Coordinated Care Organizations--How Are They Doing?

OPHA October 13, 2015Afternoon breakout session byMichael C. Huntington M.D.

In 30 years working with cancer patients I saw many patients with advanced and neglected cancers.  Some of these patients had avoided doctors for months or even years in spite of worrisome symptoms because they felt they could not afford care. Seeing this happen repeatedly was a very saddening experience for me.  I learned that it didn’t need to happen.  I began to realize that illness can be as much a result of politics as biology. The political question is, “By law, who will be allowed a good chance for a healthy life and good health care?” This talk is about how well CCOs are answering that question.

What is a Coordinated Care Organization (CCO)? 

 Health-care providers cooperate under a capitated budget,   communicate better, and deliver better care.

 Health-care providers cooperate under a capitated budget,   communicate better, and deliver better care.

Unified care.  The care-delivery component of each CCO is the patient-centered primary medical home (PCPMH) in which primary care practitioners collaborate with a standardized array of other caregivers under a capitated budget to deliver better care at lower cost.

Each CCO board is advised by the leader of its community advisory council.  However, board meetings are closed to the public.

Each CCO board is advised by the leader of its community advisory council.  However, board meetings are closed to the public.

Sixteen CCOs have formed since August, 2012, each run by a board composed of local healthcare providers and community members. These boards are advised by a local community advisory council whose chair sits on the CCO board.  However, board meetings are closed to the public. More later about that as a frailty of CCOs. 

People churn in and out of Medicaid eligibilities because of varying incomes year to year.  Discontinuity of care.

People churn in and out of Medicaid eligibilities because of varying incomes year to year.  Discontinuity of care.

Churning.  27% of patients who are initially eligible churn in and out of Medicaid eligibility because of varying incomes year to year. This leads to disruptions in continuity, therefore poor quality healthcare. A single eligibility pool would solve the churning problem. Yearly reapplication is required because of changes in eligibility. People forget, can’t find required documents, don't understand.  They unintentionally let coverage lapse and are surprised to discover they aren’t covered by Medicaid anymore. More churning.

So how are we doing?  
17 health care metrics:  Each June the Oregon Health Authority publishes its assessment of
performance by Oregon CCOs. Performance is based on 17 key healthcare metrics. Benchmarks:  unless stated otherwise are averages of the 2013 national Medicaid 75th percentiles for adults and children.
More Insured  95% of Oregonians now have some form of health insurance (84% in 2012).  The 2015 Robert Wood Johnson report says 83% (but is based on 2012 data) …but not better access:  Medicaid CCO cards say the holder is entitled to care but 16% of CCO patients still can’t find a doctor when they need one. The percentage of members (84%) who received appointments and care when they needed them has not improved. A home health nurse I know in Lincoln County frets over this underserved 16% of the CCO enrollees and all others who can’t access a primary care provider.  
Avoidable use of emergency departments was 14%, is now 7% (Lower is better). Criterion: Rate of patient visits to an emergency department for conditions that could have been more appropriately managed by or referred to a primary care provider in an office or clinic setting.  
Prenatal Care. Things are improving with 82% (up from 65%) of pregnant women receiving a prenatal care visit within the first trimester or within 42 days of enrollment in Medicaid. 50% of births in Oregon are covered by Medicaid. Good prenatal care leads to better health outcomes and cost savings.  

CCOs may be helping diabetics. The 78.2% control rate (HbA1c < 9.0%) compares favorably with the 66% rate of control before CCOs.
Outpatient control of congestive heart failure is better by 40%. Criterion: the rate of hospital stays because of congestive heart failure. Benchmark: 10% reduction from previous year's statewide rate. 2011 and 2013 data have been updated and may differ from earlier reports.  A PCPMH helped this man control his congestive heart failure. He had been in and out of the hospital many times before the CCO was available to him.

Satisfaction level among those who actually gained access to care has improved slightly since 2011 (84.5% vs 78%).  The several CCO patients and their doctors I have spoken with are pleased with the PCPMH process. Criterion: the percentage of members (adults and children) who received needed information or help and thought they were treated with courtesy and respect by provider staff.  
Hypertension Control. People have devastating strokes from undetected and uncontrolled hypertension. For some this happens because they can’t afford insurance or don’t qualify for Medicaid. I know of two such individuals. But only 65% of enrolled CCO hypertensive patients are getting their pressures under control.  Not so good.There are no earlier CCO data to compare with, but the US Medicaid 75thpercentile in 2013 was 64%.  

