The Impact of Medicaid Reform on the Role of the Health Plan

Presented by Margaret S. Rowland, MD at the Executive Leadership Summit on March 24 - 26, 2015.

Oregon has implemented Coordinated Care Organizations (CCOs) as its Medicaid delivery system. CareOregon was the state's largest Medicaid managed care plan and is now involved with four different CCOs. Two of these CCOs are wholly owned subsidiaries of CareOregon. In the Portland metro area, CareOregon is a founding partner of the CCO (Health Share) and is a risk accepting entity. In one other (Yamhill CCO), CareOregon has a management services agreement to provide health plan services. Dr. Rowland examines the nature and structure of CCOs as well as some of the successes and challenges of these structures., paying particular attention to their impact on the function of a health plan.

Transcript

1. The Impact of Medicaid Reform on the Role of the Health Plan Margaret S. Rowland, MD
2. Oregon Health Plan: 1994 - 2012 State of Oregon mental health drugs residential services long term care Multiple MCOs physical health/ED chemical dependency pharmacy Multiple MHOs inpt. and outpt BH Multiple DCOs limited dental benefit
3. • The state contracted with managed medical (MCO), dental (DCO) and behavioral health (MHO) organizations • State kept accountability for LTC, psych drugs, certain residential treatment benefits • Prioritized list of covered benefits – “the Line” • ABD population always included • OHP Plus – expansion population – Limited benefit Oregon Medicaid: 1994-2012
4. • Founded in 1993 by 3 county FQHCs and OHSU as a way to manage the emerging OHP members • Largest MCO in Oregon • Near bankruptcy in 2002 • 2006 – started a Medicare SNP plan CareOregon Pre-2012
5. Health Plan of CareOregon, Inc. Medicare dual SNP traditional MA plan CareAccess, LLC Rockwood building CareOregon, Inc. (OHP) Corporate Structure - 2011
6. Who We Were….. 2011 • Medicaid & Medicare managed care organization • More than 170,000 Oregon Health Plan and ~8,000 Medicare Advantage members – Most MA members are enrolled in Special Needs Plan • 76% of members live in the Portland metro area • 54% of members are female • 59% are 19 & younger; 19% are 4 & younger • 26% do not speak English as their first language • 46% self identify as non-Caucasian
7. • In July, 2011 HB 3650 was passed moving Medicaid from siloed systems of care to CCOs (Coordinated Care Organizations). • Go live was Sept., 2012 Change Happens
8. Legislative Vision of CCOs Integration & coordination of benefits & services Local accountability for health & resource allocation Standards for safe & effective care Global budget indexed to sustainable growth Redesigned Delivery System Healthier population Improved Outcomes Reduced Costs [The Triple Aim] [A CCO]
9. • Community based organization bringing physical health, behavioral health and dental health under a global budget • Local Clinical Advisory Panels (CAPS) • MOU with the LTC system • Independent BOD • Community specific “transformation plan” included in the contract with the state • Establishment of a CAC (Community Advisory Committee) Elements of a CCO
10. • 4 PIPs (process improvement programs) – Physical/behavioral health integration PIP is mandatory • 17 Incentive metrics – Focused on health outcomes – Significant dollars available, used to invest in improvement – Bar is raised each year • $1.9B in Federal Support over 5 years – Future payments dependent on • Reducing the cost curve by 2% annually • Demonstrating improved health outcomes (incentive metrics) and improved experience of care (CAHPS) Elements of a CCO (cont.)
11. CareOregon 2012: Entities & Partners Yamhill County Care Organization (CCO) Health Share of Oregon (CCO) CareOregon, Inc. (OHP) Health Plan of CareOregon, Inc. (Medicare) Care Access LLC (Rockwood Bldg) Jackson Care Connect, LLC (CCO) Columbia Pacific, LLC (CCO) LHW, LLC Lean Healthcare West CareOregon Dental
12. • Columbia Pacific and Jackson Care Connect – Both wholly owned subsidiaries of CareOregon – CareOregon Dental contracts to provide dental services with JCC – CareOregon holds the risk • Health Share of Oregon – CareOregon is one of 11 founding organizations – CareOregon is a risk accepting entity (RAE) for medical, pharmacy and chemical dependency services – CareOregon contracts to provide administrative services – CareOregon Dental is a dental RAE • Yamhill Co CCO – CareOregon contracts to provide administrative services Similarities/Differences of CCOs
13. • Accountable for 240,000 members – largely through 4 CCOs – ~ 5,000 CareOregon members remain • 11,000 dually eligible Medicare SNP members • ~ 2,000 non-dual MA members • 48,000 dental members CareOregon Today
14. • CCOs create aligned financial incentives across the health care systems – Health plans – Hospitals – Providers Opportunity If you want to understand the outcomes…… just follow the money!
15. Change is Required • If the role of the health plan is to protect member safety by filling the gaps in the health care system………… • A change in the system requires a change in the role of the health plan.
16. • Integrated systems get better outcomes • The best driver of member satisfaction is provider satisfaction • Closing gaps in care cannot be done by a health plan – Needs to be standard work within clinics Observations
17. Organizational Characteristics • History of Innovation – starting in 2004 (“outrunning the bear”…..) – Bio-psycho-social case management – Care Support and System Innovation “grant” program – Primary Care Renewal (medical homes) – Palliative Care – Health Resilience program – IDEO projects: Give2Get, Food Rx, etc. • History of Change Management – OPEX (operational excellence) teams • API (Advanced Process Improvement) and Lean
18. Give2Get Combatting social isolation FoodRx Providing at risk Oregonians access to fresh healthy food Housing with Services In-home provision of health services to members Health Resilience Program High touch, trauma-informed support to high utilizers Human Centered Design and Innovation
19. • Enhanced transparency (esp. financial) • Working with the provider community – regular meetings with the local providers • Local Staff – CCO executives, medical directors, etc. • Support for building clinic infrastructure – PC3, PCIF • CMMI grant – Providers take on discharge planning – Health resilience program • Embedded staff Doing Work Differently
20. • The best driver of member satisfaction is member satisfaction – PCIF – Primary Care Investment Fund – Embedded pharmacy, clinical staff and panel managers – Minimize perceived administrative barriers (authorizations) Working for Outcomes
21. Evolving Structure
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