Oregon coordinated care organizations may see the state base nearly half of the incentive money they will receive for 2021 on the COVID-19 vaccination rates the insurers achieve with their members.
The potential money at stake is nearly one hundred times greater than the $1 million offered by the state to one vaccinated person in a lottery June 28.
Under the proposal, the Oregon Health Authority would make a vaccination metric one of the measures that coordinated care organizations would have to satisfy in order to receive part of the special quality incentive funding that the state disperses each year.
The total quality pool money for 2021 is estimated at roughly $200 million. Potentially almost half could be paid based on vaccination rates.
The state traditionally distributes the incentive funding based on different health improvement measures that each coordinated care organization tries to reach, from dental sealants for children to better birth control for women who risk unintended pregnancies. The state picks the measures each year based on public health steps it wants to prioritize.
Coordinated care organizations insure nearly 1.3 million people on Medicaid -- almost 30% of the state’s population.
The CCOs submitted a quality-pool proposal to state officials, and the Oregon Health Authority has made a counter-proposal. The behind-the-scenes proposals reflect the current state of Oregon’s COVID-19 vaccine rollout: With hospital-run mass vaccination clinics drawing fewer patients, the vaccination drive is turning to primary care providers and others to carry out the bulk of vaccinations in clinics and small community events. And coordinated care organizations have a long track record of working with primary care providers to meet state incentive-money goals.
The proposals offer a glimpse of one avenue the state is pursuing to boost the vaccination rate beyond Gov. Kate Brown’s goal of vaccinating 70% of Oregonians 16 and older. The state’s current vaccination rate is about 64%. The state’s incentive-funding proposal would require a coordinated care organization to hit an 80% vaccination rate with its members by the end of 2021 to qualify for the highest level of funding.
The state contracts with 16 coordinated care organizations that provide Medicaid insurance to low-income residents. Each coordinated care organization is assigned one or more regions.
Last October, the Oregon Health Authority provided $160 million in total quality pool funding to coordinated care organizations to reward them for achieving health improvement goals in 2019. The sum is a sliver of the $5 billion the state gave coordinated care organizations that year to cover the health care expenses of members. The coordinated care organizations typically share the quality pool money with health care providers that helped them achieve their goals.
Vaccine Proposals Differ
Coordinated care organizations and state officials differ on what percentage of the quality pool funding they want to go towards a vaccination metric, public records show.
Six coordinated care organizations submitted a proposal that suggests earmarking 10% of the quality incentive pool funding on a new vaccine measure. The proposal also suggests that the measure be scored based on the portion of providers in the network that offers vaccinations, the coordinated care organization’s communication to members about the vaccine and the opportunity members have to get a timely vaccine.
Coalition for a Healthy Oregon’s March 29 letter calls it a “preliminary concept that would leverage the CCO metrics program for vaccines, thereby incentivizing providers to fully vaccinate hard-to-reach populations.” The coalition represents Trillium Community Health Plan, Umpqua Health Alliance, Cascade Health Alliance, Advanced Health, AllCare CCO and Yamhill Community Care. They represent Medicaid recipients in regions that include the Portland area, Lane County and southwestern Oregon.
“We know a vaccine bottleneck is coming in the next 4-6 months: The supply will be there, but a significant number of Oregonians will be either hesitant and/or hard to reach,” the group said in its letter, adding that internal polling puts vaccine hesitancy as high as 50% in some regions.
The letter also suggests turning some other quality pool measures into reporting only, including those related to diabetes, initiation and engagement in alcohol and drug treatment and childhood immunizations, citing the challenges of 2020 hurting vaccination rates of children turning two this year. The group recommends other measures continue to be scored and rewarded by the remaining 90% of the pool money, including well child visits to primary care providers.
Health Authority’s Proposal
The health authority’s proposal would make a much larger share of the pool funding contingent on vaccination rates. The health authority would divide the quality pool funding for 2021 into two portions. Nearly half would go toward the COVID-19 vaccination efforts and the rest would go toward the existing quality pool measures, according to an April 27 draft proposal.
Under the state’s proposed metric, coordinated care organizations that reach a 65% vaccination rate overall among members would qualify for 75% of their portion of the vaccine funding. To qualify, a coordinated care organization would need to reach that level among all ethnic groups and races by Dec. 31.
