline, but Greenlick and
others think it’s enough. “It’s very exciting,”
Monnat says. “But, like any change, it’s also
daunting and hard to get your head around.”
Much depends oh Oregon’s health
transformation. Many critique the Oregon
Health Plan for being fragmented and not
patient-focused. The legislature also took a
risky gamble in budgeting $239 million in
savings from the effects of integrating care.
If care coordination does not work, then
care will remain fragmented, leaving a
population of people who are poor ahd
sicker than the average, challenged with
navigating a massive system, bouncing from
provider to provider, and falling through thq
cracks.
“We have a moral imperative to make
health care more efficient,” says Gideonse,
the medical director of Oregon Health &
Sciences University’s Richmond Clinic.
“We’re not talking about people Who live
in the west hills of Portland,” says Thomas
Aschenbrenner, the president of the
Northwest Health Foundation, and a
member of the CCO workgroup, “These are
people who have struggled their whole life.
They don’t have the emotional energy , to put
up a fight, and if we
for, , q u a n ta . o £..cace-ujide r .l h e . -QHP. i n . t h e . ............
“cffffent “fee for sendee” model, providers” ’
them, they will suffer even more.”
are paid the same per patient visit,
regardless of what services are provided,
Cranking out visits
how sick the patient may be, or how much
in fragmented silos
(care they need.
Thatcreates a tension between providing
To understand why such radical change is
adequate care and generating enough
being undertaken, it is important to
revenue to keep a clinic financially viable.
understand whom the Oregon Health Plan
“The Cost per visit is the same, so you do it
serves. The plan is available to people with
through visits,” Gideonse says.
an income 138 percent below the federal
“It’s volume driven and not value driven,”
poverty line, or roughly $15,000. Living in
says Ern Teuber, the Richmond Clinic’s a
poverty, people on the Oregon Health Plan
executive director,
have barriers to transportation, childcare,
The choice between “10 sore throats
and other obstacles to accessing healthcare.
versus a very sick person,” is thus very
“They’re demonstratively sick patients,”
clear. “That’s not necessarily good health
Gideonse says. “The sicker you are, the less
care,” Gideonse says.
attention points you can lend toward
Solotaroff agrees. “It’s so inefficient now
navigating complex systems.”
because it is almost entirely based on
“They end up ignoring diseases that
cranking out visits and not better
should be treated,” Greenlick says, “They
outcomes.”
don’t have the ability to get good preventive
The new "global budget” plan for CCO’s is
care. Then they end up using the
viewed as a key solution. One budget, given
emergency room. It’s a huge problem.”
to a CCO, will pay for the care of a specified
The Oregon Health Plan currently
number of patients during the year.
a
street roots
ì / M
Oct. 14, 2011
of CCOs to simply make up their own, rules.
If they have particular religious or
ideological leanings, that could mean, for
example, less access to reproductive and
family planning services. It’s possible that
the Oregon Health Authority could
intervene, but it is not clear yet where the
Authority would, or could.
“Good criteria will not allow somebody to
get in the game without taking care of the
whole patient population,” says Lillian
Shirley, the director of Multnomah County’s
public health department and Vice-chair of
the Oregon Health Policy Board, during the
board’s meeting on October 11.
During that meeting, the Oregon Health
Policy Board discussed for the first time in
some xletail what the criteria and structure
of a CCO will be. Much emphasis was placed
on the need for CCOs to reduce health
inequities due to race and ethnicity,
geography, disability, sexual orientation,
income, homelessness, and a variety of
other factors.
Nothing will be set in stone until a plan is
delivered to the Legislature this winter.
There continue to be, Fair says, “a lot of
Unknowns.”
Legislators and others hope it will motivate
CCOs to carefully manage the money they’re
given and provide the most efficient care
possible.
“It’s a powerful tool,” Greenlick says.
“Right now, there’s just no discipline.”
Solotaroff agrees.
“The idea of the global budget that pays
you to take care of a person rather than
spend 15 minutes to listen to a patient and
write down what they’re saying is very
appealing,”
Searching for structure
— and criteria
One of the elusive puzzle pieces to
developing coordinating care is the
structure of a CCO. How big will it be? What
will it do? Who will be a part of it?
“It’s more than just one clinic. It’s
hospital care, specialty care, mental health,
dental care,” says Greenlick. “You need to
bring all the people into a CCO that need to
be there to provide all the health care
services.”
Teuber, the Richmond Clinic’s, executive
director, says there are at least a couple
ways a CCO can be structured.
