1. Transformation in the State of Oregon: A Collaborative Plan to Weather the Storm Erin Fair, MPH, JD CareOregon Sr. Manager of State & Federal Regulatory Policy

2. About Medicaid & Medicare Managed Care Org. More than 155,000 OHP and Medicare Advantage members – Most MA members are enrolled in SNP 76% of members live in the Portland metro area 54% of members are female 59% are 19 & younger; 19% are 4 & younger 26% do not speak English as their first language 46% self identify as non-Caucasian

3. Key Data – Portland Metro Area Total Population – 1.6 Million – Medicaid + Dually Eligible – 216,400 – Uninsured ~232,000 Annual Portland Medicaid Budget ~ $1.2 Billion (state & federal funding combined) – 11% cut to OHP budget in 2011 – Another 19% cut has been proposed in 2012 High Medicare Advantage penetration, overall 28% of Portland pop.

4. Portland Context Resource withdrawal – 11% payment reduction in late 2011 – Anticipate another 19% cut in mid-2012 In Portland that is -$230M annually, permanently – ~$115M the Inpatient and Outpatient Services; ~$115M from MD, Ancillary, Mental Health, etc. Portland/Oregon is traditionally an efficient market – Major ‘low hanging fruit’ is picked – New innovations and tight integration & coordination necessary – Systems must be embedded in our Communities – ‘Creative Disruption and Innovation’ are core actions No longer ‘Every Person for Themselves’ – Re-envisioning community health resources as Health Commons with local rules, governance and disciplines with equitable distribution among and for all stakeholders

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

6. 2012 State Budget Reduction Estimates -$230M Portland 216,000 Tri-County Enrollees -$1,064 per member per year reduction 1. YEARLY REDUCTION -$1,064 per member per year reduction 12 months -$89 average reductions per member per month required 2. MONTHLY REDUCTION

7. Challenge + Urgency = Opportunity Challenge State Budget Siloed System History of Competition Challenge State Budget Siloed System History of Competition Urgency State Budget – Shrinking Reserves – Economic “Reset” CMMI Grant Medicaid Expansion Urgency State Budget – Shrinking Reserves – Economic “Reset” CMMI Grant Medicaid Expansion Opportunity CMMI Grant Shared sense of urgency is compelling unusual behavior Opportunity CMMI Grant Shared sense of urgency is compelling unusual behavior

8. Redefining our Larger Family of Responsibilities & Relationships We’re searching for a new way to relate to a whole community’s need together – one that serves the needs of our very poor & uninsured; has hope to evolve into a healthier tomorrow; while not becoming overwhelmed or deteriorating our key organizations in the process; and actually, emotionally and morally renews our foundational American Dream of justice and opportunity for All.

9. Guiding Principles “If you want to go fast, go alone; if you want to go far, go together.” -African Proverb Transformation that is Bottom-up, Top- Enabled Invest FORWARD

10. Healthy Community Triple Aim: Key Portfolio of Changes for Impact & Success Quality Life Experience Social Resource Use Mod - Hi Medical Mod - Hi MH / AD Lower Social Health Care System Delivery System Redesign: Primary Care Home Behav / Oral / Med Integration Care Transitions Aligned Specialty / E-referral Healthy Birth Midwifery LEAN Hospital Community Standards Community Health System Lo Medical Lo MH / AD Hi Social Resource Integration: Service partnerships Community Schools Asset Support Public health alignment POPULATION SEGMENTS (By Outcome Drivers) STRATEGIC INITIATIVES Quicker ROI Slower ROI Care Cost High Care Cost Low Hi Medical Hi MH / AD Hi Social Hi Needs Customized Care: ED / Hosp. Hi-Utilizer Care Teams Complex Case Mgmt ED Diversion / Navigation Rx Opioid Abuse Reduction Supportive Service Assessment Hot Spots Burning Smoldering Population Health

11. Immediate Strategic Co-Initiatives Hi Yield Immediate Cost Reduction Strategies Reducing Unnecessary ED Costs Reducing Avoidable Demand ED Navigation **Taskforce ED Opioid Standards **Taskforce Embedded Primary Care Pilot ED / FQHC NP Model Reducing Unnecessary Hospital Costs High Utilizer Stabilization “Hot Spot” Integrated MH / Addictions / Prim Care Community Based Team Deployment **Taskforce Reducing Readmissions Hospital / Safety Net PCP Standards on Transitions **Taskforce

12. Medium Term Strategic Co-Initiatives Medium Term Cost Reduction Strategies Reducing Unnecessary Hosp / ED Costs Complex Patient Stabilization Embedded Case Management **OHLC Phase 2 Improved PCP Access / Continuity Primary Care Home **PC3 Scale Up Reducing Unnecessary Specialty Costs Specialty Alignments with Safety Net E-referral **Taskforce Mental Health / Addictions / Primary Care Integration Primary Care Based IMPACT + Collaborative Care Model Spread MH / Addictions Based Reverse Co- Location / Medical Collaborative Care

