In depth: CCOs Report Mixed Gains on Performance Metrics

None of the CCO met all benchmarks, with Medicaid expansion, changing health recommendations complicating efforts to measure performance.

Oregon’s coordinated care organizations are moving forwards, backwards and sideways in their efforts to measure improvements to the care they provide, according to a state snapshot of performance metrics released this month.

In “Oregon's Health System Transformation: CCO Metrics 2015 Mid-Year Update,” the Oregon Health Authority reviewed how the state’s 16 CCOS performed on 17 “incentive metrics” from July 1, 2014, through June 30, 2015. These metrics were chosen through a collaboration between the state and federal Medicaid officials, who are carefully watching Oregon’s only-one-of-its-kind attempt to reinvent healthcare. By mid-2016, the Oregon Health Authority will crunch the numbers to determine how performance on these metrics affects the money these CCOs receive.

“Each CCO is given an improvement target. As long as they meet their target each year, they get paid for making progress on the metric,” Lori Coyner, Oregon’s state Medicaid director, told The Lund Report.

“For a CCO to receive 100 percent of its quality pool funding, they need to meet their improvement target, or they have to meet the benchmark for 12 of the 17 incentive metrics. They have to have 60 percent of their members in patient-centered primary care homes,” she said.

No CCO is at that level yet, according to the figures released this month. And the state’s not prepared to rank CCOs or reveal how much money each will receive based on its calculations so far. But Coyner said the data does show that the state’s effort to allow a diverse array of for-profit and nonprofit CCOs to learn by experimenting, and to develop community specific approaches, seems to be working overall, despite sideways and backwards movement along some metrics.

“There’s steady improvement across the years,” she said. And that means many CCOs will receive incentive payments, even if they don’t receive the full amount possible.

“We do pay incentives for improvement, not just for meeting the benchmark,” Coyner said. “The benchmark is a goal. It’s the level we expect to have our CCOs performing at to be considered one of the top performing Medicaid agencies in the country – to be exemplary.”

Coyner cautions that the state’s 17 metrics don’t measure all the care that’s provided across Oregon, and don’t show the full quality of care at each CCO. “You have to be careful about saying whether they provide quality care to their members, based just on this report,” she said.

But, as a look at some of those metrics shows, some efforts to measure health performance are far from perfect, and some of the challenges CCOs face are beyond their control. For example, the state has been measuring how many women are screened for cervical cancer every three years – but national guidelines have changed for these screenings, and now recommend a screening ever three to five years – so CCOs that perform below the state’s target may still be doing quite well.

Here are the details for several metrics. Click here to see the state’s full analysis.

Adolescent well care

“Some metrics are much harder to move than others. For example, adolescent well care – we see small improvement over time,” Coyner said. It’s difficult to get kids in who are in that age range for their well- care visits. So that measure, we are making small, incremental progress, it’s a difficult one to move. On the flip side, developmental screening – we see big gains every year. I think part of it is the focus of the community. There are early learning hubs and alternative learning models for making sure that kids are screened.”

The state wanted 62 percent of 12- to 21-year-old CCO members to receive a well-care visit in 2015, and also wanted to improve its performance over 2014. Instead, only 32 percent of people within this age group received well-care visits – the same number as in 2014. Ten CCOs saw improvement on this measure, though it was only incremental in some cases. Another six CCOs moved backwards.

