Leveraging Health System Transformation to Improve Population Health: Oregon’s Experience


– health systems transformation team here
at the Association of State and Territorial Health officials. I’d like to welcome everyone
to today’s webinar entitled Leveraging Health System Transformation to Improve Population
Health Oregon’s Experience. We’re really pleased that we have Lillian Shirley and Lori Coyner
on the webinar this afternoon with us to talk about the work that they’ve been doing with
coordinated care organizations. This last week they issued a report to look at the first
year of experience in Oregon that they’ve been leading. Lillian is the public health director at the
Oregon Health Authority and Lori’s the director of health analytics at the Oregon Health Authority.
Lillian has been a leader in Oregon’s effort to transform the state’s healthcare system.
While she was the local health director at the Multnomah County Health Department, she
also led the governing board of the Health Share Oregon and helped launch one of the
first coordinated care organizations in that state. She also served as the vice chair of
the Oregon Health Policy Board and has played a vital role in the state’s movement towards
a healthcare system that works better for Oregon. Lori oversees the quality and insensitive
metrics for Oregon’s CCOs. CCOs are the foundation for the state’s healthcare transformation
effort for its Medicaid enrollees. Prior to this role she served as the director of measurement
and reporting at the Oregon Healthcare Quality Corp. She is an accomplished biostatistician
and was responsible for the development of the Quality Corp’s quality and utilization
reporting system and measure development. If you have a question during the webinar
please post it onto the chat box that you’ll see at the lower left hand corner of your
screen at any time during the webinar. These questions will be answered during the Q&A
at the end of today’s presentation. You’ll have an opportunity for you to ask questions
live and we’ll open up the phone lines during the Q&A sessions for those of you who are
interested in asking additional questions. At the end of the webinar you’ll be directed
to an evaluation survey. So please take a few minutes to help us by completing the survey
because any feedback that you offer will help inform future ASTHO webinars. So I’ll now
turn over the webinar to Lillian Shirley. Thank you Lillian. Good morning and thank you Monica. I want
to thank ASTHO for this opportunity here in Oregon to share our experience with colleagues
around the country as we move forward together in this important work to transform population
health. So the first thing I want to just talk about a little bit is Oregon’s recent
history to put it into a context that this is a journey we’ve been on for awhile and
in 2009 we passed a bill in our legislative that consolidated our healthcare purchasing
into one agency which includes Medicaid, Public Health and the Public Employees Benefit Board
as well. So that would be all the employees and retirees of the public sector system.
In 2011 House Bill 3650 created a framework for a Medicaid coordinated care organization
and the Oregon Health Policy Board developed the vehicle for the implementation of that
change. Here we call them coordinated care organization. In 2012 Senate Bill 1580 approved
the implementation proposal and we applied for and were approved from the Feds to get
an 1115 waiver. I will talk about what was in that. Then our CCO, coordinated care organization
procurement certification and Medicaid member enrollment began. So here we are in 2014. So what are the requirements of the waiver
that we’ve received? These bullets talk about those requirements. This is what we have to
report on. There are six very specific areas and the biggest risk is to reduce the annual
percent increase and the cost of care by 2 percentage points plus ensure that health
and quality care improves and that that is tracked simultaneously and establish a 1 percent
withhold for timely and accurate reporting of data, establish a quality pool, establish
a primary care provider and loan repayment program and train at least 300 traditional
health workers to drive a change in the actual model of care of delivering. So our SIM model testing award was a 45 month
$45 million award to spread this idea and help support health system transformation
and their implementation. We receive $4 million in the public health division to specifically
enhance population health surveillance efforts which included a Medicaid BRFSS study on race
ethnic over sample and our Oregon Health Teens survey to further develop and enhance a Web
based public health assessment tool and to support local public health authorities and
CCOs to implement evidence based population health practices. I’ll talk specifically around
the three areas that the public health division was responsible for. Oregon’s coordinated care model is built on
