CCOs, Providers Push Back On State COVID-19 Vaccination Incentive Plan

Oregon’s Medicaid insurers have widely panned a state proposal that would reward them with nearly $100 million in incentive funding provided they sharply increase the COVID-19 vaccination rates of their 1.3 million members. 

Now, the Oregon Health Authority is revising its proposal, weighing changes that would take into account regional differences and challenges in the state’s vaccine rollout, including variations in vaccination levels and member vaccine hesitancy.

The authority is also looking at other sources of funding for the Medicaid vaccination reward metric, as the original proposal would have pulled money from an existing pot usually reserved to reward coordinated care organizations when they reach other health performance goals.

Vaccination rates are as low as 20%-25% among the membership of some coordinated care organizations, state records show, presenting a substantial obstacle to the state’s desire to have its vaccination drive reach as many disadvantaged groups as possible, including low-income people and ethnic minorities. Vaccination rates are low among all CCOs for white, Black, Native American and Hispanic members, the records show, and are high for Asian members.

The feedback to the state’s proposal from coordinated care organizations, obtained by The Lund Report through a public records request, offers a candid look at the realities the insurers  and health care providers anticipate as the push to vaccinate Oregonians moves from mass vaccination sites into primary clinics and other local provider settings.

The key takeaway: Vaccine-hesitant members are subject to a barrage of vaccine misinformation that is difficult for even the most well-organized campaign to break through. Coordinated care organizations continue to do their part to drive up the vaccination rate. Their workers staff phone banks, send out thousands of mailers across the state and organize teams and events with community partners. 

But they also recognize a harsh reality: In some vaccine-resistant pockets of Oregon, they could not meet the state’s proposed metric of vaccinating 80% of members. And since the vaccine push has many partners -- hospitals, providers, public health districts and non-profit organizations -- the groups make it clear that they don’t want to be penalized and miss out on funding based on vaccination rates due to unrealistic goals.

“While we understand the need to establish challenging goals in order to drive improvement, there is a difference between establishing a challenging, but attainable, goal and one that is merely wishful thinking,” wrote Bruce Butler, CEO of lnterCommunity Health Network CCO, which has nearly 69,000 members in Benton, Lincoln and Linn counties.

Overall Vaccination Rate At 65%

Vaccination rates of coordinated care organization members show the Medicaid insurers face an uphill battle. Individual coordinated care organizations had vaccination rates that ranged from less than 25% to about 46% of adults 16 and older, according to a weekly state report released Thursday. 

The state’s overall vaccination rate was nearly 65% for that age group, health authority data show.

State officials expect Oregon by the end of June to reach Gov. Kate Brown’s goal of vaccinating at least 70% of adults. However, that 70% statewide goal is not the final stopping point. To reach herd immunity, experts estimate states need to vaccinate 75% or more of the entire population, not just adults.

Comments to the Oregon Health Authority from coordinated care organizations and health care providers show that they are uncertain of how much they can drive up vaccination rates, especially given that Medicaid members seem to be far more reluctant to get vaccinated than the rest of the population.

Proposal Favored Big Incentive

The state’s initial concept would have made coordinated care organizations eligible for the maximum amount of incentive money if at least 80% of their adult members were vaccinated by the end of 2021, including all racial and ethnic groups in their membership. They would receive only a portion of their incentive allotment if 65% of members were vaccinated. The state’s proposal would take nearly half of the existing quality pool funding and put it toward vaccine rates. The entire pool is roughly estimated at $200 million for 2021. 

However, coordinated care organizations and health care provider groups told the Oregon Health Authority that the 80% target is unrealistic, especially in regions of the state where vaccine hesitancy is high, public records show.

In addition, coordinated care organizations say the state’s proposal to put such a lot of the incentive money toward vaccine rates jeopardizes too much of the incentive pool, which has become a relied-upon annual source of funding for the companies, they argue in emails and letters submitted to Oregon Health Authority officials. 

The state traditionally distributes the incentive funding based on a variety of health improvement measures that each coordinated care organization works with its health care provider partners to reach. The goals range from dental sealants for children to better birth control for women who are at risk of unintended pregnancies. Other measures include weight assessment and counseling for patients, depression screening and smoking cessation.