Childhood Immunization. Before and since the advent of CCOs only 2/3 of children received recommended vaccines before their third birthday.Vaccines are one of the safest, easiest and most effective ways to protect children from potentially serious diseases. 

Financial Problems. Even if Oregon limits Medicaid spending growth to 3.5%/yr as we are must do to keep all of our federal subsidy for the expanded Medicaid population, the subsidy drops from 100% to 94 % in 2017 and to 90 % in 2020. Oregon will have to come up with an extra $369 million per year from 2017 to 2020 and then $500 million/yr after that.  This is unsustainable.  Oregon’s current annual Medicaid budget is $6.8 billion.  
Solutions? Four options have been tried during Medicaid revenue shortfalls in the past.  
#1: Raise taxes without changing benefits
#2: Cut other state programs: police, fire and safety, schools, elderly, infrastructure, transportation
#3: Reduce Medicaid eligibility. This immediately reduces state spending — until neglected patients again fill our emergency rooms.  
#4: Cut benefits. same as #3 above.
None of these options are appealing. Stay tuned as your next speakers talk about how we might make health care and its financing sustainable.
Other problems.  Opaque or Transparent CCOs?  How will the public track the use of its public (Medicaid) money?  One of the 11 privately owned CCOs tripled its profits in 2013 after a large enrollment of Medicaid patients.  During the time this CCO was taking in its Medicaid payments of $300-$400 per member per month (pmpm), thousands of its patients ended up depending on safety net clinics because the CCO had too few primary care providers.  Safety net clinic workers I spoke with said that the CCO could have hired more providers but had turned down applications from qualified nurse practitioners and physician assistants.  This CCO was purchased last month by a Fortune 500 company. This is not what most of us had in mind when CCOs were conceived.  The main problem I see here is that the public should be the primary decision maker regarding use of public funds, not a private for-profit company.
I encourage you to Investigate. Find out who sits on your CCO board by going online to governing boards and ask them for a clear accounting of where the money goes. Is it going for convincingly documented care of patients? How much is going to stockholders or into that mystical land of the reserves.  If your CCO doesn’t freely provide information you need, local journalists and your legislators may be willing to help.  
Tell legislators. I think we can say that Oregon's coordinated care organization experiment is starting to succeed and is based on sound principles of providing better care for more people at less cost. But we need major improvements in transparency, oversight, and incentives and we need a single risk pool and unified payer system if the ideals of the CCOs are to survive.
Tell legislators, media, Oregon Health Authority that we must:
1. Keep working on the CCO model of care delivery and capitated payments. This work is vital to success.
2. Stop determining who “deserves” care and who doesn’t with our complex eligibility schemes. The process is too costly and disruptive.  We must include everyone.
3. Fight for more public surveillance and power over how all public money, including Medicaid money, is used.   
4. Make our legislators create a system in which insurance is not just a card or promissory note but in fact allows access to health and health care.  
5. Make CCOs serve needs of the public rather than stockholders and the medical industry.
6. Create a unified coding and payment system with a single risk pool (everyone in).
These web sites listed below will help you gather and confirm the data you need if you want to help CCOs succeed. As we talk with others about health care reform I hope we can listen carefully, honor and allay their fears, and then pivot back to a mutually agreeable goal such as better care for everyone at lower cost. Help others see how achieving this goal will benefit them, their families, and their neighbors. It is pretty likely that they want all of those people to have access to good healthcare.
We have indeed come a long way in a very short time, but we have a long way to go.  Please investigate these organizations and websites, learn what you can about what’s going on, and rev up your activism for the public good and public health.  Here are two organizations that you can look in on and join to put your thoughts into action.



&nbsp;Groups you can learn from and join

 Groups you can learn from and join

Transformation is slow difficult work - meaningful change takes time, like turning an ocean liner around when many of the crew members don't know how and a few don't want to. And of course powerful special interest tugboats keep pulling this healthcare ship toward their harbors.  

