Health Share and FamilyCare: A Tale of Two CCOs
How do Medicaid patients choose between Portland’s two coordinated care organizations, Health Share and FamilyCare? Often they don’t.
Patients are usually placed into one group or the other by the Oregon Health Plan, which tries to balance populations between the two Portland groups. But patients can also choose their own CCO, even if they rarely do so. So what’s the difference between the two? Both are charged with caring for Oregon’s Medicaid population, but each goes about it in a different way.
“CCOs were approved with bipartisan support in the 2011 Oregon legislative session, with the premise of creating systems where people aren’t just paying for care, but coordinating care to improve health,” said Stephanie Vandehey, a spokeswoman for Health Share.
The state launched its first CCOs in 2012, and there are 16 of them across the state today, including the two that serve Portland’s Tri-County area. The goal is to take care of a population based on a set of annual metrics aimed at improving overall health.
“We take these metrics extremely seriously,” Vandehey said. “They don’t just determine our budgets, they also determine how healthy our people are.”
The 2016 metrics report shows CCOs have already made several improvements in the short time they’ve been around. Some of the most improved areas across the board are adolescent well-care visits (which are basically physical exams), the rate of children who receive dental sealants on molars, childhood developmental screenings in the first three years of life, contraception use and health assessments for foster children.
Areas where Oregon CCOs generally scored worse are rates of avoidable emergency department use, engaging patients in drug and alcohol treatment, and increased hospital stays.
Oregon lawmakers also made a deal with the federal government when they created the CCO model - by promising to hold down Medicaid cost growth by 2 percent over five years, which is harder than you’d think but still going well, Vandehey said.
Both Health Share and FamilyCare, like Oregon’s other CCOs, get a yearly distribution from the federal government that they budget out each time. Metric performance can determine how much money each gets, Vandehey said.
“We have to figure out how to care for our population the best, with this one budget we get every year,” she said. “If we do well, we get more money based on performance.”
The major difference between Health Share and FamilyCare is how the two agencies are organized. Health Share, which had more than 200,000 enrollees in 2016, uses its funding to coordinate resources among other healthcare partners in the region. FamilyCare, which had close to 110,000 enrollees in 2016, on the other hand, functions as the patient’s health plan and is a one-stop shop for care.
“We’ve expanded into the community with several community health groups,” Vandehey said of Health Share. “FamilyCare is more insulated with its own health plan. But they also contract out with dentists and other groups to help patients.”
Sometimes Health Share and FamilyCare also work together on projects, she added.
One of the central components of FamilyCare is something called the P2ORTS system, which stands for Patient-Provider Oriented Resource Teams (also called PORTS). The agency decided on the model after realizing that individual health departments - referrals, general care, mental health care, provider navigators, pharmacists - were each isolated in their own area, which was slowing down access to care, said Oscar Clark, FamilyCare’s vice president of integrated services.
“The PORTS system, if you think of traditional health systems, they have different areas and they all work in silos,” Clark said. “So we took people from each of those silos and put them together in a group.”
The agency has nine of these PORTS, mostly named after local rivers, that are each focused on a different area of care. The Rogue PORT, for instance, handles pediatric and family care.
Each PORT provides care management, navigation services for members and providers, service coordination, use management, referrals, a provider representative and health care coordinators for the community.
“Most health plans take physical and behavioral health as separate things,” said Jack Coleman, a spokesman for FamilyCare. “Here we have those officials talking to each other and working together.”
One benefit of that sort of network is that it reduces patient stress by putting the entire health team in the same place, where it’s easier to communicate.
“This is very important for the Medicaid population,” Clark said. “It’s hard for them to build trust and rapport. Putting everyone together in the same place helps.”
Another innovative idea from FamilyCare was to set up an assessment and care system for social problems faced by Medicaid patients.
“We’ve created an internal community resource guide, and it brings up business that help with specific issues, like finding shelter for those who are homeless,” Clark said. “It’s part of building trust with our members.”
Health Share, in contrast, generally uses its funds to build target programs with already existing health care groups, Vandehey said.
Opioid misuse is one big target area that actually dovetails with some of the issues faced by other Medicaid members, such as foster children, Vandehey said.
“A lot of kids in foster care are in there because their guardians have mental health issues, addiction issues, issues with the law,” Vandehey said. “We try to coordinate with kids and their parents to help care for them.”
In late 2016 Health Share built up programs to strengthen addiction services, working with Central City Concern and Comprehensive Options for Drug Abusers (CODA) to create the Wheelhouse network. The program aims to increase Medication Assisted Treatment (MAT) options for patients with opioid problems by through working with existing providers.
"Wheelhouse is a timely and effective means of taking on Oregon's opioid epidemic," said Tim Hartnett, executive director of CODA, in a news release. "Oregon has the second-highest rate of prescription opioid misuse in the country, and we're losing lives because we're not delivering a proven, affordable treatment to enough of the people in need. Helping the state's existing provider networks deliver evidence-based Medication Assisted Treatment is sound public health policy, good stewardship of healthcare dollars, and a compassionate approach to this devastating problem."
Health Share has about 3,000 foster kids in its system, and getting the addicts around them stabilized helps them as well, Vandehey said.
Metrics a few years ago revealed those children weren’t getting enough health screenings. And the information helped Health Share target new programs toward foster care families and follow up care.
“When we first realized that metric was doing really poorly a few years ago, we realized we needed to do something,” Vandehey said. “And we went from a rate of 30 percent of foster kids getting screened to about 80 percent.”
Mental health is another area that Health Share has been working on, and the agency has significantly improved its metric performance in the area.
One effort to address the issue was a pilot launched last year called the Community Paramedicine Program. In that effort physicians identified patients at high risk for not returning for follow up care and tagged them in the system. Community paramedics then went out to the patient’s home to do follow up care in person.
“That’s been pretty successful in some areas,” Vandehey said.
Another pilot program that recently ended formed medical legal partnerships to care for people with physical problems who also have legal issues that affect their health, such as housing discrimination. Health Share partnered with Oregon Health and Sciences University to provide pro-bono clinics with lawyers.
“When a physician finds a patient with legal issues affecting their health, a clinic like that can get them a lawyer to help out,” Vandehey said. “Right now we’re working with community health workers to look at more options like that.”