Without a vaccine metric, Oregon already has 14 measures for 2021. The state picks the measures each year based on public health steps it wants to prioritize. The state’s 16 coordinated care organizations insure the nearly 1.3 million Oregonians on Medicaid -- almost 30% of the state’s population -- using federal and state money allocated by the health agency. Each insurer is assigned one or more regions.

Last October, the state gave coordinated care organizations $160 million as a reward for hitting the health improvement goals of 2019. An estimated $200 million incentive money anticipated for 2021 is just a small portion of the $5 billion the insurers will receive for the year. But the incentive money is valued highly by the insurers because it is extra cash that they can scramble for, on top of the standard per-member monthly payment they receive from the state. The insurers typically share the money with health care providers that work to meet the incentives.

The objections and other comments submitted by the coordinated care organizations, obtained by The Lund Report through a public records request, highlight questions about how effective the insurers could be in helping the state’s vaccination drive as it shifts away  from mass vaccination clinics and into the hands of primary care providers. The documents lay bare the challenges of health care providers as they face a vaccine-hesitant public, primarily rural areas of the state where the current vaccination rate is well below 40% in some counties.

The mass vaccination clinics have drawn in members of the public who wanted to be vaccinated. Reaching those less eager may be far more difficult.

CCOs’ Gave ‘Strong Pushback’

It’s unclear what the next version of the state’s proposed vaccine metric may look like. But it may include changes to the source of funding as well as the state’s mechanism for determining if a coordinated care organization reaches the metric. For example, the state is exploring a change to the metric that would reward “incremental progress” and take into account each coordinated care organization’s starting place in the process, a health authority spokesman said.

Oregon Health Authority Director Patrick Allen told the House COVID-19 Subcommittee on Wednesday that the agency has received some “strong pushback,” especially on the proportion of the incentive funding the state proposed for rewarding vaccination rates. That’s because any incentive money put toward vaccine metrics would take away from the pot of money for coordinated care organizations that reach the other previously established health targets, Allen said. 

Allen said the agency is exploring other funding sources for the vaccine incentive work, but didn’t elaborate. “It’s all still pretty in flux, but those are the conversations we’re having,” Allen said.

A health authority spokesman on Friday declined to identify what the potential sources of funding may be. The state may release a new proposal as early as next week.

The health authority received feedback after it emailed a draft of its vaccine metric to the leaders of coordinated care organizations on May 5. The authority asked for comment. 

It came back in volumes.

‘All Stick And No Carrot’

Coordinated care organizations say the state’s proposal would remove money from the existing incentives and replace it with a new vaccination goal of 80% that would be difficult if not impossible to reach. 

“The performance thresholds are exceedingly high especially in light of the well demonstrated vaccine hesitancy,” Tayo Akins, chief executive officer of Cascade Health Alliance, wrote to the authority. “Many CCOs are likely to fail this measure.”

Akins added: “As proposed, this looks and feels like ‘all stick and no carrot.’”

Cascade Health Alliance serves parts of Klamath County with an enrollment of about 22,300. 

Akins added that providers would object, since they are already working hard on vaccination and the proposal doesn’t “fairly demonstrate the reality” in each county. 

“This proposal is designed for CCOs to fail, and not get credit for the effort and difficulty of execution of this measure as proposed,” Akins wrote.

The blunt assessment is echoed throughout the feedback from CCOs.

“Given that national experts consider it unlikely that the nation will reach herd immunity, we are concerned (about the possibility of) few to no CCOs meeting even the minimum requirements for a payout,” wrote CareOregon, Columbia Pacific CCO, and Jackson Care Connect in a joint letter.

The group said the state’s proposal runs the risk of disincentivizing providers to meet the other CCO metrics because it removes funding they would otherwise get for other work.

Columbia Pacific CCO covers nearly 31,000 people in Clatsop, Columbia and Tillamook counties. Jackson Care Connect covers nearly 56,000 in Jackson County. 

PacificSource Community Solutions questioned the ethics of connecting vaccination rates to dollars that are intended for community programs.

