Solutions from the Outside Who Asked You?

CONTEXT

Health Care Reform  Reform is not about health care – it is about money and politics.  Health Care costs are between 17-18% of GDP  They should be around 11%  No health care entity will willingly give up revenue or profit.  Health outcomes are what will be achieved after money and politics are decided.

Health Care Triangle COSTQUALITYACCESS

Health Care Reform  Demand – Causes  Genetics, environment, economic status, education  Access – How one gets into the system  Finance – Who gets paid what  Price – Controlling the market  Cost – Budget  Quality – How good we want the system to be

Oregon’s Managed Care History  Began in 1985 with PPO risk model for Medicaid  Legislature authorized Oregon Health Plan in 1989  Full HMO Model  Full integration of all health services except LTC  Cost based provider reimbursement  Prioritized list of covered services  Guaranteed access to providers  Implemented in 1995 W/O Mental Health  Added Mental Health in 1997, partial success  Cost based reimbursement lost in 2003

Key Results of OHP  Most comprehensive evidence based benefit list in the US.  14 Fully Capitated Health Plans  2 Insurance companies  12 community based managed care organizations  All are full HMO operations  500,000 Clients with guaranteed timely access to care  All Clients have a primary care provider  Approximate 12% savings per managed care client per year  $15 Billion over 16 years

2012 Health Reform  Legislature passed Health Transformation act in 2009  Integration of Mental Health and Dentistry  Modified Act in 2011  Protected existing MCO’s  Set rules for Governance  Transparency in Government payments (sort of)  CCO’s began operation in August, 2012

What’s a CCO?  CCO’s are fully integrated health plans responsible physical, mental, alcohol and drug, and dental care.  CCO’s are given a global budget, paid by a monthly premium, that covers full risk for all services.  CCO’s are viewed as community based organizations and are required to have community representation regardless of their corporate structure.  CCOs are held accountable by reporting performance on quality measures such as prevention, disease identification, ongoing intervention, patient satisfaction and total cost of care.

What is changing?  Practitioners across the disciplines are talking to each other  CCO Insurers are changing their business models  Traditional silos: Claims, Customer service, R&A, Care Coordinators, etc.  New model: Integrated customer teams – Navigators, referral and social service coordinators for providers, care coordinators and patient mentors.  Redistribution of money and services  PCP’s paid more and used more.  Specialty utilization is down  Outpatient and ER services are declining  Hospital reimbursement is tied to Medicare methodology and rates are capped  Long term cost trends ??

What is being accomplished?  Health care is a community effort  Integration of health care services is happening  Integration of health care, social, housing and food services is being designed and implemented.  Community Health discussions now involve  Health care providers  Social Services  Schools  Public safety

What Does Alaska Do?  Medicaid Expansion  You pay the Bill either way  Reform or not  Where do you want your money to go?  Health care or other areas?  Education, roads, sewers, economic development  You get to choose or not choose  If you don’t, someone else will