Just what the legislature ordered: Oregon races the clock to restructure its low-income health care system
By Amanda Waldroupe, Staff Writer
Autumn Bolds begins the day’s huddle by telling Dr. Rachel Solotaroff, the medical director of Central City Concern’s Old Town Clinic, that her patient schedule that afternoon has changed dramatically.
Solotaroff will see eight patients that afternoon. Bolds, a panel manager on Solotaroff’s patient team, is responsible for coordinating Solotaroff’s patients, and she quickly launches into briefing Solotaroff and Magadalena Juan, a medical assistant, on each patient and their health.
She goes through each patient chart, quickly saying why he or she is coming for a visit, what medications the patient is on, and whether pap smears, blood tests and other routine check-ups are up to date.
Juan scribbles notes, and Solotaroff asks some clarifying questions. The rapid pace pauses briefly as the three discuss, in the case of a couple patients, whether they have or need mental health providers, and if a particular concern the team has might be discussed with the patient at that time.
Ending with a high five, the day’s huddle is over after a short 20 minutes.
Solotaroff says these daily meetings are hugely beneficial in helping her and the team prepare for each patient visit, knowing what to expect, and also what to anticipate in terms of providing the best possible health care to the Old Town Clinic’s low-income and homeless patients.
“The idea is that your work of the day is not your schedule, but the population of patients you serve,” Solotaroff says.
Across town at southeast Portland’s Richmond Clinic, Dr. Nick Gideonse has similar daily meetings with his patient team, a group made up of doctors, nurses, medical assistants, and a behavioral health specialist.
Both clinics, and a handful of others around the state, are blazing the trail in providing this type of care to patients — health care in which a variety of providers addressing a spectrum of health needs communicate and work together. Care that is coordinated.
Oregon is adopting this model of care for its state Medicaid program, the Oregon Health Plan, in what are the most ambitious changes to the program since it began providing health care to Oregon’s poor in 1994.
By July, it is expected that the physical, mental and dental health care provided to 600,000 Oregonians on OHP will be restructured in this new coordinated system, with all providers — including doctors, nurses, mental health counselors, dentists, and other medical professionals — communicating and working in tandem. Its goals are to increase access and quality of health care — and create savings, $239 million worth, by the legislature’s budget.
The changes are being ushered in by House Bill 3650, called the Health Transformation Bill, which passed the Oregon State Legislature after intensive political negotiations in late June.
The cornerstone of the changes is the coordinated care organizations, or CCOs. Although HB 3650 gives no definition of what a CCO is, many describe them as being regionally-based geographic organizations that will be flexible enough to address specific health needs within a community and working multiple medical providers to coordinate care.
They will have a governance structure with representation from the providers and stakeholder groups involved in providing care. And each CCO will be given a lump, “global” budget to pay for the care of all its patients.
The expectations are high.
“Hopefully, they will create flexibility to do care differently and save money in the process,” says Rep. Tina Kotek (D-Portland), who helped negotiate and write HB 3650. “Our hope is that there will be higher quality of care, more timely interventions, and more appropriate care, just by virtue of understanding the individual better.”
“The idea is so good,” says Solotaroff. “My really optimistic hope is that they’re outcome oriented, and that the outcomes matter to the population (providers are) working with.”
But no one is sure how CCOs will be structured, or how exactly they will operate.
“That’s the magic question,” says Mary Monnat, the executive director of LifeWorks NW, and a member of a governor-appointed workgroup to hash out criteria for CCOs.
“There’s not a lot of flesh to the bone,” agrees Solotaroff.
And the clock is ticking.
The Gov. Kitzhaber’s signature on HB 3650 was barely dry when a whirlwind of activity began to implement the new law: The governor appointed 133 people to serve on four workgroups made up of health care workers, policy makers, advocates and consumers to develop a more detailed plan of creating CCOs, establishing quality control measures, the methodology for the budget, and how to integrate care for the roughly 60,000 people on both Medicaid and Medicare. They met in August and September, and meet again in October and November. They will give their recommendations to the Oregon Health Policy Board, which advises the Oregon Health Authority.