these five building blocks under the � these are represented in the legislation and also
part of what we submitted to the Feds to get the waiver. So we are going to integrate and
coordinate care which includes making sure that we have high penetration of medical homes,
that we have a global budget with a fixed rate of growth that ties back to that 2 percentage
points that we said that we would make sure that we held cost to and our metrics with
incentives are actually the area that we’re looking at for quality, accountability and
flexibility, telling local communities and CCOs � not telling them the what of how
to achieve these elements but we’re trying to tell � we’re telling them the what and
not the how. They can go about it with their own assets and local conditions but we’re
telling them what it is they need to do. Then local accountability and governance. I will
talk about the community advisory councils. The global budget also includes mental health
funding, physical health funding and dental health funding and that was staged in different
parts. The last group to come in was the dental piece of it. So 16 CCOs really give coverage
for the vast majority of Medicaid members of our state. That global budget grows at
a fixed rate again and they’re responsible for health outcomes. The withhold that you
heard me reference from the waiver is that that pays as a performance payment for the
17 quality measures and the other element is that you are required to have agreement
with local public health authorities. This is a service area map for Oregon. You
can see that the 16 CCOs cover the entire state and in Eastern Oregon if you look off
to that orange color you’ll see that that’s a vast amount of rural and frontier areas
where there is one CCO that is working with the counties in that area. We’ll talk a little
bit about how we’re incentivizing that collaborative work through our SIM grant. So each CCO is required to have a community
health council, advisory council. This is in the legislation. It must be at least 51
percent consumer membership. We took this guidance really from the success of the federally
qualified health center movement that has a consumer board of at least 51 percent membership.
The seat for community advisory council member, there must be one person that moves on to
the corporate board of the CCO whether or not it’s a not for profit or a for profit
CCO and responsible for overseeing the development of the Community Health Assessment as well
as the community health improvement plan. So each CCO in developing these are required
to work with local public health and other partners to develop a Community Health Assessment
and by other partners we also refer to our equity coalitions in these areas and the non-profit
hospitals as well. So our key leverage are – oops, I think I skipped a slide here. That’s
right. The organization for our public health oversight with the SIM grant and integrated
into healthcare transformation on the state level is that I am the public health director
and I serve on the executive leadership team with the Medicaid director, the Oregon Health
Authority director, the mental health director and the director of policy and research. The
policy officer in the public health director’s office serves on a cross-agency system transformation
initiative team. Again, someone else sitting in my office, the Health System Transformation
Lead also serves to connect our public health division programs with the other health authority
programs, local public health authorities as well as the transformation center initiative
for this specific work. Our key leverage we believe are these four
elements. This is the leverage that will help us achieve the data metrics, primary care
transformation, again medical home, medical model changes, work force development and
our Community Health Assessments and improvements. Our goal with data metrics is timely access
to data on the health status of the population as well as how the CCOs are doing individually
and Laurie will be talking about that. In terms of primary care the population health
perspective through these complex healthcare needs, community and clinic linkages, as well
again one of the secret sauce I think is patient centered primary care homes. For workforce
development these are the elements that we’ve included in our work and the supporting the
public health system around policy systems and environmental change in communication
was a specific strategy knowing that locally and at the state level public health is very
strong on programmatic work but needs some capacity building in these areas. So the role
as a SIM funded prevention grant programs these frameworks that we’re using you can
see that they’re not something that isn’t known across public health practice and work
but I think that the emphasis that the community setting as well as the health system setting
have to have an integration and an agreement for what evidence based strategies in their
particular community. So these are our SIM grants across the state.