Given that “many of those covered by Medicaid are from underrepresented groups who have been historically subjected to coercive medical practices, tying vaccination rates to dollars that will go back to those communities is not ethical,” the group wrote. PacificSource covers nearly 270,000 people in central Oregon, the Columbia River Gorge and Maron, Polk and Lane counties.

Criticism also came from Coalition for a Healthy Oregon, which represents six coordinated care organizations, and which had asked the state to consider a vaccine metric in late March. The coalition’s idea, however, called for only putting 10% of the incentive funding into a new vaccine measure. The group also had recommended the metric be based on the portion of providers in the network that offers vaccinations, the care organization’s communication to members about the vaccine and the opportunity of members to get a timely vaccine.

“The proposal to vaccinate 65% or 80% of the population by year’s end is not realistic

given the population remaining and the growing skepticism toward the manner in which COVID-19 has been addressed over the last year,” Paul Phillips, executive director for the coalition, wrote. “Further, using the same benchmark statewide is inequitable given the unique populations we serve. These are personal choices that CCOs have little influence over.”

The coalition represents Trillium Community Health Plan, Umpqua Health Alliance, Cascade Health Alliance, Advanced Health, AllCare CCO and Yamhill Community Care. They serve Medicaid recipients in regions that include the Portland area, Lane County and southwestern Oregon.

Trillium submitted a separate letter and reminded state officials that prioritizing COVID-19 vaccinations, while important, is “at the expense of other equally critical preventive care focus areas including diabetes monitoring, child and adolescent immunizations, and behavioral health interventions, among others.”

“This is not the year to pull funds from the quality metrics program and will directly impact and frustrate providers,” wrote Chris Hummer, CEO of Trillium Community Health Plan. 

Rural CCO Voice Concerns 

Officials at coordinated care organizations that serve rural areas are particularly concerned. They stand to not receive millions in incentive funding if the state puts forward an unrealistic vaccine target that doesn’t match the reality of vaccine hesitancy and the limited influence of coordinated care organizations and the health care providers they work with.

Eastern Oregon CCO said it would not receive up to $7 million in incentive funding for 2021 if the state’s metric proposal is put in place without changes. Incentive money is channeled to providers and communities, the group said in its letter, adding that the lack of funding would have a “devastating impact” on its ability to engage health care providers.

“EOCCO can certainly have an impact on vaccine efforts, but unfortunately our role and influence can only go so far,” the group wrote. “It has been challenging to identify ways that CCOs can help health departments and clinics get more ‘shots in arms.’ The limitations to higher vaccine rates to date are more related to attitudes and beliefs than organizational issues that EOCCO can address.”

Eastern Oregon CCO said the 80% target would be all the harder to hit in rural areas compared to urban areas. Its internal vaccination rates bear that out, records show. Its eligible members had a vaccination rate of 12% to 26% in each of the dozen rural counties in the CCO’s territory as of May 4. That’s well below the region’s vaccination rate for the total population at the time, which ranged from 31% to 49% in each county.

EOCCO’s has nearly 61,000 members in a vast swath of 12 counties in rural Oregon -- the most geographic territory of all the CCOs.

Numerous factors contribute to the disparity. Low-income people on Medicaid face barriers to vaccinations, may be more vaccine hesitant, or may be less likely to get regular primary medical treatment. 

“It is unrealistic to think that EOCCO alone should be financially at risk to more than double vaccination rates between now and the end of the year,” the group said.

lnterCommunity Health Network CCO said the target needs to take into account the demographic and cultural differences that make uniform vaccination levels statewide unrealistic. Butler, its CEO, urged the authority to pursue “appropriate and realistic targets.”

The organization also is concerned that creating a direct financial link for CCOs to drive immunizations could jeopardize its trust with members and communities.

“When (Medicaid) members learn that CCOs will be paid significant amounts to get them immunized, especially BIPOC populations, it may only reinforce negative perceptions of CCO motives and impair CCOs' abilities to interact with their communities in culturally sensitive and appropriate ways,” Butler wrote.

Like other Medicaid insurers, AllCare Health CCO said the metric’s proposed one-size-fits all approach doesn’t take into account the different vaccine hesitancy rates, while also reducing funding available for the other unrelated health measures. The organization has about 54,000 members in Curry, Douglas, Jacson and Josephine counties.

