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 Oregon.gov/CCO 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.

References

References

 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.  

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