We did a competitive roll out and as you can see from the pictures it’s very different,
very rural, very frontier as well as the major population center. The developmental screening
in the rural area, preconception health, tobacco in the mid valley and in the Multnomah County,
Clackamas and Washington County area working with opioid overdose. These priorities came
specifically from their Community Health Assessment and the community health improvement plan. The community health improvement plan implementation,
our role at the state is to support the local communities in this work and our specific
work here as we revisit our state health improvement plan is to make sure that they’re aligned
both with the community health improvement plans for local government, the CCOs as well
as on the local level they’re doing a really good job of including and coordinating with
the IRS required hospital community health improvement plans and assessments. Our Medicaid
cessation initiative is one example. We modeled it after our work in Massachusetts. It’s cross-agency
and these goals are for the Office of Equity and Inclusion within the health authority,
mental health, the transformation center and Medicaid as well. Some of our early lessons learned is communicate,
communicate, communicate. We need to align with our state’s strategic vision. We have
a lot of political support in the Governor’s vision for doing this work and for doing it
across state agencies and across different sectors. We recognize the amount of change
that’s going on in the healthcare delivery system and we always ask first, “Are our solutions
to help actually rooted in where they are in their journey,” because we know that change
is a process and it’s happening all the time. We’re constantly trying to get more upstream.
We refer to transformation as that early work that I showed you earlier with the legislation
that we passed with Transformation 1.0. 2.0 was setting up the CCOs and rolling them out.
We think we’re in 3.0 now. We in public health are designing our strategic planning processes
and our internal work to look at 4.0, health system 4.0 when we will be ready for much
more of a collective impact around, “What are the goals that we want community by community,
region by region to create a healthy Oregon?” So I’m going to stop there and turn it back
to Monica. Thank you for this opportunity. Thank you so much Lillian. We’re going to
transition now to Lori’s slides. Just want to remind people please continue to send us
some of the questions in the chat box. We’ve already got a couple queued up. So I’ll hand
back to Lori. Good morning. Can everyone hear me? Monica,
I just want to make sure that the speaker transferred successfully. Good morning. Thank
you to ASTHO for having us as Lillian said. I’m going to pick up where Lillian left off
and give a brief background on the metrics and our accountability both as the coordinated
care organization accountability to the health authority as well as the health authority’s
accountability to the federal government. I’ll provide some summary of the CCO overall
performance and then also provide some specific metrics highlights. The full report on our
first year of health system transformation was released last Tuesday and it’s available
on our website and I’ll provide that at the end for anyone who’d like to investigate further. So just to give some background. As I mentioned
there’s multiple accountabilities that are built into the health system transformation
approach. So we, being my office, the Office of Health Analytics reports on 33 measures
annually. Well actually we report them on a quarterly basis to the CMS or the Center
for Medicare/Medicaid Services. The purposes of these 33 measures is to ensure that quality
and access don’t grade during the time that we’re trying to hold costs down by 2 percent.
If after two years if we do not start to show improvement then there are some financial
penalties to the state if these goals are not achieved. We will be performing our first
test of quality and access and providing that information to the CMS in January of 2015.
However we’ve been tracking it and so far we are meeting our goals. Then separately the CCOs or the coordinated
care organizations are held accountable to the state on 17 measures. Annually we look
at whether those 17 measures for each CCO, whether they met the performance improvement
target or the benchmark and determine how much of a quality pool are these incentive
funds that are paid out. In this first year we compared 2011 as a baseline. That’s before
the CCOs were in existence to experience that occurred in 2013. We began to report to COOs
their data on a monthly basis in September of 2013. We included not only their performance
metrics but also lifted the hood as it were so that they could see who the specific members
that were included and each of the members and we spent lots of time in validation with
the CCOs in this first round so that they really understood where they stood in terms
of the metrics and that we had the methodology for computing the metrics down in a way that
everyone agreed on. The other point that I want to get a little
time to mention is that the 17 metrics were established through a metrics and scoring
committee which was a public committee process. The committee was established through the
state legislature. That committee continues to assess the measures and make recommendations
on an annual basis. So in our July meeting, for example, we’ll be reviewing progress on
all the 17 measures and at that time there’s an opportunity to drop the measure if we have
exemplary performance on it or modify benchmarks as needed to continue to see improvements.
