Big changes coming for low-income patients, hopefully increasing options and curbing growth in spending

July 07, 2013 11:45 am  •  By Jeff Nielson -- Corvallis Gazette-Times

Coming changes in health care will mean a big difference for providers and low-income patients alike: Patients will be asked to assume a greater role in reaching their own health goals, and providers will earn Medicaid reimbursement based on progress patients make toward better health.

It’s a radical change from the past, when health care providers were paid for “encounters,” or each time a doctor saw a patient in a clinical setting. Starting in the near future, patients on Medicaid will be assigned to a specific health care organization, which will receive reimbursement each month for every enrolled member regardless of how many times a patient is seen during a given time.

Although this approach is already being tested under pilot programs in Oregon, it isn’t yet a sure thing here, health officials said. The coordinated care organization, or CCO, that includes Benton, Lincoln and Linn counties is known as the Intercommunity Health Network. It is administered by Samaritan Health Services, which still is negotiating with providers over alternative payment options.

One thing that won’t change, though, is patients who are insured under the Oregon Health Plan still will have the same doctor and benefits will stay the same.

The idea is to give health care providers the flexibility to provide several treatment options based on individual needs, rather than just involving doctors. Instead of simply seeing a doctor, for example, a patient might be offered help such as peer group support, exercise classes or even help shopping for groceries to make better food choices.

Eric Owen, deputy director of clinical operations for Benton County Health Services, believes the changes will be positive for health care providers and patients alike. (Benton County Health Services is the administrative arm of the Community Health Centers of Benton and Linn Counties.) Mental health patients served by the Community Health Centers of Benton and Linn Counties, which operates a total of five clinics in Benton and Linn counties, will be the first to see changes by the end of the year. A timetable for primary care patients still is being finalized.

“So much of what makes people healthy happens in the community and the home,” said Owen, who came to Benton County last year after 10 years of experience operating health clinics in Seattle. “This will give us more flexibility to start working with nurses and health navigators to engage clients in their goals to become healthier.

“We’re restricted now because funding is restricted to office visits.”

Treating the uninsured

Oregon, led by Gov. John Kitzhaber, a former emergency room physician, long has been nationally recognized as a leader in trying to provide quality health care to the uninsured — people who often found their only option was to seek treatment at hospital emergency rooms. State officials and the Legislature, working with health care partners, formed the Oregon Health Plan in the mid-1980s.

Last year, Oregon began forming CCOs, which are charged with implementing the changes to the Oregon Health Plan. The state’s stated goal is to “meet key quality measurements for improved health for Oregon Health Plan clients while reducing growth in (OHP) spending by 2 percent per member in the next two years.” The quality measurements also are a work in progress.

Benton County Health Services will see a future big difference in its financial structure as well, said Morry McClintock, chief financial officer.

In any given year, about 8,500 people are regular patients for mental health or primary care services or both, McClintock said. In the biennial budget that began July 1, McClintock estimates the percentage of patients who have no insurance, known as self-pay, will drop to 10 percent from the current 30 percent as insurance is made more available to everyone.

McClintock also estimates the percentage of patients covered by Medicaid under the Oregon Health Plan will increase to 48 percent from the current 38 percent as more people are eligible for the OHP.

Under current rules, noninsured people who want OHP coverage and meet low-income guidelines must sign up for a once-a-year random drawing for a few available slots.

Starting in 2014, anyone with income below 133 percent of the federal poverty level will be eligible for the OHP, and those with incomes up to 400 percent of the federal poverty level will be eligible for subsidies to purchase insurance from private companies.

An individual earning up to $15,282 per year would qualify for the OHP, or up to $45,960 per year to be eligible for private insurance subsidies. The dollar amounts rise depending on the size of a household. (See accompanying chart.)

Under the new Affordable Care Act, all persons will be required to carry health insurance, the cost of which has been the source of a continuing debate. In late June, Oregon state regulators cut rate requests from insurance carriers for those who will have to purchase their own insurance by as much as 35 percent.

One thing is certain: Under the new health insurance landscape, both the way care is delivered and who bears the costs will bear little resemblance to the past.

“We’re looking at a whole new way of doing things,” Owen said.

Jeff Nielson is a Corvallis freelance writer and a member of the board of directors of the Community Health Centers of Benton and Linn Counties. He can be reached at: jnielson@bendcable.com.