You can help MVHCA as we work for publicly funded universal health care like the rest of the developed world by donatinghosting a house party, signing up for the newsletter, and attending our monthly meetings. You can also Like us on Facebook, and Follow us on Twitter. Thank you.

State Prepares Study of Health Care Payment Models

By Peter Wong of the Oregon Capitol Insider:

Different groups have differing expectations for a study of how Oregon should pay for health care — a study that lawmakers authorized two years ago but did not fund until now.

The Legislature set aside $300,000 in the new two-year budget to fund the study, which will be carried out through the Oregon Health Authority. House Bill 2828, which extends the study authorization for two years, also allows for donations.

Courtni Dresser of the Oregon Medical Association, which contributed, said: “The results of this study could serve to strengthen the existing coordinated-care organization (CCO) system, as well as identify other innovative strategies to provide cost-effective care to all Oregonians.

But Jenn Baker, speaking for the Oregon Nurses Association, envisions the study as a step toward a system under which the government pays all health care bills.

“They (nurses) also understand that the state must have an adequate and stable financing plan to move towards a statewide single-payer system,” Baker said.

The study will compare the status quo with a single-payer system, and also a public insurance option to the private insurance plans under the national health-care overhaul (Affordable Care Act), and a high-deductible insurance plan funded by a sales tax.

Oregon has an estimated 95 percent coverage.

But in a series of recent Oregon appearances, T.R. Reid — journalist turned activist — said Colorado aims to be the first state to provide 100 percent coverage.

“We beat you to marijuana and we will beat you to universal health care,” said Reid, the one-time Washington Post reporter who is now leading a campaign to qualify a payroll-tax measure for the 2016 ballot in Colorado.

Oregon voters, by more than 3-to-1 in 2002, rejected a ballot measure for increased income and payroll taxes to pay for expanded coverage. Similar bills have not advanced beyond legislative committee hearings.

Changes in Salem: From Kitzhaber to Kate Brown

From an email newsletter from CCO Oregon, " A member collaborative for coordinated care stakeholders."

There has been a lot going on in Salem in the past week. The big news is, of course, Kate Brown taking the Oath of Office as Oregon’s 38th Governor this morning. There are many questions with regards to the new governor’s health care policy.

Part of Governor Kitzhaber’s legacy includes the formation of Coordinated Care Organizations. It will be interesting to see what, if any, changes Governor Brown makes to Oregon Health Authority and CCOs.

Her first speech as governor didn't touch on health care much.

The initial questions to be answered likely concern staffing, both in the Governor’s Office and at the Oregon Health Authority.

With Lynne Saxton serving as the acting director of OHA, when will the legislature confirm her appointment? Will the hearings be postponed?

The Transformation Center has not had a Director since Cathy Kaufmann departed in December 2014. How much longer will that role remain vacant?

Does Sean Kolmer stay on board as the Governor’s Health Policy Advisor?

This week, Governor Brown announced several new appointments, including Chief of Staff Brian Shipley: Kate Brown Sworn in as Governor, Announces Staff

Kate Brown Taps CCO Oregon Board Member Brian Shipley as Chief of Staff

Oregon Health & Science University Lobbyist and CCO Oregon Board Member Brian Shipley has been appointed to serve the state again. 

Most recently, Shipley was the Associate Vice President of Government Relations with OHSU. Previously, he served as Brown's Deputy Secretary of State from December 2012 to September 2013. He was once the Director of External Affairs for Forest Capital Partners, LLC, Legislative Director for Governor John Kitzhaber and Deputy Chief of Staff for Governor Ted Kulongoski. Prior, he held leadership roles within the Oregon Legislative Assembly, including the Senate Majority Office and the Office of the Senate President Peter Courtney.

Brian Shipley has served on the CCO Oregon Board of Directors for the past six months. We are proud that one of CCO Oregon's leaders has been chosen for such a critical position. We look forward to working closely with Brian and Governor Brown in the future.

See more coverage in The Oregonian, Willamette Week and other sources.

Oregon health care reform succeeds despite problems at Cover Oregon (guest opinion)

By Gil Muñoz

There’s no doubt that the Cover Oregon website has been dogged with problems since it launched last October, but the exchange’s IT problems are overshadowing a major policy success. To date, thousands of Oregonians who were previously uninsured have gained access to health care, benefiting all of us.

