Oregon needs to break down the silos that keep doctors, dentists, therapists and other providers from working together, for the state to succeed in reinventing the coordinated care organizations that provide health care to Medicaid residents.
That was the consensus of experts who gathered in Portland last week to discuss the process dubbed “CCO 2.0” at a breakfast event sponsored by the Oregon Health Forum. More than 300 people showed up for the discussion of Oregon’s plans to revamp Medicaid, which serves one in four residents of the state.
“The system is so siloed, so unaccountable, and there’s so much money,” said former Oregon Gov. John Kitzhaber, architect of the original Oregon Health Plan in the 1990s. The plan is Oregon’s version of Medicaid.
In the reinvention of the program that launched in 2012 under Affordable Care Act provisions, 16 businesses and nonprofits were awarded contracts to manage Medicaid across the state, with the aim of using financial incentives to improve health and hold down spending. The state estimates these coordinated care organizations, or CCOs, have saved $1 billion – but Kitzhaber told attendees at the Oregon Health Forum breakfast meeting that the transformation has not gone enough.
(The Oregon Health Forum is a program of The Lund Report.)
“We do not have – in this state, or anywhere in the country – an aligned coordinated delivery model that can get the right services and treatment to the right children and families, in the right amount and at the right time, so that it can make a difference,” Kitzhaber said.
But as the state prepares to draft the rules for the next round of five-year coordinated care contracts, which will start in 2020, the Oregon Health Authority has a rare opportunity to break down the silos preventing coordination, Kitzhaber said.
Under the current system, each provider, from physician to nurse to hospital and clinic, is in its own silo. Each is paid for the work they do within their specialty, but they are not paid for coordinating with other medical disciplines. So even as primary care doctors are charged with overseeing the full health of their patients, for example, they rarely collaborate with drug counselors or dentists.
Panelist Mike Shirtcliff, founder and former president of Advantage Dental, concurred, and urged state leaders to bring a grander vision to CCO 2.0.
“With leadership changes at the top of the Oregon Health Authority and in state government, there’s a disconnect sometimes over where we are really going,” Shirtcliff said.
CCOs were supposed to coordinate care, allowing people’s health care providers to work together. Yet a proposal Shirtcliff backs – to have doctors peer inside children’s mouths during routine check-ups so kids can be referred to a dentist if necessary – won’t get paid for under the current system.
“We are still in silos,” said Shirtcliff, who sits on The Lund Report’s board. “Rather than collaborate, we compete. We pass blame, rather than get together.”
That’s in part because of federal Medicaid rules that compensate doctors for one set of procedures, dentists for a different set, and don’t pay at all for many efforts that could improve health outside of the traditional medical system, he said.
When CCOs were envisioned, the Oregon Health Authority hoped to assign a global budget to each, and to allow the different organizations to determine how best to manage their funds to improve health, Kitzhaber said. Instead, actuaries analyze past claims and develop an estimate of future costs.
“That embeds the existing incentives and silos in CCOs,” Kitzhaber said. “This is exactly what we were trying to avoid.”
Care Oregon CEO Eric Hunter, whose nonprofit provides services to four of the state’s CCOs, acknowledged the challenges raised by his fellow panelists, but also argued that these Medicaid providers have been more successful than Kitzhaber’s and Shirtcliff’s concerns might indicate.
Transforming health care unfolds on two fronts, Hunter said: flashy high-profile ideas that require federal Medicaid waivers are important, yes, but incremental changes are “where the rubber hits the road.”
CCOs were innovative, splashy and brought critical changes, he said. Now it’s time to tweak, adjust and build on what has been achieved. “Hopefully CCO 2.0 is not about starting over. There has been incredible success and innovation with CCO 1.0. Hopefully we can build on what we’ve got.”
A streaming video of the event will be available for purchase here.
Reach Courtney Sherwood at [email protected].