To qualify for the maximum funding, a coordinated care organization would have to achieve a vaccination rate of at least 80%, including among all races and ethnicities.
In an interview, Jeremy Vandehey, director of the authority’s Health Policy & Analytics Division, estimated that the quality pool will be roughly $200 million a year, or $400 million for the two-year budget cycle. That makes the vaccination-based portion for 2021 nearly $100 million, he said. Those figures are preliminary and could change.
Next Steps As Feedback Continues
Vandehey said the state’s approach is still in discussion and officials plan to put together a revised proposal based on feedback from coordinated care organizations. He said the state’s approach and proposal recognizes that there are other health measures to follow besides vaccinations.
“There (are) many other health issues that people are dealing with in a given year,” he said. “We don't want to slide backwards.”
Details of the revised proposal, which is still in the works, were not available.
The authority hopes to finalize its plan in about two weeks, Vandehey said. The health authority would make the change administratively. It doesn’t require approval from the Legislature or the Oregon Health Policy Board, which oversees the health authority.
The potential changes to the state’s metric may include regional considerations, such as coordinated care organizations that serve rural areas with high vaccine hesitancy.
Health authority spokesman Jonathan Modie said the state is exploring a possible change to the metric that would reward “incremental progress and acknowledge each individual CCO’s starting place.”
The vaccine measure could potentially provide financial rewards to coordinated care organizations for the work of other entities. That’s because a CCO member’s vaccination would count toward the metric regardless of whether they got their jab through their coordinated care organization’s in-network provider or somewhere else, like a public health agency’s vaccine drive or mobile clinic.
In an email exchange, Modie was vague about why a coordinated care organization should benefit financially from the work of outside groups that vaccinate people.
“We want CCOs to encourage their members to get vaccinated, whether that vaccination is done inside or outside the CCO network,” Modie said. “They deserve that incentive credit if their providers are working to encourage patients to get vaccinated.”
Care Organizations React
Coordinated care organizations are carefully watching the situation unfold.
In a statement, CareOregon said it appreciates the opportunity to give the state input on the metric. CareOregon serves rural and Portland-area Oregonians as a nonprofit through Jackson Care Connect, which serves 45,000 members in Jackson County; and Columbia Pacific CCO, which has 30,000 members in Clatsop, Columbia and Tillamook counties. CareOregon also manages behavioral health benefits for 300,000 members of Health Share of Oregon in the Portland metro region and medical health benefits of two-thirds of them.
“We are committed to connecting our members to the vaccination resources they need, and that work will happen with or without a quality metric,” the group said in a statement. “We also remain focused on our current efforts to coordinate whole person health care for our members, and we need to make sure that our efforts to deal with this pandemic are well aligned with what our providers need to deliver the right health care at the right time.”
CareOregon’s work to boost the vaccination rates include regional care teams that work with most high-risk populations to build vaccine confidence and help them with scheduling and transportation.
CareOregon has a vaccine “rapid response team” to help community members with questions through clinical and non-clinical staff. It mails 20,000-30,000 mailers to groups of members each week that advertise the rapid response team’s help with navigating vaccine sites and options.
Health Share of Oregon simply said it’s working with the health authority on the issue. The 380,000-member coordinated care organization serves people in the tri-county Portland area.
The coordinated care organization’s efforts to boost vaccination rates include direct mail, data tracking to develop strategy, support with partners for efforts to provide in-home vaccinations to people who are homebound, and partnerships and work with public health agencies and community organizations. This includes working with partners on efforts that shift away from mass vaccination events towards smaller community events.
In a statement, PacificSource said it supports the health authority’s goal for every eligible Oregonian to receive the vaccine. PacificSource has coordinated care organizations that serve areas that include central Oregon and the Columbia River Gorge.
“We also recognize the challenges that goal brings to providers, CCOs, and communities, as well as the risks of targets that aren’t adjusted or aligned,” its statement said. “As such, we want to be sure the policy is thoughtfully designed and rolled out, and appreciate the opportunity to give the OHA input to help shape and revise the new metric.”
You can reach Ben Botkin at [email protected] or via Twitter @BenBotkin1.
