Clark County Expansion Provides Contrast to Oregon Medicaid System

Oregon had an incentive to get as many new Oregon Health Plan enrollees it could handle -- every new member increases revenue for the CCOs, increases the risk pool, and helps bolster finances needed to make the Medicaid system transformation work.

With 425,000 people, Clark County is the third-largest county in the Portland metro area and has more than 20 percent of the metro area’s 2.1 million residents, but the Columbia River cuts a wide gulf when it comes to healthcare access for the Northwest’s most vulnerable citizens.

Gov. John Kitzhaber has engaged physicians, managed care plans and hospitals to work together in coordinated care organizations to figure out how to serve the state’s Medicaid population.

But Washington is still left with the older system and a patchwork of managed care that has left Clark County with two separate health arenas -- one for those on Medicaid, known in Washington as Apple Health, and one for those with private insurance and Medicare.

In Clark County, the vast majority of Apple Health members receive their care through federally qualified health centers, particularly Sea Mar Community Centers, a clinic chain based in Seattle.

Because of differences in Medicaid management, Sea Mar is one of the few clinics in Vancouver that will accept Medicaid patients, and clinic director Lynnette Pickup estimated that they see about 90 percent of the Apple Health members in Clark County.

By contrast, Dean Andretta, the interim director of Willamette Valley Community Health, which is responsible for the Oregon Health Plan in Salem, said only 23 percent of its members see primary care providers in Marion and Polk counties’ federally qualified health centers.

Pickup said referring patients outside the clinic to speciality care involves a delicate process, and most Portland specialists won’t accept their patients, who typically must head north to the Puget Sound area. Oddly, she said they do send urology patients to Oregon -- 90 miles upriver to The Dalles -- not Portland.

Because it receives a separate set of federal funding for community health centers, Sea Mar is able to function and do its work with many of the innovations that are being adopted by the coordinated care organizations, such as wraparound care, community health workers and have included some mental health staff inside the clinic.

Nate Robinson, the clinic manager for the location on Mill Plain Boulevard on the east side of Vancouver, said his clinic has gone from serving 4,500 patients last December to keeping a caseload of 9,400 in its primary care home. “That’s just Apple Health. We haven’t added another practitioner,” Robinson said. “We’re actively trying to add a new provider.”

Sea Mar has plans to open a third primary care clinic in Vancouver within the next six to nine months to keep up with demand, and is actively looking to hire more primary care practitioners.

For specialty care, Sea Mar has gotten around its lack of access to Portland specialists by doing what it can in-house, hiring its own gastrointestinal physician, as well as a keeping a staff cardiologist and pediatricians. It has orthodontists in its own dental clinics, psychiatrists in its own mental health clinics and recently bought a gynecologist’s office in Orchards. Sea Mar worked with that physician to start a women’s health clinic in Orchards this spring.

When asked about access to his hospital system, Legacy Health spokesman Brian Terrett declined to comment for this article, but Gary Walker, the Oregon spokesman for Providence Health System, said that its Oregon hospitals do accept Apple Health members. Walker added that Apple Health members in Clark County are assigned to one of four managed care plans, and Providence receives patients at its Vancouver clinics,  through Columbia United Providers.

Since Jan. 1, Washington has enrolled 400,000 people in Apple Health, bringing that program’s total to 1.6 million, according to Jim Stevenson at the Washington Health Care Authority. Oregon has tallied 382,000 sign ups for its Oregon Health Plan, bringing the program to nearly 1 million.

Based on population size, Oregon should not be pulling neck-and-neck with its much larger cousin to the north -- Oregon has barely half the population of Washington.

It’s likely the credit of the healthcare transformation that Oregon has signed up so many people -- the global payments that pay the coordinated care organizations by the number of members each month, gives the state a heavy incentive to get as many people enrolled as possible.

Washington has a method similar of signing up people similar to Cover Oregon, and Sea Mar outreach worker Becky Gonzalez told The Lund Report that Clark County has more than 70 in-person “assisters” helping people enroll in Apple Health around the community, attending events and canvassing neighborhoods. Similar efforts have been made in Oregon. Sea Mar also signs up dozens of people each month who come through its doors

But Oregon had an additional tool that made it even easier on people who qualify for Medicaid  -- the Fast Track program, which gave everyone who had already qualified for Food Stamps the chance to get medical coverage. Since these people had more actively sought food stamps, not healthcare, they are likely to be less engaged in the medical system, and less likely to actively use medical services.

Fast Track has signed up 141,000 people; Cover Oregon has brought in another 241,000, which by itself nearly eclipsed the state’s projected new enrollment of 257,000 -- by 2016.

Whether by shrewd foresight or by happy accident, the aggressive expansion effort has greatly increased revenues for the coordinated care organizations, helping to finance the delivery system. Kitzhaber’s office wouldn’t comment directly for this article, but Patty Wentz, the spokeswoman for the Oregon Health Authority, agreed that the added tool of Fast Track helped the state get people signed up faster.

“It absolutely helped us get people in earlier,” Wentz said.  “It has been a fantastic tool to help people get coverage. That said, I’m pretty confident we would have hit the projection by 2016 without it.

“The reason we did the fast-track waiver was the same reason we streamlined the application process and used presumptive eligibility for Healthy Kids,  which started in 2009,” she added. “That is: get as many into coverage as possible.”

In some areas, such as Eugene and Klamath Falls, the CCOs have been unable to keep up with the enormous expansion, but in areas where they do, the CCOs are given a much larger pool, which lowers risk.

The new Oregon Health Plan population also skews young -- 44 percent of its adult population is under 35, giving the CCOs a population that is apt to be much healthier than the Cover Oregon pool, where just 23 percent of adults are in this age group.

Young adults in Oregon have signed up for Obamacare in droves, taking Oregon Health Plan coverage when it’s offered. They’ve just been less likely to climb on board when they have to pay a premium.

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