About Non-profit, public benefit corporation that manages Medicare and Medicaid services More than 270,00 OHP and 13,000 Medicare Advantage members ~25% of the total Medicaid population Most CareOregon Advantage (Medicare) members are enrolled in our Special Needs Plan for dually-eligible members 76% of members live in the Portland metro area 54% of members are female 26% do not speak English as their first language 46% self identify as non-Caucasian

Oregon Poverty Rate 8.9% in 2000 12.2% in 2010 NYT, November 17, 2011

Legislative History Leading to Oregon’s Healthcare Transformation 2009 Oregon Legislature HB 2009 “Healthy Oregon Act” 2010 U.S. Congress Patient Protection & Accountable Care Act (PPACA or ACA), aka “Obamacare” 2011 Oregon Legislature HB 3650 – Health Care Transformation Created concept of a CCO Charged the Oregon Health Policy Board with coming up with a plan for CCO implementation 2012 Oregon Legislature SB 1580 – Coordinated Care Organizations Essentially endorsed OHPB’s plan for CCO implementation

Oregon’s North Star: The Triple Aim Better health (Population Health) Better care (Experience of Care) Lower costs (Cost Containment)

Why Transform? Why Now? Fragmented, siloed systems Unsustainable health care costs Not great health outcomes State budget woes

Oregon CCO Inception Context Resource withdrawal: 20% State Budget Shortfall 11% rate reduction in 2011 Another 19% shortfall in 2012 (eventually filled with federal investment in transformation, with strings) Oregon is a relatively efficient market Traditional ‘low hanging fruit’ is picked Creative disruption, innovation and rapid adaptation now must be core business strategies

How to reduce the cost of health care: Traditional Method: Cut, cut, cut Reduce how much we pay for services (rates) Reduce the number of people covered (eligibility) Reduce the benefits covered e.g: move the “Line” on the Prioritized List OR... Implement an innovative, long-game method: Fundamentally change the way care is organized and delivered

Vision of HB 3650 and CCO Implementation (2011 Legislative Session, Oregon Legislature) Integration & coordination of benefits & services Local accountability for health & resource allocation Standards for safe & effective care Global budget indexed to sustainable growth Redesigned Delivery System Healthier population Improved Outcomes Reduced Costs [The Triple Aim] [A CCO]

Challenge + Urgency = Opportunity “I think you should be more explicit here in Step two.”

...and everyone is watching Senate Bill 99 created the Oregon Health Insurance Exchange, which will allow Oregonians to easily compare plans, find out if they are eligible for tax credits and other financial assistance, and enroll for health coverage. An estimated 636,000 Oregonians are uninsured House Bill 3650 and Senate Bill 1580 established new provider groups serving Oregon Health Plan clients. The groups, called coordinated care organizations or CCOs, are designed to emphasize prevention and integrate medical, dental and mental health care. LEGACY HEALTH

What is a Coordinated Care Organization (CCO)? What is a CCO? What is a Coordinated Care Organization (CCO)? A CCO is a single organization that accepts responsibility for the cost of health care within a global budget and for delivery, management and quality of care delivered to the specific population of patients enrolled with the organization. MCO, DCO, MHO, Rx, County Programs, Medicare, Medicaid, Specialty, Hospital, PCPCH Fragmented, Siloed System CCO Shared Systems & Learning Coordination & Communication Local Accountability Global Budget Coordinated “Commons” System

Key Principles for Governing the Commons: Commons as metaphor for Coordinated Care Individuals know the boundaries and limits Of the resource (“Common Pool Resource”) Of the community of users (“Appropriators”) Rules are locally made and adapted to context Decisions are made together Active measurement and monitoring Effective sanctions Mechanisms for conflict resolution Latitude from higher authorities to act locally Nested Commons Source: Elinor Ostrom quote by Don Berwick in 2009 IHI Forum Plenary

CCO Theory Demands a more horizontal approach Democratizing systems that promote health, not just health care Dependent on a network model Interdependent / Inter-independent agents CCO Shared Systems & Learning Coordination & Communication Local Accountability Global Budget Requires involvement and input of a multitude of stakeholders Is accountable to those stakeholders Is a community solution, as opposed to an industry solution No longer every man (organization) for itself

