Departing Oregon Health Policy Board Member 'Shocked' At Response To Health Equity

Felisa Hagins says the state has failed to ensure that Oregon’s coordinated care organizations have the financial incentive next year to improve access to care for diverse populations.

A longtime member of the board that advises the state on health policy and reform questioned the state’s commitment to ensuring equitable health care to low-income Oregonians.

Labor union leader Felisa Hagins expressed her concern at her last meeting of the Oregon Health Policy Board.  Her term is over after nine years of advocating for health equity, often asking tough questions and calling on officials to deliver better health care to Oregon’s most vulnerable populations.

In her final meeting Tuesday, Hagins asked her fellow board members to do more to ensure all residents have the same access to care. She also blasted the state’s lack of financial incentives to improve care for diverse populations following a fellow board member’s report. He said that health equity will not be included in the quality metrics that will determine financial bonuses to coordinated care organizations next year.  

Felisa Hagins
“I cannot believe after a year of having these conversations directly with this committee that they still have not done something meaningful on it,” Hagins said. “It’s so shocking to me.”

Oregon’s coordinated care organizations — which manage care for the state’s low-income Medicaid patients on the Oregon Health Plan  — can earn as much as $187 million in bonuses this year by meeting or exceeding the metrics on 12 out of 16 incentive measures.

Known as the quality incentive pool, the bonus money is meant to encourage positive health outcomes by rewarding coordinated care organizations for prioritizing quality of care instead of just earning money for each procedure completed.

“We’ve watched these CCOs make major improvements when they’ve been financially incentivized to do so,” Hagins said.

The incentive metrics for 2019 include child immunizations, cigarette smoking, depression screening and follow up, the ability to control hypertension, timeliness of prenatal care and contraceptive use.

They do not, however, include metrics on health equity.

“Seeing where they’ve decided to put their cash money without a mention of equity in it is really disappointing,” Hagins said. “If we really want to (improve) health disparities, we’re going to have to incentivize it.”

Board member Dr. John Santa, the liaison for the quality metrics committee, said at the meeting that there will be future opportunities to put health equity into the incentive metrics, which change each year.

Improving health equity is among the priorities the state adopted last month for the next chapter of its Medicaid program, known as CCO 2.0. The guidelines will help the Oregon Health Authority choose which coordinated care organizations will manage the state’s Medicaid program from 2020 through 2025.

Santa said the responsibility for setting benchmarks lies with the Oregon Health Authority, which has convened a working group of state specialists on metrics, health analytics and equity to analyze the issue.

“Ultimately, the Oregon Health Authority has to do the work,” Santa said.

That work group will recommend a health equity measure to the metrics-setting committees for inclusion in the list of incentives for 2020, when the next five-year contract for coordinated care organizations starts, said Jon Collins, the health authority’s director of health analytics. They first have to determine how to define health equity and then measure any progress.

“It will serve as a good time to put in place a measure like that, which would be a groundbreaking measure, given that there isn’t anything of that sort that’s being used nationally,” Collins said.

Oregon statute requires the group to follow a specific process for introducing new metrics.

Since 2015, a quality metrics committee selects a list of possible quality measures based largely on research done by national groups. A second metrics committee chooses which measures make the incentives list from the list of pre-approved options.

The Oregon Health Policy Board’s recommendation to include the health equity metric in the 2019 incentive measures last spring came too late, Collins said. The quality committee had already put its list together, which the committee sent to coordinated care organizations in the fall.

“We want to give CCOs enough notice for the upcoming year so they can be prepared for it,” Collins said.

Board members argued that waiting to incentivize health equity through the next round of coordinated care contracts does not address the issue soon enough.

“We’re going to tell people who waited 200 years to get some quality health care, wait another year,” Hagins said.

Another board member, Dr. David Bangsberg, suggested breaking down the quality metrics across racial and ethnic lines and then comparing improvement between the two groups.

“I hear an explicit need to put something in here,” said Bangsberg, who was appointed vice chairman of the health policy board on Tuesday. “From an analytic point of view, it’s not difficult.”

Jeremy Vandehey, the Oregon Health Authority’s director of health policy and analytics, suggested the health policy board write to the committees responsible for setting metrics to make sure they are on track to include health equity in their measures.

The Oregon Health Policy Board is an advisory group that recommends policy and oversees the Oregon Health Authority. The board does not have regulatory or enforcement authority over the health agency, which reports to Gov. Kate Brown.

“Now is the right time to provide some additional guidance,” said outgoing board chair Zeke Smith. He will step down as chair after this year.

With her time on the board behind her, Hagins continues as the political director for the Portland-based Service Employees International Union -- SEIU Local 49. She said wished that health equity could have made the incentives list by the end of her term.

“It’s just phenomenal, the changes that I’ve been lucky enough to be a part of,” Hagins said Tuesday. “Staying the course is super critical.”

Gov. Brown appointed Hagins to the Oregon Health Policy board. She thanked Hagins in a letter that commended her for her role in making Oregon a national leader in health care.

"I cannot thank you enough for all the work that you have done, except to say that I will ensure your efforts are built upon in years to come and beyond," Brown's letter said.

Smith complimented Hagins for being a vigorously involved member, “sometimes as “rabble-rouser, sometimes as a collaborator.”

“It was always great to have somebody who was not afraid to bring our history into the story of what we’re trying to do here, both of the board, but also of this state,” Smith said. “It impacts the way we should be thinking about what we want to do moving forward.”

You can reach Jessica Floum at [email protected].

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