Family Physicians, State Both Want Credit for Medicaid Improvements

The first progress report since the transformation of the state Medicaid delivery system to coordinated care organizations showed some impressive results when released earlier this month.   Emergency room use for those covered by CCOs is down 18 percent since their launch in August 2012, while primary care outpatient visits are up by the same percentage.   But correlation is not causation, and as troubles abound in other aspects of the healthcare system, different players in the healthcare system are trying to take credit for the success in improving care in the Oregon Health Plan.   “I don’t want to take away from anything the CCOs are doing. … We’re seeing some synergy and support,” said Dr. Evan Saulino, the president of the Oregon Academy of Family Physicians. “The data we’ve seen so far come from a time when we know CCOs were not fully functioning.”   Until this October, Saulino said that despite a Lund Report article that noted the Oregon Health Authority’s release of initial success in improving the delivery of care to the Medicaid population, none of the physicians in his organization reported significant interactions with their CCO.    “They have not received orders to do anything different nor have they received support from the newly established CCOs in changing how they advise and care for patients,” he added. “This leads us to believe that the CCOs are not responsible for the data improvements you reported.”    Saulino said family physicians across the state have been changing their practices in the past few years to comply with the concept of the patient-centered primary care home, which takes a more holistic approach toward patient health and emphasizes the family doctor or nurse practitioner as the primary point of contact for healthcare needs.    At Providence Medical Group – Southeast, in Portland, where Saulino practices, a psychologist has been brought on board along with community health workers who help keep closer tabs on patients with chronic conditions and engage patients to lead healthier lifestyles.  “Doctors have traditionally supposed to be Superman. Now we really need a team of folks.”   Clinics like his have also extended their office hours into weekends, evenings and early mornings. “That helps a lot of folks stay out of the ER,” Saulino said.   But at Willamette Valley Community Health, the CCO in Salem, acting director Dean Andretta reiterated that his organization had indeed directed more clients into patient-centered primary care homes compared to the old model and said that emergency department usage is sharply down.   “I don’t really care who gets the credit,” said Andretta. “The important thing is that it’s happening.”   Beyond the primary care homes, Andretta’s organization is investing in community health workers, who connect with patients seeking non-emergency care at the emergency department and work with these patients to hook them up with services that are both cheaper to deliver and more effective in improving their overall health, such as diabetes management and mental health services.   Tina Edlund, the chief of policy at the Oregon Health Authority, said the Portland area’s two CCOs – FamilyCare and Health Share – both had similar emergency room diversion programs as Salem.   “The metrics show that we’re moving the dial,” Edlund said. While Edlund conceded that the state did not invent the primary care home model in the recent Oregon Health Plan transformation, she said private insurance companies just signed a pact with the Oregon Health Authority last week, agreeing to promote the model.   The primary care homes that Saulino championed are also not all as comprehensive as envisioned by the CCOs, and he broke them down into three tiers – with only the third tier as rigorous as his Providence clinic. A first-tier clinic or doctor’s office might simply need to take a closer look at the aggregate data of their patients to understand community health needs.   But Oregon’s CCOs are not alone in their primary care focus. Saulino shared a Michigan BlueCross BlueShield incentive program that showed a 10 percent decline in ER utilization.  Closer to home, Legacy Health in Washington and Oregon also reported a 50 percent decline in ER use and $500,000 in savings over six months in costs for patients enrolled in its clinics, according to Saulino.   Chris can be reached at [email protected].