What is known with certainty is that
managed care organizations will cease to
exist. Teuber says a CCO may be fairly
small organization that simply contracts
with provider groups to provide care, with
the contract requiring collaboration and
coordination. Money would funnel through
the organization to the various providers,
and the organization would provide some ,
type of oversight ând accountability.
Another possibility is that a CCO could be
a non-profit In Such a Scenario, all
categories of providers would be in the '
CCO..
“As long as the CCO holds itself and all
players accountable for doing only that
Of teams and touches
a
w h ic h ia
th e , p a tre n F s b e s t i n te r e s t, t h e n
The Old Town Clinic adopted its
coordinated care model in 2007. The clinic
has three teams made up of a medical
doctor, a physician assistant or naturopath,
a behavioral health counselor, a panel
manager who keeps track of all the patients,
a medical assistant, and an acupuncturist.
The clinic currently has three patient
teams, each responsible for between 800
and 900 patients. Solotaroff says a fourth
team will be created when an addition to the
Old Town Clinic opens late this winter. A
fifth patient team is planned to start
sometime in 2012.
’
' ~ E a c h te a m m e m b e r
rhai wiilTe^mtoaiTierenTfrohiwriat the
average managed care organization has been
doing,” Teuber says.
Another vexing question is what the
criteria for a CCO will be; An organization
will have to apply to the Oregon Health
Authority in order to become a CCO; The
organization will need to prove that it meets
certain criteria and guidelines.
A balancé must be struck between
flexibility and concrete criteria so that CCOs
can be flexible enough to address particular
health problems in its particular community.
But some fear that if the criteria are not
strong enough, there will be less of an
incentive for the CCOs to truly change how
health care is delivered.
“It’s probably going to look pretty loose,”
says one member of the CCO workgroup
who did pot want to be named. “As we move
forward, I hope something will happen that
will make it clear to people that this is about
behavior change.”
Broad criteria, this member said, could
cause some organizations that become part
h a s s p e cific
responsibilities in. relation to a patient s
health. If something is outside the realm of
that person’s specialization, he or she
communicates with the person on the team
most qualified to address that issue.
The patient will interact with each team
member to varying degrees. An individual
may visit a clinic multiple times when first
admitted to discuss multiple health
problems and have exams, lab tests,
screenings and other procedures done.
“I might see them every week or two
until they are stabilized,” Solotaroff say.
“There’s just pent up demand. If someone
has been in a decompensated state for some
time, there’s lot of stuff you need to take
care right out of the gate.”
The intensive engagement in the
beginning, Solotaroff and Gideonse say, has
multiple benefits: a closer relationship forms
between patient and provider; the patient
begins learning how to manage their
illnesses; and, most important, providers
a
See ORDERED, page 5
State already banking on savings in health care reform
No one is certain health
mi
going to save that money in the first year
says
BY AMANDA WALDROUPE
STAFF WRITER
memb( rs wholly supportive of the changes
tate legislators and other groups
the new policies make are skeptical.
watching the overhaul of the. Oregon
“There is a lot of risk in the budget,” says
Health Plan that would begin
Rep. Tina Kotek (D-Portland). “We have to
providing integrated, coordinated care are
try because we don’t have another option.”
hoping that $239 million will be saved, as
The state faced a $3.5 billion shortfall
the state’s budget has already pressumed.
in its budget this latest cycle. Legislators’
It is unknown how many organizations
cut the reimbursement rate paid to
will become coordinate care organizations, Oregon Health Plan providers by 11
or CCOs in July, the earliest date that
percent and made cuts to administrative
CCOs could begin operating. If there are
costs and health plan benefits.
not many, or they start late, it will be
For the rest of the deficit, policy makers
harder to find savings.
. hope that CCOs will make it up in more
The assumed savings were caustically
efficient care.
criticized by Republican legislators. Even
At best, says Rep. Mitch Greenlick
B
care organization.
caused people to start thinking about what
will be cut instead.
further reducing provider’s
reimbursement rate and increasing the 1
on private hospitals..
Another avenue is to ration the care
and health services people receive -
Dr.
f
,.v
OHSU’s Richmond Clinic, said that he
wants the choice made “to ration care, not
people.”
But he says simple changes can be
made in the clinic to save money. Two
years ago, the Richmond Clinic changed
the way it did urine screens. At that time,
the clinic sent the urine to an outside lab.
It took five days for results to come back,
and cost $500, The clinic began using a
different technology allowing the screens
to be done the same day at the clinic. The
cost was $30.
But no pne is skeptical that CCOs will
have long-term savings. “I think anytime
you integrate care you see better quality
care and you reduce costs,” Kotek says.
“In the long term, we’re going to see
sure.”