For 2014 the baseline will move to 2013 experience so that the CCOs are required to improve every
year. Lillian mentioned a quality pool. What that
is is the dollars that are held for CCOs to reward on improving performance as opposed
to payments for services and the numbers and types of services. So this is our first move
towards paying for outcomes rather than a fee for service type model. The quality pool
for 2013 was 2 percent of the actual CCO paid amounts. It was $47 million and CCOs need
to either meet a benchmark or an improvement target. Each of the 17 measures is on a pass/fail
basis with the exception of the measure on patient centered primary care home enrollment
and that was a sliding scale. So in order to earn their full quality pool payment CCOs
had to meet the benchmark on at least of 12 of the measures and then as I mentioned that
PCPCH or patient centered primary care home measure they needed to have at least 60 percent
of their members enrolled in a PCPCH. We distribute all the dollars every year and so for those
CCOs that don’t meet 100 percent of their quality pool that money is left on the table
as it were and it goes into what we call the challenge pool. The metrics and scoring committee
selected four measures that they felt were the most transformative. So the challenge
pool is paid based on just depression screening, diabetes, blood sugar control, screening for
alcohol and drug misuse and patient centered primary care home enrollment. So the report that we released last week provides
a summary of how the CCOs did on the metrics and I’m going to show you that in the next
slide. Again, we compared 2011 to 2013 and the report also has for almost all the measures
race and ethnicity breakouts comparing 2011 and 2013. I’ll show you a few of those as
well. Then there are some utilization and financial measures at the end of the report.
This is the link: www.oregon.gov if you’d like to take a look at the report and also
lots of details about our metrics and metric specifications and such. So for this first year there are 15 CCOs.
Specific source now is split. For 2014 we’ll be splitting into two but we had 11 of the
15 CCOs received 100 percent of their quality pool payment and then there were 4 that met
most but not all. We were very pleased with this initial distribution because those that
didn’t meet all of the metrics met ten or more. So we felt there was really huge progress
in just one year of work. This is the final payment distribution. You’ll see that each
of the CCOs or many of them received a little bit more than the first round and that’s due
to the challenge pool payments. So those CCOs that met 100 percent in the first distribution
then got some extra money in many cases from the challenge pool. So where did we see these improvements? We
saw large improvements in emergency department visit reduction. Overall state wide we reduced
by 17 percent and we’d reduced costs for emergency department by 19 percent. I’ll show some specific
data in a moment. We saw decreases in hospitalizations for chronic conditions. We saw very big decreases
in developmental screening. Again, as Lillian mentioned really a key component of health
system transformation is primary care home enrollment for patients and building that
coordinated care model within patient centered primary care homes. We also saw big improvements
in electronic health record adoption and large reduction in early elective deliveries. The
early elective deliveries are the result of the hospitals having a hard stop on them and
CCOs working in their communities to make that happen. The early elective deliveries
went from about 10 percent in 2011 down around 3 percent in 2013. We had mixed results and lots of progress
on a number of the measures. You’ll see we showed how many CCOs met targets. We had very
few CCOs meet or exceed benchmarks on most of the measures and that was by design. The
benchmarks are really established as goals with the idea that we would meet them in five
to ten years. So in some cases we had improvements over benchmark but for the most part the CCOs
met their improvement targets. If they continue to meet those improvement targets across time
then they will exceed the benchmarks as I said within five to ten years. Here’s some examples of data. We decreased
emergency department visits. This is a rate per I think 1,000 member months. So we went
from 61 in 2011 down to 50.5. We’re approaching the benchmark. Just to pause about the benchmarks.
In most cases is there is a national benchmark especially national Medicaid benchmark we
selected the 75th percentile or in many cases the 90th percentile with the idea that the
CCOs in Oregon would be performing at the 90th percentile for the nation. For some measures
there isn’t a national benchmark and then the metrics and scoring committee had staff
do research and selected those. Here’s an example of the decreases in emergency
department visits by race and ethnicity. The way that you read this is the gray shaded
dots are the 2011 rate. The blue dots are the 2013 rate and the red line is the benchmark.