At the same time that Oregonians are signing up for health insurance through Cover Oregon, Community Health Centers like Virginia Garcia are working with Coordinated Care Organizations (CCOs) to update the way we provide care and implement cost-effective measures that improve patient outcomes. We’re establishing patients with a primary care home and providing them with a team of providers and staff who share knowledge and give patients personal attention. This team-based model of care is working for the benefit of our patients and it’s something we continue to expand and improve.

Virginia Garcia currently serves over 36,000 patients, but there are thousands of people in Washington and Yamhill counties who still don’t have access to care. To meet this growing demand, Virginia Garcia is increasing our capacity to provide services for patients where they live and work.

Full article here.

InterCommunity Health Network Coordinated Care Organization Seeks Lincoln Co. Representatives for Community Advisory Council

The Community Advisory Council is looking to fill vacancies in Lincoln county with two IHN-CCO members (or a parent/guardian of a member) and one representative from the community at large.To be considered for the Council, complete this application and submit it by March 21. Click here to learn more about the duties of the Council.

The Council meets the second Monday of January, March, May, July, September and November (March 3 being the one exception) from 2 to 5 p.m. in alternating counties.


El Consejo Consultivo de la Comunidad está buscando representantes en el condado de Lincoln para cubrir las vacantes de dos miembros de IHN-CCO (o un padre / guardián de un miembro) y un representante de la comunidad en general. Para ser considerado para el Consejo, complete esta solicitud y enviarlo antes del 21 de marzo.

El Consejo se reúne el segundo lunes de enero, marzo, mayo, julio, septiembre y noviembre (el 3 de marzo siendo la única excepción)  de 2:00pm hasta las 5:00pm en los condados alterna.

Coordinated care organization progress data shows continued reduction in emergency department visits, lower costs

John A. Kitzhaber, MD, Governor 
News release 
February 4, 2014

Oregon‘s fourth Health System Transformation report indicates that the coordinated care model is continuing to improve key areas of care for Oregon’s Medicaid population, while keeping costs down. The report released today shows coordinated care organization (CCO) progress for the first nine months of 2013 on key performance and cost measurements.  
“Emergency department visits and spending are decreasing under the coordinated care model,” said Tina Edlund, acting OHA Director. Measurements indicate Oregon’s CCOs are lowering unnecessary hospitalizations for conditions that can better be treated elsewhere. “There are also reductions in hospital readmissions, largely due to community efforts to achieve the highest quality care and to keep people at their healthiest,” she said. 

Highlighted findings
•  Decreased emergency department visits: Nine full months of reporting shows that emergency department visits by people served by CCOs has decreased 13 percent from 2011 baseline data.  
•  Decreased hospitalization for chronic conditions: Coordinated care organizations reduced hospital admissions for congestive heart failure by 32 percent, chronic obstructive pulmonary disease by 36 percent, and adult asthma by 18 percent.
•  Increased primary care: Spending for primary care is up more than 18 percent. Enrollment in patient-centered primary care homes has also increased by 51 percent since 2012, the baseline year for that program.  More than two-thirds of CCO members are now enrolled in patient-centered primary care homes.  
•  Increased adoption of electronic health records: Electronic health record adoption among measured providers has doubled. In 2011, 28 percent of eligible providers had adopted electronic health records. By September of 2013, 58 percent of eligible providers were using them.  
•  All-cause readmission: The percentage of adults who had a hospital stay and were readmitted for any reason within 30 days of discharge dropped from a 2011 baseline of 12.3 percent to 11.3 percent in the first nine months of 2013, a reduction of 8 percent.

Full press release here

CCO Advisory Council Meeting in Corvallis, January 13

InterCommunity Health Network Coordinated Care Organization (IHN-CCO) serves Oregon Health Plan members from Linn, Benton, and Lincoln counties. The Community Advisory Council works together with InterCommunity Health Network CCO to identify and advocate for preventive care practices, oversee a community health assessment, adopt a regional health improvement plan, and annually publish a report on the progress of the improvement plan.

Date: Monday, January 13, 2014
Time: 2:00 p.m. – 5:00 p.m.
Location: Sunset Building, Sunset Conference Room (first floor)
Address: 4077 Research Way, Corvallis, Oregon
Call-In: 1-866-439-0933, participant code 5093665467

Public Welcome.