How each CCO performed on this particular metric:

  • AllCare Health Plan: 22.6% of 12-21 year olds had a well-care visit in 2015, up from 22.1% in 2014.
  • Cascade Health Alliance: 19.5% of 12-21 year olds had a well-care visit in 2015, up from 19.4% in 2014.
  • Columbia Pacific: 25.3% of 12-21 year olds had a well-care visit in 2015, down from 25.3% in 2014.
  • Eastern Oregon CCO: 23.8% of 12-21 year olds had a well-care visit in 2015, down from 23.8% in 2014.
  • FamilyCare Inc: 41.2% of 12-21 year olds had a well-care visit in 2015, down from 41.2% in 2014.
  • Health Share of Oregon CCO: 41.2% of 12-21 year olds had a well-care visit in 2015, down from 45.6% in 2014.
  • Intercommunity Health Network CCO: 25.7% of 12-21 year olds had a well-care visit in 2015, up from 24.1% in 2014.
  • Jackson Care Connect: 26.4% of 12-21 year olds had a well-care visit in 2015, down from 26.4% in 2014.
  • PacificSource-Central: 26.9% of 12-21 year olds had a well-care visit in 2015, down from 27.1% in 2014.
  • PacificSource-Gorge: 32.7% of 12-21 year olds had a well-care visit in 2015, up from 32.2%.
  • PrimaryHealth of Josephine County: 29.8% of 12-21 year olds had a well-care visit in 2015, up from 28.7% in 2014.
  • Trillium Community Health Plan: 29.5% of 12-21 year olds had a well-care visit in 2015, up from 28.7% in 2014.
  • Umpqua Health Alliance: 21.3% of 12-21 year olds had a well-care visit in 2015, up from 30.8% in 2014.
  • Western Oregon Advanced Health: 36.4% of 12-21 year olds had a well-care visit in 2015, up from 34.3% in 2014.
  • Willamette Valley Community Health LLC: 29% of 12-21 year olds had a well-care visit in 2015, up from 28.7% in 2014.
  • Yamhill CCO: 36.5% of 12-21 year olds had a well-care visit in 2015, up from 31.6% in 2014.

Avoiding excessive emergency department care

Oregon officials believe far too many emergency department visits are still for non-emergency medical needs. The state is trying to reduce these visits to fewer than 39.4 per 1,000 member months. Oregon's CCOs are making steady progress at this goal. In 2011, state Medicaid providers saw 61 emergency department visits per 1,000 member months. By 2015, that was down to 47 per 1,000 member months – still below the goal, but a strong move in the right direction.

Though there’s been some speculation that new CCO members could be using the emergency department too frequently – keeping this metric high as a result of the Medicaid expansion -- the Oregon Health Authority’s analysis found that was not the case.

“We saw lower emergency department use among those new members, actually, that was reported in our last report,” Coyer said. “Members with disability and members with mental health diagnoses do use the emergency department quite a bit more frequently than statewide numbers for Medicaid. There are some opportunities to target and work with certain populations that could help further reduce emergency department visits. That’s one of the advantages of starting to be able to stratify data by some different metrics.”

How each CCO performed on this metric (a lower number is better) – the goal is 39.4 or lower:

  • AllCare Health Plan: 38.7, compared to 41.4 in 2014.
  • Cascade Health Alliance: 36.2, compared to 34.4 in 2014.
  • Columbia Pacific: 46, compared to 47.5 in 2014.
  • Eastern Oregon CCO: 54.8, compared to 54 in 2014.
  • FamilyCare Inc: 42.4, compared to 43.8 in 2014.
  • Health Share of Oregon CCO: 48.9, compared to 49.3 in 2014.
  • Intercommunity Health Network CCO: 50.2, compared to 48.6 in 2014.
  • Jackson Care Connect: 47.8, compared to 48 in 2014.
  • PacificSource-Central: 42, compared to 41.9 in 2014.
  • PacificSource-Gorge: 41.5, compared to 42 in 2014.
  • PrimaryHealth of Josephine County: 33.4, compared to 38 in 2014.
  • Trillium Community Health Plan: 51.4, compared to 50.6 in 2014.
  • Umpqua Health Alliance: 62, compared to 64.7 in 2014.
  • Western Oregon Advanced Health:41.9, compared to 44.2 in 2014.
  • Willamette Valley Community Health LLC: 43.1, compared to 42.2 in 2014.
  • Yamhill CCO: 62.4, compared to 61.1 in 2014.