The Oregon Health Policy Board will use the recommendations to finalize a plan that must be approved by the Legislature in February in order for reform to move forward.
“We’re waiting with bated breath,” says Rep. Mitch Greenlick (D-Portland), another legislator heavily involved in HB 3650’s writing.
If the Legislature gives approval, the state will work to have CCOs operational by July. It is a fast timeline, but Greenlick and others think it’s enough. “It’s very exciting,” Monnat says. “But, like any change, it’s also daunting and hard to get your head around.”
Much depends on Oregon’s health transformation. Many critique the Oregon Health Plan for being fragmented and not patient-focused. The legislature also took a risky gamble in budgeting $239 million in savings from the effects of integrating care.
If care coordination does not work, then care will remain fragmented, leaving a population of people who are poor and sicker than the average, challenged with navigating a massive system, bouncing from provider to provider, and falling through the cracks.
“We have a moral imperative to make health care more efficient,” says Gideonse, the medical director of Oregon Health & Sciences University’s Richmond Clinic.
“We’re not talking about people who live in the west hills of Portland,” says Thomas Aschenbrenner, the president of the Northwest Health Foundation, and a member of the CCO workgroup. “These are people who have struggled their whole life. They don’t have the emotional energy to put up a fight, and if we don’t put up a fight for them, they will suffer even more.”
Cranking out visits in fragmented silos
To understand why such radical change is being undertaken, it is important to understand whom the Oregon Health Plan serves. The plan is available to people with an income 138 percent below the federal poverty line, or roughly $15,000. Living in poverty, people on the Oregon Health Plan have barriers to transportation, childcare, and other obstacles to accessing healthcare.
“They’re demonstratively sick patients,” Gideonse says. “The sicker you are, the less attention points you can lend toward navigating complex systems.”
“They end up ignoring diseases that should be treated,” Greenlick says. “They don’t have the ability to get good preventive care. Then they end up using the emergency room. It’s a huge problem.”
The Oregon Health Plan currently provides services through “managed care organizations.” Similar to insurance companies, managed care organizations develop health plans it offers to patients on the Oregon Health Plan, and contracts with medical providers. Patients have separate health plans for their physical, mental and dental care. That means patients may go to three different places for their health care.
“None of those plans talk to each other,” says Erin Fair, the manager of state and federal policy at CareOregon, a Portland-based managed care organization. “That creates not only siloed care and administrative hassle” but also leaves the patient very confused.
“You could not create a more convoluted system,” says Mike Bonetto, Gov. John Kitzhaber’s health policy advisor.
Solotaroff can say from experience that the lack of communication among the silos directly affects patients.
One example she offers is a patient in long-term care with congestive heart failure, whose weight must be checked every day to determine whether fluid is building up in his body. A staff person at the long-term care facility might weigh him every day, but then not call it in to his doctor, nor e-mail, but rather send a fax.
“Two or three pounds could be a big deal,” Solotaroff says. “And I might not see it unless I’m running around saying, ‘where is that piece of fax paper?’”
“The hope of a CCO is that they will be able to deliver a much more integrated package of services,” Greenlick says.
The way providers are paid has also presented significant challenges to the quality of care under the OHP. In the current “fee for service” model, providers are paid the same per patient visit, regardless of what services are provided, how sick the patient may be, or how much care they need.
That creates a tension between providing adequate care and generating enough revenue to keep a clinic financially viable. “The cost per visit is the same, so you do it through visits,” Gideonse says.
“It’s volume driven and not value driven,” says Ern Teuber, the Richmond Clinic’s executive director.
The choice between “10 sore throats versus a very sick person,” is thus very clear. “That’s not necessarily good health care,” Gideonse says.
Solotaroff agrees. “It’s so inefficient now because it is almost entirely based on cranking out visits and not better outcomes.”
