- Oregon’s coordinated care organizations (CCOs) are well ahead of HHS Secretary Sylvia Burwell’s desire to bring accountable care to the majority of patients in the United States. In just a few short years, the state’s Medicaid program has cut emergency department visits by 21 percent, decreased diabetes-related hospital admissions by 9.3 percent, and boosted patient-centered medical home (PCMH) enrollment by a staggering 55 percent since 2011.
In its latest progress report, which covers the period from mid-2013 through the first half of 2014, the program continues to build on earlier successes with the help of a growing data analytics and health information exchange infrastructure that encourages more sophisticated measurement and reporting.
“We have sixteen coordinated care organizations in Oregon, and they are held accountable for physical health, behavioral and mental health, and dental health services for members of the Oregon state Medicaid program,” explained Lori Coyner, Director of Health Analytics at the Oregon Health Authority. “For 2014, three percent of their expenditures were held back and put into something that we call the ‘quality pool.’ Each of the CCOs are paid out of that pool based on their performance on 17 incentive measures.”
The clinical quality measures include many of the same metrics required for eligible professionals by Stage 2 of the EHR Incentive Programs, such as screenings for alcohol and tobacco misuse, cervical cancer, and sexually transmitted infections, along with ensuring comprehensive diabetes care, child development, and immunizations. As EHR use races to the state’s 72 percent adoption benchmark, the CCOs are bulking up their data reporting capabilities, as well.
“Most of the measures that we reported this time come from encounter and claims data. And so a lot of it comes just from the organizations’ standard billing practices,” Coyner told HealthITAnalytics. “However, three of the incentive measures are clinical quality measures, and we phased in how the CCOs report on those.”
“The first year, they had to submit a technology plan and a ten percent sample of their data,” she continued. “This year, they had to send a revised and more expanded technology plan, and they needed to report on 50 percent of their members. The data has to come directly from medical group electronic medical records. So part of the reason that we put in this phased in approach is to allow them time to build some of the health IT infrastructure they need in order to report on data directly from the EHR.”
Building a statewide reporting and analytics infrastructure is no easy task, as EHR interoperability, a lack of consensus around data standards, and financial barriers often get in the way of cooperation across regions that may be in competition with each other for patients and resources. In Oregon, however, there is little to no overlap in patients between CCOs. Members must choose an organization to belong to, which reduces competition and allows the CCOs to focus on the nuts and bolts of patient care. It also provides a more seamless foundation for the state’s next big infrastructure tasks.
“We’re building a clinical data repository so that eventually, when the CCOs submit their clinical data, it will come directly there,” Coyner said. “There is also some health information exchange (HIE) coming online. There’s one that serves the southern part of Oregon, and multiple CCOs are connected there. So we have been tracking what sort of health information technology is happening.”
“One of the key pieces is that we actually provide data to the CCOs through a portal on a monthly basis. So they see this information a lot more often than we report publicly. We track and monitor the measures so that we know where our transformations are being effective, and how we can provide learning collaboratives and other resources for some of the metrics where the CCOs aren’t continuing to show improvement.”
The state is also tracking the early impact of its new emergency department utilization reporting system, Coyer said. “Most of the hospitals in the state are implementing something called EDDIE, which is an emergency department notification program that allows EDs to send care plans to primary care offices, as well as notify the CCOs and the delivery system when patients are coming to the ED a lot. It might even be that those patients are coming to different emergency departments, and now we are able to track that. The CCOs have been involved along with the hospitals and the state to help get that program implemented. It just got up and running this fall.”
Emergency department utilization has fallen from 61 percent in 2011 to 48.1 percent in 2014, just above the ideal target of 44.6 percent. This is despite the fact that nearly 400,000 new Medicaid patients have joined the system thanks to Oregon’s expansion program.
“We compared members who have been on Medicaid with those who have returned as part of the state’s program expansion within the last two years,” said Coyner. “And then we also took a look at people who have not been on Medicaid for the past few years, as far as we know. For the new members across the first six months, their rate of emergency department use was less than both the returning and the existing members. And their avoidable emergency department utilization was lower.”
Studies on ED use under Medicaid expansion can be read both positively and negatively, with some researchers writing off increased coverage as an invitation to swarm the triage desk for free and others noting that spikes in ED use are often temporary.
“We believe there are a few things going on with that,” Coyner acknowledged. “One is that the new expansion population is likely healthier and younger than originally anticipated,” she explained. “The biggest growth in membership, at least proportion-wise, is age 19-35 under Medicaid expansion.”
“We also know that patient-centered medical home (PCMH) enrollment among our CCOs is up. We know that many of the CCOs, when a new member was enrolled, would contact the member and make them aware of who their primary care team is. We believe that that early connection with primary care probably allowed new members to start going directly to their primary care home and not just to the emergency department because they didn’t know where to go.”
“When we first started two years ago, the number of practices that were actually certified as PCMHs was much lower than now. Many of the CCOs took steps to make sure that more of the practices within their networks were certified, and then they worked with their members to get them enrolled. So it’s been a process.”
The PCMH approach has been successful in a number of different cases, and has certainly helped Oregon achieve its notable results for improving population health management, primary care, and preventative service delivery. Access to primary care for toddlers sits at 95.1 percent, while teenagers 12 to 19 visit their PCPs at a rate of 87.3 percent. A1c testing for diabetics is at 82.7 percent, just below the state’s benchmark, and three-quarters of adults with diabetes receive cholesterol screenings.
Oregon isn’t nearly done with its work, and plans to closely monitor the data from the second half of 2014 to assess the true impact of its ballooning Medicaid enrollment. But Coyner believes the Health Authority has collected some valuable experiences so far, which will only help to spur more progress in the future. What should other regional projects take away from the fight to bring accountable care to patients?
“I think some of the lessons learned for us is that you need to have both local control and strong partnering between the state agency and the entities that are providing care to their Medicaid members,” she said. “Definitely, the measures that have incentives attached to them are the ones that get paid attention to. We see much more improvement on those that are incentivized than on some of the others.”
“And the other big lesson is that you should be transparent both in your message and in your reporting,” Coyner added. “We are very open, and we provide information to anybody who wants it. It helps build trust in our partnerships. In order to have an incentive program work, you really need that.”