Oregon Health Authority Announces State's First Certified Coordinated Care Organizations

A majority of the state's Oregon Health Plan patients will be served by the newly forming organizations, but applications covering rural and coastal parts of the state were denied
The Lund Report

May 30, 2012--The Oregon Health Authority announced this afternoon its approval of 11 organizations applying to become coordinated care organizations, the newly forming organizations that will completely change how Oregon Health Plan patients receive care. 

Coordinated care organizations (also known as "CCOs") are the backbone of reforms made to the Oregon Health Plan that the Legislature set in motion with the passage of House Bill 3650 and Senate Bill 1580 in 2011 and earlier this year.

CCOs will integrate and coordinate each Oregon Health Plan patient's physical, mental and dental health starting this August. The hope is by creating patient teams of doctors, nurses, mental health practitioners, community health workers, dentists and various other health providers working with Oregon Health Plan patients, more efficient and effective care will be provided, thus saving costs and decreasing emergency room and specialty care use.

Approximately 650,000 Oregonians are covered by the Oregon Health Plan, and the 11 applications approved by the Oregon Health Authority propose to provide care in most areas of the state. The list of approved and rejected applications can be seen on the Oregon Health Authority's website.

The 11 approved applications have been "provisionally certified," and their formal certification will depend on "additional information necessary to meet the core certification criteria that will be required from these applicants before contracts can be finalized," according to information on the Oregon Health Authority's website. 

The organizations will now enter into contract negotiations with the Oregon Health Authority, and their applications must also be approved by the Center for Medicare and Medicaid Services (CMS). By the end of June, the Oregon Health Authority expects to have the contracts with the organizations finalized.

Four organizations were not approved. They have the ability to change their applications and resubmit them during a "second wave" of applications, due on July 1. What is significant about those disapproved applications is the service area they proposed providing care to--much of Oregon's north coast, including Clatsop, Columbia, Tillamook and parts of Coos and Douglas counties. Another disapproved application proposed covering much of rural, eastern Oregon, including Gilliam, Grant, Harney Lake, Morrow, Sherman, Umatilla and Wheeler counties.

But the Portland metropolitan area--which has the state's largest concentration of Oregon Health Plan patients, estimated at approximately 215,000--need not worry about whether it will have a coordinated care organization. The Tri-County Medicaid Collaborative, a large organization made up of the area's major hospitals, managed care organizations and other organizations, was approved.

In a somewhat surprising turn of events, so was the coordinated care organization proposed by Jeff Heatherington, the CEO and president of FamilyCare, Inc., a Portland-based managed care plan, and one of the state's largest. 

Heatherington, at first, was engaged in discussions to have FamilyCare join the Tri-County Medicaid Collaborative. But when the Collaborative required its members to sign an agreement with a number of provisions--including to not pursue creating another coordinated care organization in the metro area--Heatherington refused, and struck out on his own.

He's happy FamilyCare's proposed coordinated care organization, which intends to provide care in Multnomah, Washington, Clackamas, and parts of Marion counties, was approved--but he also has questions. 

"The provisional part of the certification is something that was a surprise to all of us," Heatherington says. "I think it gives them a lot of leverage in negotiating the contracts and establishing the rules to go forward."

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The deadline for Oregon's CCO's is fast approaching. Unfortunately the Oregon Health Authority has been slow to provide the needed guidance to CCOs and others who support CCO implementation. This may serve as a significant barrier to Oregon's newly forming CCOs to meet the August 1st "go live" deadline. It will also serve to increase barriers to the exchange of patient information between member providers of CCOs. As an example, the non-profit CCOs are considered "business associates" and legally need to execute contracts with all provider and payer members of CCOs. No guidance has been forthcoming from OHA in this area. Community health workers may or may not be employed by providers. If they are not, they are not entitled to access patient information unless the patient specifically authorizes it pursuant to the HIPAA Privacy Rule. There are ways to address what may turn into barriers but as of yet OHA has been silent leaving CCOs and those assisting CCO establishment to flounder in the dark and see barriers to efficient care coordination be erected that will limit CCO effectiveness. Chris Apgar, CISSP CEO & President Apgar & Associates, LLC