“This metric, as currently proposed, does not provide flexibility; will largely benefit suburban providers and large health plans over the rest of the state; and will likely be counterproductive because it will anger (health care) providers in our communities having to achieve another metric in a long list of others,” the group wrote.

CareOregon, in its letter, said CCOs in rural areas face a disadvantage, with limited access to doses at the start of 2021, and a “steeper path to achieving targets.”

CCOs Suggest Alternative Funding And Measurements 

Broadly, coordinated care organizations urged the health authority to lower the share of the quality incentive funding that would go to the vaccine metric, or look for an alternative source of money, such as COVID-19 federal relief dollars through the American Rescue Plan.

CareOregon suggested a methodology taking into account CCO efforts at outreach and boosting access, rather than a vaccination rate. 

The group said this would address regional variances in vaccine hesitancy and vaccine distribution.

Its alternative also would address another bone of contention: the health authority’s initial proposal would only award money if CCOs hit targets for every ethnic and racial group. 

Under CareOregon’s option, an organization could receive a stepped approach of 10% to 100% funding awarded, depending on its vaccination rate. Coordinated care organizations that reached overall targets but failed to reach every race and ethnicity would receive reduced funding instead of none. 

“While we agree to strive for reaching the goal of 80% vaccination, even a 65% vaccination rate would be an achievement,” the group wrote. “This alternate proposal honors the aspirational goals while also taking into consideration what is likely achievable.”

Health Share of Oregon, which has about 379,000 members in the tri-county Portland region, floated a similar idea, suggesting that the state consider more payment categories for varying degrees of success.

Coalition For a Healthy Oregon suggested targets based on the rate of improvement for a particular region, rather than one flat rate.

“Not everyone wants a vaccine,” the coalition wrote. “Some people fear the government; CCOs and providers are not seen as ‘the government’ and are well positioned to drive the vaccination efforts in their communities. However, we can’t have an all-or-nothing metric. We share your goals around vaccination, but we need to bring people along.”

Providers Critical Of State Proposal 

In a letter, the Oregon Association of Hospitals and Health Systems said it supports the concept of a vaccine metric, but has concerns about tying almost half of the quality pool funds to “strict vaccination thresholds.” 

“These funds are often used to incentivize overall quality and outcomes for the Medicaid program,” wrote Becky Hultberg, the association’s CEO. “Redirecting existing resources during a time of great need for this underserved population could ultimately harm quality, having the opposite of the intended effect. Tying these funds to untested vaccine outcomes would hurt vulnerable populations as well as the organizations that have stepped up to help with vaccinations in Oregon, all with little to no discussion with CCOs and the provider community.”

Hultberg suggested the health authority convene health care providers, coordinated care organizations and others and work on a plan to increase vaccinations.

In a joint letter, insurer Providence Health Plan and the Providence Health & Services hospital system urged the health authority to collaborate more with the industry and vet the proposal. 

Providence officials urged the health authority to reconsider its approach, which would bypass the agency’s Health Plan Quality Metrics Committee, a public process set in state law. Instead, the health authority would administratively create an “emergency outcome tracking” goal that pulls money out of the incentive funding. The health authority, in its proposal, noted that the regular process to approve a new metric can easily take two years or longer. 

“While we understand that this is an unprecedented time, Providence believes we should remain consistent with statutory requirements and our proven processes related to quality metric development and adoption,” Providence executives wrote, adding that “circumventing the existing process” will not serve the state’s long-term needs.

The Oregon Academy of Family Physicians said small practices with limited resources face logistical challenges to provide vaccinations and help their regions meet the metric. The group  raised concerns about the public perception that health care providers would receive money to increase vaccination rates.

“If patients perceive that their healthcare provider is being paid to increase vaccination rates, but only for some patients, that may damage the patient-provider relationship,” the group said. “That trust, once damaged, is exceedingly difficult to rebuild.” 

The group recommended changing the funding mechanism for boosting vaccination rates. If the health authority decides to use the incentive funding, the group said, the amount for the vaccine metric should be less, given there are 14 other health measures. The group suggested the authority use federal American Rescue Plan dollars to fund vaccination incentives.

You can reach Ben Botkin at [email protected] or via Twitter @BenBotkin1.