Oregon s Health System Transformation: Coordinated Care Model. November 2013 Jeanene Smith MD, MPH OHA Chief Medical Officer

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1 Oregon s Health System Transformation: Coordinated Care Model November 2013 Jeanene Smith MD, MPH OHA Chief Medical Officer

2 The Challenges Oregon Faced Rising healthcare costs outpacing state budget in Oregon Health Plan (Medicaid) and in state employees benefits 85 percent of Oregon Health Plan clients were managed in silos: 16 managed physical health care organizations 10 mental health organizations 8 dental care organizations. Traditional vendor relationships with health plans in both Medicaid and State Employees, without directed accountability nor incentives to be innovative. Only a few alternative payment reform efforts by some payers and a few patient centered medical home pilot efforts 2 Smith

3 Oregon Chose a New Way Better health, Better Care & Lower Costs Governor s Vision Transform the Delivery System Robust public process Bi partisan support Federal waiver approved $1.9B investment tied to quality and reduction in costs New coordinated care model starting in Medicaid, aiming to spread to other state purchased coverage, and into Oregon s Health Insurance Exchange, private payers

4 Smith Coordinated Care Organizations

5 Transforming the health care delivery system

6 What we have accomplished so far March 2012 SB 1580 passed, waiver completed and submitted May 2012 CMS agreement $1.9B July 2012 Waiver approved; contracts with 600,000 new CCOs finalized OHP members transitioned to 15 CCOs in 3 months Sept CCOs launch April 2012 $1B procurement to establish CCOs starts June 2012 First CCO RFPs completed Aug CCOs launch Nov CCOs launch

7 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 Council

8 Federal- State Partnership: Cost and Quality Accountability July 5 waiver signed with Centers for Medicare & Medicaid (CMS), finalized terms and conditions Dec 17, 2012 Approval for CCOs as delivery system Oregon agreed to: lower per capita cost by 2 percentage points Improve quality and access or lose the federal investment of $1.9billion Transparency Ability to compare CCO performance Metrics will be reported quarterly and posted on OHA website Financials posted quarterly

9 Cost and Quality Accountability for the CCOs via Quality Pool: Incentive payments tied to 17 metrics in seven areas critical to reducing costs and improving quality: Addressing chronic conditions Reducing preventable and costly utilization Integrating physical and behavioral health care Improving access to effective and timely care Improving perinatal and maternity care Reducing preventable rehospitalizations Improving primary care for all populations

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11 STATUS TODAY February 2012: Bipartisan legislation passed March July: 1115 Waiver and statewide procurement for CCOs 16 CCOs certified and operational as of today. ~90% of Medicaid recipients get care through a CCO Proof of concept in Medicaid, then to extend the care model.

12 First CCOs have been operating ~ 400 days and the youngest is ~300 days old

13 Just Some of the Current and Future Challenges We Are Working to Address Integrating dental care Ensuring robust provider networks to meet client needs Anti trust Integrating with early learning and education systems

14 Just Some of the Current and Future Challenges We Are Working to Address Increasing consumer engagement and personal responsibility for health Training and using new health care workers Health information exchange Robustly transforming care and paying for outcomes Accounting for flexible services

15 Just Some of the Current and Future Challenges We Are Working to Address Change is hard Change is very hard Time, resources and expectations No time, limited resources and large expectations Operating in both an old and new paradigm

16 How we move forward Health Reform 2.0 Changing care model to bend the cost curve and improve health Proof of concept in Medicaid, then to extend the care model. Align purchasing of care model: begin with Oregon Health Plan, extend to other state purchasing and then align with private sector purchasing

17 Smith Coordinated Care Model Spreading Beyond Medicaid State Purchasing Power: Key elements of accountability included in just released State employees RFP for 2015 plan year Multi payer partnerships underway in Primary Care Home enhanced payments via CMMI/Medicare and local and national private payers Oregon Transformation Center aim to include CCOs and other payers in learning collaboratives on alternative payment methodologies, share innovations Oregon s Insurance Exchange s Qualified Health Plans: development underway to include similar elements, metrics, accountability

18 To learn more.