Health System Transformation and the Oregon Health Plan

Chris DeMars, AdministratorSummer Boslaugh, Transformation Analyst

Transformation Center2/20/18

Attach 4

Agenda

• Health System Transformation and the Oregon Health Plan (OHP):– Overview– Progress

• Waiver• CCO 2.0• Potential PEBB/OHP alignment opportunities

– Patient-centered Primary Care Home metric– Behavioral Health integration– Multi-payer alignment efforts & Value-based Payment Roadmap

Oregon’s Health Reform Timeline

• 2011: Oregon Legislature passed a bi-partisan bill proposing a statewide system of coordinated care organizations (CCOs) – CCOs are networks of all types of health care providers

(physical health, addictions and mental health, and dental care) who work together to serve Oregon Health Plan (Medicaid) members through implementing the Coordinated Care Model.

• 2012: State legislation created CCOs; CCOs launched; federal Medicaid waiver approved

Before CCOs With CCOsFragmented care Coordinated care:

physical/behavioral/oral health

Disconnected funding streams with unsustainable rates of growth

One global budget with a fixed rate of growth

No incentives for improving health (payment for volume, not value)

Metrics with incentives to improve quality and access

Health care services paid for Health-related services beyond traditional medical care may be provided to improve health

Health care delivery disconnected from population health

Community health assessments and improvement plans

Limited community voice and local area partnerships

Local accountability and governance, including a community advisory council

Oregon’s Coordinated Care Model within CCOS

2018 CCO Incentive MetricsAdolescent well-care visits*Assessments for children in foster care (physical, mental, dental)*CAHPS - access to care (bundled measure)Childhood immunizations*Childhood obesity - BMI, nutrition and activity counseling*Cigarette smoking prevalenceColorectal cancer screeningControlling high blood pressure*Dental sealants for childrenDepression screeningDevelopmental screeningDiabetes HbA1c control*Disparity measure – ED utilization of members with mental illnessEffective contraceptive useEmergency Department Utilization - general populationPatient-centered primary care home enrollmentTimely prenatal care

(*Not a PEBB metric)

OFFICE OF HEALTH ANALYICSHealth Policy and Analytics

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OFFICE OF HEALTH ANALYICSHealth Policy and Analytics

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• Accelerate integration of physical, behavioral and oral health care through a performance-driven system

• More deeply address social determinants of health and health equity with the goal of improving population health and health outcomes

• Commit to ongoing sustainable rate of growth, advance the use of value-based payments, and promote increased investments in health-related services

• Continue to expand the coordinated care model

Oregon’s Renewed 1115 Waiver (2017-2022)

CCO Contract Extension

• Oregon Health Authority is extending its current 5-year contract with the CCOs for an additional year.

• The contract was to expire on December 31, 2018, but will now expire on December 31, 2019.

CCO Contract Extension (Cont.)

• The decision was made in collaboration with the Oregon Legislature, the Governor’s office, and the Oregon Health Policy Board.

• This extra year will give OHA more time to work with partners to develop a new 5-year contract that will further advance Oregon’s health transformation goals.

Priorities & Timeline For Next 5-year Contract

CCO 2.0 Priorities• Social determinants of health and improving health equity• Increase value and pay for performance• Improve the behavioral health system• Maintain a sustainable cost growth(From Oregon Health Policy Board and Governor)

Timeline• Phase 1: Amend current CCO contracts to extend one year, to

December 31, 2019• Phase 2: Lengthen new contract development period; New 5-year

contracts begin January 1, 2020

POTENTIAL OPPORTUNITIES FOR PEBB TO ALIGN WITH OHP

Patient-Centered Primary Care Home Program Metric

• Updated PCPCH tiers in 2017• 3 tiers to 5 tiers• 5 STAR recognition

• Metric formula:(Tier 1 members*1) + (Tier 2 members*2) + (Tier 3 members*3) + (Tier 4

members *4) + (5 STAR members *5) • (Total CCO enrollment *5)

• No benchmark: • CCOs receive credit for this measure on a sliding scale based on the

overall percentage of their membership enrolled in a PCPCH. • 60 percent threshold is used to differentiate between quality pool

payment levels

Vision for Behavioral Health Create a modern 21st century behavioral health system of care

• Use the coordinated care model that integrates substance use disorders and mental health with physical and oral health.

The system should put the individual and their support system at the center of care; it should also be:

– Coordinated, seamless and treats the whole person, rather than a collection of problems and diagnoses

– Accountable for all aspects of an individual’s care– Focused on early intervention, health promotion and prevention– Community focused – systems and stakeholders come together to

identify priorities and solutions specific to their community

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Behavioral Health Collaborative Recommendations Recommendations will transform the behavioral health system so that all Oregonians (both Medicaid and non-Medicaid) will be served by a coordinated care model for behavioral health needs. Close to 50 participants met over seven months. The members developed four high-level recommendations through workgroups.

1. Regional Behavioral Health Collaboratives

2. Standards of Care and Competencies3. Workforce4. Information Exchange and

Coordination of Care

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Regional Behavioral Health Collaboratives

• Regional Behavioral Health Collaboratives (RBHCs) will be formed to integrate mental health, substance use and other health services equitably in local communities across the state in 2018.

• RBHCs will select priority areas to: – prevent mental health and substance use disorder issues– use best/promising practices to create measureable outcomes– apply trauma-informed principles at all points of contact

• CCOs will be required to work with Local Mental Health Authorities, Local Public Health Authorities, Tribes, individuals with lived experience, and other key system partners. – Desire to engage commercial payers

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MULTI-PAYER ALIGNMENT EFFORTS & CCO VALUE-BASED PAYMENT ROADMAP

Comprehensive Primary Care Plus (CPC+)

Centers for Medicare and Medicaid Services (CMS) model to improve quality, access, and efficiency of primary care:• Payment redesign gives practices greater flexibility to provide the

care patients needs• Five-year program (2017 to 2021)• Two practice tracks based on practice readiness for transformation• Partnership between Medicare, Medicaid and commercial payers• Oregon is one of 18 CPC+ regions nationally

– 156 participating Oregon practices • 100,549 Medicare beneficiaries

– 18 Oregon payers; 13 of 15 CCOs and 5 commercial payers

Oregon Region’s CPC+ Payers• AllCare Health, Inc. • CareOregon • Columbia Pacific CCO• Eastern Oregon CCO• InterCommunity Health Network• Jackson Care Connect• Moda Health Plan • Oregon Health Authority (Medicaid Fee-for-service) • PacificSource • PrimaryHealth• Trillium CCO• Providence Health Plan and Providence Health Assurance • United Healthcare• Western Oregon Advanced Health• Willamette Valley Community Health• Yamhill Community Care Organization

CPC+ Multi-Payer Payment Reform

Payment Model Objective MechanismCare management fee Support increased staffing

and training for delivery comprehensive primary care

Per-member, per-month payment (PMPM)

Performance-based incentive payment

Reward practice performance on utilization and quality of care

PMPM

Payment structure redesign for Track 2 practices

Reduce dependence on visit-based fee-for-service to offer flexibility in care setting (e.g. email, phone, etc.)

Upfront payment with reduced FFS payment

Primary Care Payment Reform CollaborativeSB 231 (2015) and SB 934 (2017) require a Collaborative to implement a Primary Care Transformation Initiative to:• Increase investment in primary care (without increasing costs to consumers

or total cost of health care)• Improve reimbursement methods• Align primary care reimbursement across purchasers of care

Strategies• Use of value-based payment methods• Provision of technical assistance to clinics and payers • Aggregation of data across payers and providers• Alignment of metrics (with the Health Plan Quality Metrics Committee) • Integration of primary care behavioral and physical health care

Senate Bill 934: OEBB/PEBB Requirements

• Establishes 12% primary care spending target:– By January 1, 2023, PEBB/OEBB are required to spend at least

12% of their total medical expenditures in self-insured health benefit plans on payments for primary care.

– No later than February 1 of each year, OEBB/PEBB must report to the Oregon Legislature on their progress toward meeting the target.

– If OEBB/PEBB spend less than 12%, they are required to implement a plan for increasing their primary care spending by at least one percent each year.

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SB 934: Non-PEBB/OEBB requirements

• CCOs and commercial insurers are held to the 12% spending target– Those not meeting the target must submit a plan to the Oregon

Health Authority or Dept. of Consumer and Business Services• CCOs and insurers participating in a Center for Medicare and

Medicaid Innovation program (such as CPC+) “offer similar alternative payment methodologies to all patient centered primary care homes…

• Primary Care Payment Reform Collaborative extended to 2027– Collaborative must provide annual update on CCOs’ and

commercial insurers’ progress to the Oregon Health Policy Board and the Legislature

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CCO Value-based Payment (VBP) Roadmap

• January 2017: 1115 Medicaid waiver renewal requires OHA to develop a plan describing how the State, CCOs and network providers will achieve a set target of VBPs by June 30, 2022– Transition to a payment system that rewards health outcomes

improvement and not volume of services

• Process: Develop in partnership with CCOs and their network providers– Part of the CCO 2.0 process

• Finalize Roadmap: October, 2018• Roadmap targets incorporated into CCOs’ 2020

contracts

Thank you!Questions & Discussion

Learn more about Oregon’s Health System Transformation at Health.Oregon.gov