In this case we’d like to see the emergency department visit rates go down. In most cases
that happened and in some it remained very close as you can see for Hispanic/Latino and
Asian-American though they are below the benchmark. So we saw progress across all race and ethnicity
categories. Then in the report for each measure we also
show the specific CCO results and again saw decreases in emergency department use across
all the CCOs with three of them now below the benchmark. As I mentioned we saw decreases
in hospitalizations for chronic conditions. Here’s an example of congestive heart failure.
This measure is important because if patients with congestive heart failure are well managed
particularly in places like a patient centered primary care home then they can remain out
of the hospital and reduce costs and have better health for the patient. We saw similar
results for COPD and also for adult asthma. We did not see decreases in hospitalizations
for short term diabetes issues and so we’ll be looking at that data more carefully across
the next few months. An area where we saw market improvement is
in developmental screening. This is developmental screening for children up to age 36 months.
We haven’t reached the benchmark but saw large progress in one year. Again, we saw at least
some improvement for all race and ethnicity categories as well as most of the CCOs. The
two that are down in the lower right corner of your screen you’ll see how an arrow points
down. That means that their rate – for example, Cascade went from 60.1 down to 58 however
that’s well above the benchmark. We had two CCOs surpass the benchmark in just one year. Just a little side note. We have spent a fair
amount of time and there isn’t unfortunately time in this talk to go through it but for
those – we’re looking at those CCOs that had large improvements and working with the SIM
funded transformation center then to help learn what they did and spread those best
practices to other CCOs and that’s a partnership with the transformation center. We had very large increases in member enrollment
in patient centered primary care homes. The goal is to have all members enrolled in a
tier three which is kind of a highest performing patient centered primary care homes. At this
point nearly 79 percent of the CCO members are enrolled in a patient centered primary
care home. This is important. We believe Medicaid expansion is happening now in 2014. The data
I’m showing you does not include that expansion but we’re hopeful that by having the CCOs
reach out to newly enrolled members and have them enrolled in a patient centered primary
care home can continue to keep our emergency department rates down and start members on
coordinated care right away. This is an example of how the CCOs improved
on patient centered primary care home enrollment. You’ll see eastern Oregon as Lillian mentioned.
It’s a frontier area. It’s very sparsely populated with a lot of small practices and they worked
very hard with their primary care practices to get them certified as primary care homes
and went from about 4 percent of their members enrolled to 63 percent. We saw for other CCOs
those huge gains. Again, the focus is on learning what they did and how they did it so that
we can share best practice. So the CCOs didn’t perform as well on a few
of the measures and in this case the measure is called SBIRT and that stands for Screening,
Brief Intervention and Referral to Treatment. It’s a process by which members are screened
once a year at a primary care home visit for risky alcohol or drug use. Then if they’re
found to have risky behavior someone in the practice conducts a brief intervention. Statewide
at the beginning essentially the rate was zero. This is a new practice. So we saw an
improvement up to 2 percent. We saw one CCO that went to 8.7 percent of screening. I guess
I’ll pause here because it doesn’t sound – you’ll see the benchmark’s 13 percent. What we’re mentioning here is a secondary
screen. So it’s not the initial couple questions but if a member says that they drink or use
drugs then they go through a larger, more structured screening process and that’s the
13 percent benchmark. But this is an area where we have lots of work that still needs
to be done. We do have what we call an SBIRT work group and that’s stakeholders including
primary care practices, some of the CCO medical directors and analysts that are working to
figure out better ways to both capture data and change work flows in the clinic setting
to make this happen. Another area that we will be talking to CCOs
over the course of the next few months and to learn about is access to care. This is
through the CAP survey so it’s a patient reported measure. What you don’t see in this slide
is that – what you do see is that some of the CCOs increased and improved over benchmark,
some decreased and some stayed relatively the same but if we look at it by children
versus adults we saw that more of the adults have difficulty with access. Then also we
are watching this and want to learn from those CCOs that improved access with the big influx
