1. 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

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

3. 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

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

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

6. 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

7. 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

8. 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]

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

10. ...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

11. 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

12. 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

13. 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

14. 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

15. [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

16. 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

17. 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

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

19. 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

20. 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

21. 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)

22. 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

24. ERIN: This came from original slide deck