13. Longer Term Strategic Co-Initiatives Healthy Birth / Midwifery Program Housing Services Assessment / Strategy Public Health Alignment Social Service Alignment LEAN Institute

14. Strategies for Innovation: Sample Investing Forward Portfolio Processes Value Chains Structures New Formations Resource Use Improvements Mental Health and Clinical Integration Releasing Time to Care Commons Health Record Primary Care Renewal (PC3) Community Care Teams Specialty E-Referral Public Health Invigoration SUN as Community Center Focused Lean Improvements Changing Site of Care Technology Infrastructures Environment Attitudes Behaviors Child and Adult Discharge Engagements ED Navigation Local Telemedicine Methods of Change

15. CMMI Health Innovation Challenge Grant – The Spark $1M - $30M 3-year cooperative agreement Focuses on high cost/high risk groups Significant workforce development/deployment Rapid deployment (“shovel ready”) LOI – 12/19 Application Deadline – 1/27/12

16. Macro Mezzo Timeline 1/12/1 Feb-March 2012 Legislative Session 2013 Legislative Session 7/1 ‘13-’15 Budget Begins 8/111/1 CCO Global Budget Begins? Year 2 of ‘11-’13 Biennium Election Day 1/1 2012 DMAP Contract 7/1 11/61/1 Full oral & mental health integration ‘13-’15 Budget Begins ER Diver- sion Pain Mgmt PCPCH C- Section In- patient Admits Micro ROW Demon- strated Outcomes ROW Demon- strated Outcomes ROW Demon- strated Outcomes ROW Demon- strated Outcomes Hotspotting M e d i c a i d E x p a n s i o n New Partnerships? Accelerated Timeline for Building Collaborations Mid- wifery CCO Governance Design Legal Structure Finance & Operations CCO Governance Design Legal Structure Finance & Operations Oregon Health Leadership Council CCO Community Workgroups Speed-dating & Collaboration CMMI Grant Proposal Collaborative Oversight, Shared Learning, CCO?

17. Partnership/Alliance/ Collaborative Funding/ Financing Evaluation & Measurement Health IT Acute Care Inpatient & ED Outpatient/ Behavioral Health/ High Risk Pop. Pharmacy Shared Learning & Change Mgmt. CMMI Grant – Draft Workgroup & Oversight Structure

18. Primary Risk: Insurance Risk Secondary Risk: Clinical, Value, Performance- Based Risk Community Health Alliance Board of Directors Payer 4 Payer 3 Payer 2 Payer 1 Provider Network 1 Provider Network 1 Provider Network 2 Provider Network 2 Provider Network 3 Provider Network 3 Provider Network 4 Provider Network 4 Community/Member Advisory Board(s) Delivery Technical and Learning Supports ( Coordinated & Shared Services ) Council: Clinical Integrated Care Delivery Partners (Physical/Mental/Dental/Social Service/Addictions/Etc.) Council: Clinical Integrated Care Delivery Partners (Physical/Mental/Dental/Social Service/Addictions/Etc.) Whole System Outcomes State Integrated Funding State Integrated Funding TriCounty Health Collaborative Draft Risk/Delivery/Governance Structure Draft Drawing for Discussion Only System Transparent Feedback & Learning Metrics Alliance: Joint Performance & Accountability, CCO? Mental Health

19. 1.Individuals know the boundaries and limits – Of the resource (“Common Pool Resource”) – Of the community of users (“Appropriators”) 2.Rules are locally made and adapted to context 3.Decisions are made together 4.Active measurement and monitoring 5.Effective sanctions 6.Mechanisms for conflict resolution 7.Latitude from higher authorities to act locally 8.Nested Commons Design Principles for Governing the Commons: Commons as metaphor for Collaborative Source: Ostrom quote by Don Berwick in 2009 IHI Forum Plenary

20. HMA Revenue Enhancement Estimates

21. Experience of Care (EC) Cost Containment (CC) Population Health (PH) 1 2 3 4 5 1 1 2 34 4 5 5 2 3 Good Policy: achieves all three goals of the Triple Aim Bad Policy: one that does not achieve the goals Triple Aim Mediocre Policy: A policy that achieves only one or two goals of the Triple Aim PHECCC Instructions 1.Give the policy a score 1-5 for each of the three Triple Aim goals in the table below; 2.Plot the score on the Triangle 3.Connect the dots (5 = Achieves best possible outcome; 1= does NOT achieve at all) PHECCC 555 PH EC CC PH EC CC PH EC CC PHECCC 524 PHECCC 213