Patient Centered Primary Care

Successfully enrolling patients in patient-centered primary care homes – which gives CCO members a starting point to coordinate all other healthcare – is central to Oregon’s health transformation, and also to performance on many other metrics, Coyner said. Many CCOs are relying on patient-centered primary care homes to lead outreach to patients, which means that strong patient-centered care enrollment is central to strong performance on other metrics.

“We have really stressed the patient-centered primary care home model. Then members do know where to go to receive care, at least for the first stop. They have a doctor’s office they know about,” Coyner said.

Rapidly expanding Medicaid infrastructure as Oregon’s CCOs have grown has created some challenges, however. Many CCOs have had to expand their provider networks, and it takes time to adapt a growing network to this model.

Oregon requires CCOs to enroll at least 60 percent of members in patient-centered care homes in order to receive performance incentive funds – and every CCO has met this goal. In 2012, after the Affordable Care Act had passed but before the CCO transformation took off, 51.8 percent of Medicaid members were enrolled in patient-centered care homes. By September 2015, that had climbed to 83.6 percent.

Here’s the portion of members enrolled in patient-centered primary care homes as of September 2015:

  • AllCare Health Plan: 77%, up from 70% in 2014.
  • Cascade Health Alliance: 72.9%, up from 70.6% in 2014.
  • Columbia Pacific: 76.9%, down from 85.4% in 2014.
  • Eastern Oregon CCO: 73.5%, up from 61% in 2014.
  • FamilyCare Inc.: 84.1%, up from 80.1% in 2014.
  • Health Share of Oregon CCO: 85.7%, up from 84.9% in 2014.
  • Intercommunity Health Network CCO: 92.8%, up from 89.2% in 2014.
  • Jackson Care Connect: 73.1%, down from 77% in 2014.
  • PacificSource-Central: 94.9%, up from 92.6% in 2014.
  • PacificSource-Gorge: 95.3%, down from 96.4% in 2014.
  • PrimaryHealth of Josephine County: 99.4%, up from 99% in 2014.
  • Trillium Community Health Plan: 69%, up from 60.7% in 2014.
  • Umpqua Health Alliance: 95.3%, up from 89.2% in 2014.
  • Western Oregon Advanced Health: 83.1%, up from 82.2% in 2014.
  • Willamette Valley Community Health LLC: 93.6%, up from 91.2% in 2015.
  • Yamhill CCO: 67.3%, down from 65% in 2014.

What’s next for CCO metrics?

In June, the Oregon Health Authority expects to complete crunching the numbers so it can determine how much to pay each CCO as a reward for its incentive performance. While those calculations are underway, CCOs have also adopted adjusted incentives for 2016.

This year, the state will measure 18 incentive metrics (up from 16 in 2015) – childhood immunization and tobacco use have been added to the list. The state is still reporting electronic health record adoption, but will no longer use that measurement as a financial incentive.

This approach to incentives and CCO experimentation is one-of-a-kind, and requires approval by federal Medicaid officials as Oregon tweaks and learns from its efforts.

“Our program is unique. The idea of coordinated care organizations, local control and integration of behavioral health, dental and physical health, and paying for it through a global budget, is unique to Oregon,” Coyner said. “Many states in the country have watched the Oregon experience, and I believe some are taking what we’ve developing in their own states.”

To continue that approach, the Oregon Health Authority is working to renew what’s called its 1115 waiver, which allows variation from the Centers for Medicare & Medicaid Services norm.

“We are in the progress of putting together a renewal of our 1115 waiver that will be submitted to CMS in the springtime. We need to look carefully and work with stakeholders like CCOs in terms of what the incentive metric program will look like moving forward,” Coyner said. “It’s been very successful. We feel very happy with the progress CCOs have made. I don’t anticipate any major changes in the program.”

Courtney Sherwood can be reached at [email protected]. Follow her on Twitter at @csherwood.

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