The new “global budget” plan for CCO’s is viewed as a key solution. One budget, given to a CCO, will pay for the care of a specified number of patients during the year. Legislators and others hope it will motivate CCOs to carefully manage the money they’re given and provide the most efficient care possible.
“It’s a powerful tool,” Greenlick says. “Right now, there’s just no discipline.”
Solotaroff agrees.
“The idea of the global budget that pays you to take care of a person rather than spend 15 minutes to listen to a patient and write down what they’re saying is very appealing,”
Searching for structure and criteria
One of the elusive puzzle pieces to developing coordinating care is the structure of a CCO. How big will it be? What will it do? Who will be a part of it?
“It’s more than just one clinic. It’s hospital care, specialty care, mental health, dental care,” says Greenlick. “You need to bring all the people into a CCO that need to be there to provide all the health care services.”
Teuber, the Richmond Clinic’s executive director, says there are at least a couple ways a CCO can be structured.
What is known with certainty is that managed care organizations will cease to exist. Teuber says a CCO may be a fairly small organization that simply contracts with provider groups to provide care, with the contract requiring collaboration and coordination. Money would funnel through the organization to the various providers, and the organization would provide some type of oversight and accountability.
Another possibility is that a CCO could be a non-profit. In such a scenario, all categories of providers would be in the CCO.
“As long as the CCO holds itself and all players accountable for doing only that which is in the patient’s best interest, then that will be quite different from what the average managed care organization has been doing,” Teuber says.
Another vexing question is what the criteria for a CCO will be. An organization will have to apply to the Oregon Health Authority in order to become a CCO. The organization will need to prove that it meets certain criteria and guidelines.
A balance must be struck between flexibility and concrete criteria so that CCOs can be flexible enough to address particular health problems in its particular community. But some fear that if the criteria are not strong enough, there will be less of an incentive for the CCOs to truly change how health care is delivered.
“It’s probably going to look pretty loose,” says one member of the CCO workgroup who did not want to be named. “As we move forward, I hope something will happen that will make it clear to people that this is about behavior change.”
Broad criteria, this member said, could cause some organizations that become part of CCOs to simply make up their own rules. If they have particular religious or ideological leanings, that could mean, for example, less access to reproductive and family planning services. It’s possible that the Oregon Health Authority could intervene, but it is not clear yet where the Authority would, or could.
“Good criteria will not allow somebody to get in the game without taking care of the whole patient population,” says Lillian Shirley, the director of Multnomah County’s public health department and vice-chair of the Oregon Health Policy Board, during the board’s meeting on October 11.
During that meeting, the Oregon Health Policy Board discussed for the first time in some detail what the criteria and structure of a CCO will be. Much emphasis was placed on the need for CCOs to reduce health inequities due to race and ethnicity, geography, disability, sexual orientation, income, homelessness, and a variety of other factors.
Nothing will be set in stone until a plan is delivered to the Legislature this winter. There continue to be, Fair says, “a lot of unknowns.”
Of teams and touches
The Old Town Clinic adopted its coordinated care model in 2007. The clinic has three teams made up of a medical doctor, a physician assistant or naturopath, a behavioral health counselor, a panel manager who keeps track of all the patients, a medical assistant, and an acupuncturist.
The clinic currently has three patient teams, each responsible for between 800 and 900 patients. Solotaroff says a fourth team will be created when an addition to the Old Town Clinic opens late this winter. A fifth patient team is planned to start sometime in 2012.
Each team member has specific responsibilities in relation to a patient’s health. If something is outside the realm of that person’s specialization, he or she communicates with the person on the team most qualified to address that issue.
The patient will interact with each team member to varying degrees. An individual may visit a clinic multiple times when first admitted to discuss multiple health problems and have exams, lab tests, screenings and other procedures done.
“I might see them every week or two until they are stabilized,” Solotaroff say. “There’s just pent up demand. If someone has been in a decompensated state for some time, there’s a lot of stuff you need to take care right out of the gate.”