Here is the Agenda.

Video of CCO meeting

InterCommunity Health Network Coordinated Care Organization invited community members to join them on Sept. 19, 2013, in Newport, to discuss the future of health care in our local counties. This recording captures the update reports from CCO leaders and interaction with the audience.  Click here to view the meeting.  In order to view it on mobile devices, Flash must be installed.

Republican Senator Objects to Secret Meetings for CCO Councils


It’s not “Health Care for All,” but it could be a step in the right direction.

Bud Laurent, Chair, MVHCA

Among the many acronyms used as shorthand in conversations about health care, we can add a new one beginning in 2012:  CCO.  That stands for “Coordinated Care Organization” and is a product of recent legislation by state lawmakers responding to the federal Affordable Care Act.  (House Bill 3650, if you’re interested: )
CCO’s  (several have been certified in the state) were created to improve the delivery of health care to Medicaid clients and, it is hoped, make Oregonians healthier. As envisioned, CCOs will coordinate care among a spectrum of providers, from primary care physicians and hospitals to dentists and behavioral health professionals. In our region, the CCO has been organized into the “InterCommunity Health Network” (IHN-CCO), a consortium of Good Samaritan Health Systems, Benton, Linn and Lincoln Counties, and several private providers.

One of the requirements for Coordinated Care Organizations is to hold public meetings at least quarterly to receive and answer questions on the minds of public health clients or supporters of public health care.  The IHN-CCO held a quarterly meeting at the Benton County Fairgrounds on November 28th and several representatives of MVHCA attended and asked questions.  We also submitted a list of questions from several members for written response, and Ms. Kelley Kaiser, the CEO of Samaritan Health Plans, provided the following answers:  

1.    Specifically what is being done to help health care practitioners modify how they practice medicine and become part of a TEAM in the patient centered primary care home?

IHN-CCO answers:  This is a great question and one we continue to focus on. As we mentioned we have a group of providers that meet every two weeks to discuss clinical transformation and what it entails. There is significant discussion about the PCPCMH [Patient-centered primary care medical home], as well. Each provider group also is working on this internally in terms of educating and communicating with their providers (Samaritan Health Systems, The Corvallis Clinic, the independents etc.)

2.    Please explain how community health workers will function and help "activate" Oregon Health Plan members to take responsibility for their health?

IHN-CCO answers:  We continue to work with the state on their specific expectations of community health works. We are also working with the local counties who already have many of these workers in place. We will learn and build upon what is already out there and then make sure the pieces are there that the OHA (Oregon Health Authority) wants.

3.    How will the CCO hold providers accountable for their performance in the medical home?

IHN-CCO answers:  This is part of the metrics and specifics already in place by the OHA. Then as a CCO we would work through our Delivery Systems Transformation team to ensure that appropriate reporting is in place to meet our additional CCO requirements should there be some.

As a CCO we will also have to respond to the OHA metrics and will work with our providers through contract requirements to make sure we are meeting the OHA metrics.

4.    How will decisions be made to utilize savings which may result from transforming delivery of care?

IHN-CCO answers:  This will work through the Regional Planning Committee and the Finance Committee to make recommendations to the Governing Board.

5.    What effort is being made to help the Community Advisory Council members get to know each other, find common ground and work together as a regional advisory body.?

IHN-CCO answers:  We continue to meet with them as a group and work on the Charter. We are moving forward with hiring a CAC Coordinator to help keep the group moving forward and educated on their purpose. The meetings we have had so far have started to allow the group to get to know each other.

6.    How will the community know if the CCO is doing their job?  Will the Oregon Health Authority report their findings to the community?

IHN-CCO answers:  The OHA through their Metrics Committee will be reporting out on all CCO’s [about] how they are doing. For us as a CCO we will work collaboratively with the CAC and the Community to continue to communicate our progress.

7.    The Transformation bill passed by the Legislature includes language that assures that chiropractors and naturopaths who are qualified to be primary care providers be included -- along with nurse practitioners, doctors of medicine and of osteopathy -- in CCOs and made available to patients who wish their services. This language has been referred to as a "Non-discrimination" clause, meaning that no type of provider who is licensed by the state of Oregon be excluded. Today, many non-Medicaid patients turn to, prefer, and benefit from these providers. So my QUESTION is: Has the IHN CCO included several of these practitioners? Who are they?

