Southern Oregon CCOs Provide Unique Perspectives to Health Policy Board

The four counties along the California border going east from the Pacific Ocean have 10 percent of the population, but four CCOs are experimenting with the delivery of healthcare.

Southern Oregon has the state’s most concentrated presence of coordinated care organizations, with four organizations serving four counties with less than 10 percent of the state’s population.

Josephine County has two physician-owned CCOs: Primary Care of Josephine County and AllCare Health Plan, and they overlap with Jackson Care Connect, which is an affiliate of CareOregon, and enjoys a close relationship with the Asante and Providence Health Systems. Additionally, the Cascade Health Alliance serves Klamath County.

“From a member’s point of view, it gives them choice,” said Dr. Lyle Jackson, the chief medical officer of AllCare Health Plan.  When there’s a monopoly of CCOs, which is the case in most of Oregon, it can cause organizations to take on an attitude of “We’ll take care of it tomorrow,” he added.

But Jennifer Lind, a regional executive from his rival CCO, JacksonCare Connect, said that while the competition did keep the organizations sharp, it wasn’t an ideal situation for a safety net health service. “I also believe that Medicaid should not be a competitive environment.”

The Oregon Health Policy Board met in Medford on Tuesday, which provided a chance to hear from these four organizations, which offered different perspectives on providing healthcare than their sister CCOs upstate.

Jennifer Johnstun, the director of quality improvement at Primary Care, said her organization had seen their statistics for prenatal care soar after they started rewarding providers for offering certain kinds of care in a pregnancy package -- making an upfront investment, before the reports came in.

“We’re paying for the experience,” Johnstun said. “We’re not paying for the metric.”

Bill Guest, the former CEO of the Cascade Health Alliance, said the attention to quality control he’d seen from the health authority over the metrics was the best he’d seen after three decades on the job.

“Doctors do fight what they call cookbook medicine, but checklists do help,” said Guest -- now the CEO of the Willamette Valley Community Health Plan in Salem.

Jackson was less conciliatory to the health authority, complaining that bureaucratic restrictions regarding the state’s much-touted “patient-centered primary care home” made it difficult to work with the realities of rural places with small doctors’ offices like Cave Junction. “That kind of hands-down, hold-nose approach was not what was sold to us.”

One challenge in many areas has been how to move away from paying per procedure -- the dubious hallmark of the American healthcare system that rewards quantity rather than quality. CCOs are paid on a per member per month basis, using a global budget, not on the quantity of services rendered, and they have an incentive to pass that budgeting method onto their providers, including physicians and hospitals -- the latter of which have been especially opposed to payment reform, culminating with Salem Hospital suing its CCO to avoid a different payment scheme for emergency care, which would have put the hospital on the hook for steering patients away from that department.

But Jackson told The Lund Report that his organization came into the CCO process paying its primary care providers based on the number of members, and to bring about further reforms, gave bonuses to providers so that people would get the care they needed, including community health workers and nurse case managers.

Since not all patients have equal needs, providers who take the more difficult cases are paid at a higher rate. “We pay for the more difficult patients so they don’t cherry-pick,” Jackson said.

Jackson and Lind agreed on one point -- opiod abuse in southern Oregon is rampant and one of the chief health crises in the area.

Lind said they had some of the highest rates of deaths from opiods. “We also have one of the highest rates for prescriptions,” she said.

But in addition to the opiate abuse, Jackson argued that a state law barring the CCOs from regulating psychiatric medications has damaged the health of his CCO members and prevented AllCare from properly monitoring those drugs and getting people the most effective medications -- as they are free to do with all other drugs and diagnoses.

“CCOs are in charge of all medications except the mental health drugs,” Jackson said.

He said off-label use of many psychiatric medications was common in southern Oregon, often when it had no backing from the scientific literature. One recent example of drug companies pushing unapproved off-label use of risky psychiatric meds was Pfizer with the anti-convulsant Gabapentin for bipolar disorder, sold under the brand name Neurontin. Pfizer lost a $142 million lawsuit with Kaiser Health Plan in California over the drug.

But changing that law will prove to be a huge challenge. Backed by thousands of dollars in campaign money from PhRMA and the big drug companies, Sen. Jackie Winters, R-Salem, has been able to repeatedly block any attempt to eliminate the special carve-out that has helped the drug companies rip off the Oregon Health Plan and the CCOs when it comes to mental health drugs .

One reason for the loophole was to protect racial minorities, who often need slightly different medications than European-Americans. (Winters is African-American).

But that is true of all medications, not just the highly profitable psychotropic medications. African-Americans in particular experience high rates of diabetes, heart disease and hypertension, yet the CCOs have been entrusted to manage medications for those illnesses and set the appropriate guidelines.

Undoubtedly this battle could emerge once again next February when the Legislature convenes.

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