The intensive engagement in the beginning, Solotaroff and Gideonse say, has multiple benefits: a closer relationship forms between patient and provider; the patient begins learning how to manage their illnesses; and, most important, providers gain a solid understanding of their patient’s health to know the care the patient needs without having to wait until the patient gets sick again and seeks more costly hospital and emergency room care.
After that first phase, the patient will most often interact with the panel manager. Autumn Bolds, the panel manager on Solotaroff’s team, says she calls as many as 30 patients a day and speaks to them for as long as 30 minutes.
Bolds role may sound simple, but it is a critical link in sustaining care. Bolds reminds patients about scheduled visits, lab or other routine tests, and inquires about any health goals a patient may have set. “It’s letting them know that we care,” she says.
She says patients become more responsible for their care, knowing that someone will occasionally call. “They realize they are not the only ones involved in their care,” Bolds says.
Bolds keeps multiple thick white binders full of information on social-service agencies in Portland. Connecting healthcare to social services, many say, is vital. Oregon Health Plan patients, because of their socio-economic status, most often need an array of services besides health care, including housing, employment services, and other needs.
“The social interventions are going to be critical,” says Ed Blackburn, Central City Concern’s executive director.
As Central City Concern’s programs began developing 25 years ago, there was a deliberate effort to offer, in addiction to health and addiction services, detox services, alcohol and drug free housing, low-barrier housing, employment services, services to help people get on disability, etc.
“We get better outcomes because of it,” Blackburn says. “We realized early on that you can’t successfully treat people on an outpatient basis if they’re homeless and don’t have a place to live.”
The Richmond Clinic coordinates care similarly to the Old Town Clinic and relies heavily on phone calls, emails, and even text messages to communicate with patients. Gideonse calls these brief, non-clinic based interactions “touches.” He says they are essential to engaging the patient in their own healthcare and helping them stay healthy.
Coordinated care, he says, “is not about increasing visits. It’s about increasing touches. You meet their needs in a non-visit way.”
A benefit of coordinated care is that if patients need mental health care, or need to be introduced to a social worker, those people are in the building to meet the patient in person, that day. “Giving someone a slip of paper with a phone number on it is really different from introducing them to a social worker. You’re directly linking the next step,” Gideonse says.
Kay Dickerson says the Richmond Clinic’s patient teams encouraged her tremendously when she was dealing with a combination of mental and physical illnessess.
She had just arrived in Portland in September 2006, shortly after Hurricane Katrina devastated New Orleans, Louisiana, where she lived. She and her husband had relocated to Portland, and were processed through Washington High School. Gideonse was volunteering, and told Dickerson she had depression, anxiety, posttraumatic stress disorder, and that she had Type II diabetes. He asked if she had insurance. “I don’t have nothing,” she remembers responding. “I don’t have a home. I have a few boxes, two mountain bikes, a dog, and a husband.”
Gideonse gave her his card. “Come to our clinic, and we’ll take care of you,” she remembers him saying.
Dickerson went to the clinic within a week, and now has her diabetes under such control that she does not need to do regular tests. “I’ll always have diabetes,” she says. “But I have it extremely well under control with diet, exercise and pills. I’ve worked very hard on it.”
Her patient team worked closely with her and answered any question that she had. “They take time to address your specific problems,” she says. “And patients understand what the nurses and doctors are trying to tell them.”
Without the encouragement of the doctors she worked with, Dickerson is not sure she would have made the changes in her lifestyle that are helping her manage her illnesses.
That nexus of requiring providers to collaborate and encouraging patients to assume responsibility for their health, Kotek says, is at the heart of HB 3650’s efforts. “We’re changing not only the habits of the health care system, but the habits of the people who use it,” she says.
If CCOs can accomplish the hopes and visions of those looking to them to provide care to one of the most vulnerable populations in the state, then they will greatly contributed to changing lives.
As Greenlick says, “they have great promise.”
Photo by Kay Dickerson.