IHN-CCO answers:  We continue to respond to those providers interested in contracting with us. We will continue to follow our credentialing guidelines that are in place. For those providers who have expressed interest we are working on getting them our credentialing information by the end of the year.

8.  Do you have a list of primary care providers, and their training and specialties, that are part of the IHN?    We would be interested in knowing who are the auxiliary providers and services (such as physical therapists, etc.) also.

IHN-CCO answers:  Our contracted provider panel is available on our website for all providers and specialties currently contracted with us. [The IHN-CCO website can be found at:]

MVHCA has requested that future public meetings of the CCO be accompanied by written summaries of presentations and any Q&A session following.  This will require more work of the IHN-CCO, but MVHCA feels that records of these important meetings need to be publicly available.  We’ll keep you posted.

Oregon health reforms proceeding as issues arise, lawmakers told

By Nick Budnick, The Oregonian

A top state health administrator told lawmakers Thursday that reform of the state's Oregon Health Plan is proceeding quickly but not without issues, while some lawmakers questioned whether it is moving quickly enough.

In laws passed in 2011 and 2012, lawmakers approved new provider organizations called coordinated care groups to rein the growth of state Medicaid spending. Since August, 13 of these groups have started up and three more are awaiting approval, meaning about 75 percent of the health plan's 650,000 members will be enrolled, Bruce Goldberg, director of the Oregon Health Authority, said in a joint meeting of the state Senate and House health care committees.

"I wouldn't say there's been absolutely no problems," Goldberg said. "There always are some issues."

Among the issues, according to Goldberg and lawmakers: ensuring enough primary care providers in rural areas, as well as complaints from dental care groups, chiropractors, naturopathic doctors and other practitioners that say they're being shut out of the new care groups.

The state is setting up rules and a process to mediate such disputes, said Goldberg: "We are working through these issues."

State Rep. Mitch Greenlick, D-Portland, said his impression is the new groups are not much different from the managed care organizations they replaced, that it's "business as usual."

Goldberg disagreed, saying conversations are well under way and providers seem committed to change. But he said it could take time before cost-cutting efforts start bearing fruit.

Continuing coverage of efforts to reform health care in Oregon.
Another topic was plans to track performance measures to ensure the new care groups improve care starting in November. Sen. Alan Bates, D- Ashland, questioned whether that is too soon for the new system. "Can we get some breathing room here?"

Goldberg said, however, the quality measurements are a priority for federal regulators. The federal government has promised to fund the reforms with $1.9 billion over the first five years. "I don't think we're going to get any leeway," he said.

Sen. Chip Shields, D-Portland, asked when the new groups' boards would be required to hold public meetings, saying he's heard complaints of secrecy in the Portland area. "This is billions of dollars in state money," he said.

Goldberg replied that while he agrees transparency is important, there is no plan for the groups' boards to meet publicly. "These CCOs are not public bodies."

Rep. Jason Conger, R-Bend, asked about progress in enrolling people into the new care groups who had not been enrolled before. Goldberg responded that the state is negotiating with the care groups over how much the new enrollees will cost, and how much risk the state will bear if costs exceed projections.

 -– Nick Budnick

Wanted: Good Representatives for the Coordinated Care Organization’s Community Advisory Council

As readers of this site know, health care reform in Oregon is currently focused on Medicaid/Oregon Health Plan members.  On August 1st of this year, a private-public consortium of health care providers in Linn, Benton and Lincoln Counies began a new system under the title of “InterCommunity Health Network”, otherwise known as IHN-CCO.  How successful this new system will be remains to be seen – but you can help!

The regulations creating this new CCO require the formation of an advisory council composed of residents of the three-county area, half of whom will be clients served by the new system.  It’s very important that we have conscientious people serve on this new Community Advisory Council to provide oversight and advice to the IHN-CCO board of directors, and MVHCA encourages those interested to submit an application ASAP – the filing deadline is September 14, 2012  The next opportunity to apply will be in 2013.  

The application for the CAC can be found at: