oregon's coordinated care organizations: first year expenditure and utilization authors: neal...
TRANSCRIPT
Oregon's Coordinated Care Organizations: First Year Expenditure and Utilization
Authors: Neal Wallace, PhD, Peter Geissert, MPH1, and K. John McConnell, Ph.D.2
1. Portland State University 2. Oregon Health & Science University
As a part of its continuing health system transformation activities, the state of Oregon has implemented Coordinated Care Organizations (CCOs) to provide care for Oregon’s Medicaid beneficiaries. Like Accountable Care Organizations (ACOs), CCOs are community-based networks of providers, community members, and insurers who bear financial risk for a portion of the Medicaid population. Each CCO will receive a global budget and will be responsible for coordinating physical, behavioral and dental health care for its members while being held accountable for maintaining or improving population health. Specific characteristics of Oregon’s CCOs will vary, since they are intended to evolve from individual communities who best know their own needs. CCO implementation began in July 2012. There are currently 16 CCOs covering all geographic regions of the state providing care to over 90% of Oregon’s Medicaid enrollees.
Estimate changes in expenditures and utilization related to implementation of Oregon’s Medicaid Coordinated Care Organizations overall and by CCO type.
CCO effects were estimated as the difference-in-difference of continuously enrolled adult OHP members and propensity score matched commercially insured Oregonians. Subject matching was based on presence during the study period of a diagnosis for eight chronic conditions (asthma, COPD, diabetes, CHF, schizophrenia/bipolar disorder, dementia, hypertension, hyperlipidemia) along with age, gender and geographic location. Study data were derived from the Oregon All Payers All Claims database (APAC), reflecting one year pre- and post- CCO implementation (July 2011 - June 2012 & October 2012 -September 2013). CCO “Level” reflects community advisory committee and CCO board engagement, as well as span of representation of CCO organizational members, Level 1 reflects highest engagement and representation. A two-part model with propensity score weighting and adjustments for temporal price changes was employed to generate estimates of the rate of change in probability of use, cost per user and cost per subject in total and for salient service categories.
Background
Research Objective
Study Design
Study Population
• Primary care expenses increased while specialty care decreased• No other changes in $/person were statistically significant • Pharmacy use down, $/user up, but no net effect on expenses• Some reductions in overall probability of service use• Level 1 &2 CCOs appear to have similar effects• Level 3 CCOs appear to be targeting service use more
• Enhanced primary care services and reduced specialty care appear to be consistent with expectations of the program and with findings for concurrent implementation of Patient Centered Primary Care Homes (PCPCH)
• Other expected changes, such as reduced ED and IP, may be emerging but are not yet evident through the first year
• CCOs with organizational features most aligned with program intent appeared to effect the most change overall
• Different strategic approaches may be occurring across CCO types
Principal Findings
Policy Implications
• CCOs appear to be effective in shifting patterns of treatment at least in respect to use of ambulatory care
• CCOs with organizational features most aligned with program intent appear to be having the most impact on overall expenses
• Individual CCO impacts may vary appreciably
ConclusionsTable 1: Study Sample Characteristics
Table 2: Pre-Post CCO Utilization and Expenditure Change
A random sample of 4,241 continuously enrolled adult OHP members and 67,511 propensity score matched commercially insured Oregonians. Sample reflects individuals sampled and surveyed in an additional branch of this research. CCO personnel and organizational members were interviewed to develop assessment of CCO organizational characteristics.
Results
Limitations
• Results reflect only adults and thus do not capture effects for children or true overall impact of CCOs
• Results reflect short- term (one year) impacts of CCOs only• Commercially insured comparison group may differ on
unobserved characteristics that could bias results• Study may not have sufficient power to capture all
individual service level effects• Level 3 CCO subjects underrepresented
Contact InformationNeal Wallace, Ph.D., Professor of Public AdministrationMark O. Hatfield School of Government, Portland State [email protected]
CCO Control
(%) (%)
N =
4241N =
67511
Age
18-25 5.2 5.2
26-35 19 19
36-45 20.2 20.2
46-55 33.7 33.7
56-64 21.6 21.6
64+ < 1 < 1
Female 58.4 58.4
Asthma 11.7 11.7
Bipolar/Schizophrenia 7.2 7.2
Cerebrovascular disease 4.6 4.6
Congestive Heart Failure 1.8 1.8
COPD 11.7 11.7
Dementia < 1 < 1
Diabetes 18.1 18.1
Chronic Kidney disease 1.3 1.3
$ per Person All Level 1 Level 2 Level 3
(% Rate of Change) CCOs CCOs CCOs CCOs
Service Category N=4,241 N=1,603 N=1,895 N=565
Total -0.043 -0.059 -0.055 0.058
Primary care services 0.073 * 0.112 * 0.083 * -0.145
Specialty care services -0.188 * -0.22 * -0.221 * 0.083
MH services 0.100 0.042 0.133 0.088
Pharmacy 0.029 0.074 0.017 -0.014
ED -0.092 -0.197 -0.062 -0.089
Inpatient -0.161 0.116 -0.203 -0.219
$ per User (% Rate of Change)
Total -0.026 -0.032 -0.042 0.051
Primary care services 0.063* 0.108* 0.028 -0.031
Specialty care services -0.043 -0.061 -0.077 0.198
MH services 0.046 0.113 -0.021 0.269
Pharmacy 0.099* 0.164 0.079 0.018
ED -0.029 -0.212 0.005 0.129
Inpatient -0.232 -0.162 -0.002 -0.336
Rate of Change in Probability of Use
Total -0.014* -0.022* -0.011 0.005
Primary care services 0.010 0.004 0.049* -0.104*
Specialty care services -0.131* -0.143* -0.13* -0.104*
MH services 0.053 -0.07 0.15 -0.18
Pharmacy -0.063* -0.08* -0.056* -0.029
ED -0.064 0.012 -0.067 -0.213*
Inpatient 0.071 0.274 -0.198 0.116
* = p<.05