Accountability measures and financial pressures on CCOs will require us to go upstream and intervene earlier and differently Influence Factors on Health Status Environmental 5% Social 15% Human Biology 30% Lifestyle & Behavior 40% Medical Care 10% Source: McGinnis J.M., Williams-Russo, P., Knickman, J.R. (2002). Health Affairs, 21(2), 83

[Insane] CCO Development Timeline July ‘11 January ‘12 March ‘12 April ‘12 May/Jun ‘12 July ‘12 August ‘12 Sept ’12 Nov ‘12 Jan ‘13 Feb ‘13 HB 3650 signed into law OHPB’s Implementation Plan published, SB 1580 signed into law CCO Letters of Intent submitted, RFA published Application for CCO Certification due Readiness Review Execute CCO Contract with OHA CCO Go Live Current FFS enrolled into CCOs Transformation Plan draft due Transformation Plan implementation begins

Key Components of CCO Development Geographic/Demographic Scope Business & Operations Information Systems Utilization Management Administration Claims Processing Customer Relations Workforce Development Local Governance Board of Directors Community Advisory Council Model of Care Physical, mental, oral health integration Social service networking/integration Delivery system transformation Keeping people healthy Financing Global Budget Capitalization Risk Revenue Alternative Payment Methodologies

What does Transformation look like? The fundamental questions we have been asking ourselves and stakeholders in our communities: Can we do more with less? Can we do more of what works? Can we let go of what doesn’t? How do we together foster communities that support the best possible lives for everyone in Oregon? Janet

CareOregon’s CCO Partners: Yamhill County Care Organization Columbia Pacific CCO Health Share of Oregon Jackson Care Connect Yamhill County Care Organization

Why would Oregon’s health systems agree to do all this just for Medicaid? Post-ACA, 25% of Oregonians are enrolled in Medicaid $1.9 Billion in federal investment  accounts for 19% of the state’s Medicaid budget in the ‘13-’15 biennium Unclear what the expiration of this investment will do The CCO Metrics dollars are real money Policymakers are pushing to fold all publicly-funded health coverage into the CCO model PEBB & OEBB If that happened, ~40% of Oregonians would have care paid for and coordinated by CCOs

How the CCO Metrics Work (2015) Quality Pool The OHA withholds 4% of monthly payments to CCOs; to earn the 4% back, CCOs must: meet benchmarks/improvement targets for 12/17 incentive measures; and >60% of members enrolled in a PCPCH; and meet benchmark/improvement target for the EHR adoption measure Challenge Pool If there are funds remaining after the Quality Pool is distributed, they are distributed out to CCOs, based on their performance on: Alcohol and drug screening (SBIRT) Diabetes HbA1c poor control Depression screening and follow-up plan PCPCH enrollment

17 Incentive Metrics for 2014 5 Access to care (CAHPS) Adolescent well-care visits Alcohol and other substance misuse screening (SBIRT) Ambulatory care: emergency department utilization Colorectal cancer screening Controlling hypertension Depression screening and follow-up plan Developmental screenings in the first 36 months of life Diabetes HbA1c poor control Early elective delivery Electronic health record (EHR) adoption Follow-up after hospitalization for mental illness Follow-up for children prescribed ADHD medication Mental and physical health assessments for children in DHS custody Patient-centered primary care home (PCPCH) enrollment Prenatal and postpartum care: timeliness of prenatal care Satisfaction with care (CAHPS) (add ages 12+) [must actually move metric] Dental sealants on permanent molars for children Effective contraceptive use (add dental assessment)

How did our CCOs do in 2014? CCO # of measures met % of Quality Pool funds earned Challenge Pool measures met Total $ amount earned Total enrollment Columbia Pacific CCO 13.9 104% Depression, Diabetes, PCPCH, SBIRT $4,247,607 25,530 Health Share of Oregon 16.8 105% $34,592,657 225,068 Jackson Care Connect 13.8 103% Diabetes, PCPCH, SBIRT $4,704,838 27,828 Yamhill Community Care Org 12.7 $2,981,967 20,753

ERIN: This came from original slide deck