of newly enrolled members that we’re seeing with the Medicaid expansion. So next up, we will continue to report at
the state and CCO level. We are building some new dashboards that will be delivered to CCOs
on a monthly basis. We’ll continue our monthly reports to them. We also are reporting to
CMS on a quarterly basis and we’ll continue our full public reports like the one that
went out last week. We’ll be rolling in the 2014 data. Our next report will be later in
this year and we’ll be able to look at how the metrics have changed with the expansion
population. In December we were at about 600,000 CCO members and we’ve increased since January
by almost 350,000 new Medicaid members. So it’s a large increase. We’ll be providing the CCOs in August with
their calendar year data by race and ethnicity. So what we provided in the report is just
at the state level but we’ll be providing CCOs their own. We’re working with the Office
of Equity and Inclusion on a learning collaborative with medical directors in August and they
will continue to work with their communities to talk more fully about differences that
are seen by race and ethnicity. Then we also will be providing analyses of additional subpopulations
including by language and by disability status. So for those of you that would like to look
more closely at the report we do report on all of the 33 metrics. Here is the link. I
want to thank everyone for listening to my talk. Thanks very much Lori for going through those
slides for us. Appreciate all the questions that are coming into our chat box. We have
a good amount of time to try to get through some of the questions that were posted on
to the chat box. So before I get to that, operator, will you please remind participants
about how to line up for the live Q&A? Certainly. If you wish you register for a
question over the phone please press star then the number on your telephone key pad.
Again, that’s star one, to register for any audio questions. While folks are queuing up for live Q&A I’ll
go into the chat box questions. I think either Lori or Lillian can answer these. They’re
not directed to either of you specifically. The first question is whether you can give
us some examples of the CHA’s outcomes, the Community Health Assessment outcomes. A related
follow-up on that one is, “Are CCOs required to invest into communities or take into consideration’
as it’s required under the IRS CHNA rules?” I’m sorry. Can you repeat that? I can’t find
it on the chat box Monica. Oh I’m going to read them for you. So specific
examples of the Community Health Assessment outcomes and whether they’re required to invest
into communities or just take into consideration as it’s under the IRS CHNA rules. Okay. I’ll give it a stab and Lori you can
jump in. The requirement is not specific, what they do with that. There’s another one
I saw when Lori was talking about one of the CCOs receive their payment and how are they
going to decide around that. I think the mechanism that we’ve used here in the legislation is
the global budget because that incentivizes community investment as well it incentivizes
working beyond the specific population barriers and the specific clinical barriers. So I’ll
just give one quick example. One of the CCOs had a high rate of smoking in pregnant woman
and also a high rate of obesity in pregnant woman who were winding up with c-sections.
The baby was going to the NICU. Understanding that just clinical interventions around these
issues do not necessarily create sustainable change, they actually are paying on a contract
of the local public health department in their region to work on the kind of public health
interventions that we know that work around environment and policies. So that’s one example. There are others but we can talk about it
offline if people would like to get in touch with us. The other thing I think in the question,
“Who makes the decision,” and I’ll answer another one too, “How did we recruit CCOs?”
CCOs were not recruited. They are new entities. The state said that all of the Medicaid patients
are going to be assigned to this new model and then the CCOs came out of organizing themselves
in different areas of the state. So some of them became kind of new entities that came
out of Medicaid managed care plans or other types of insurers and expanded the board as
required by the legislation to have a local authority on it. The one that I’m most familiar
with in the metro area actually has someone from housing, someone from alcohol and drugs,
the mental health authorities as well as all of the hospitals are represented and almost
all of the payers in the region. So that board will decide how to reinvest the dollars. But
in many cases you have community based organizations that sit on the board itself but are definitely
involved in the community advisory council. Operator, do we have any questions? Do we
have any callers on the line for questions? No, there are none at this time. Okay. I’ll ask another question to both of
the presenters. Can you please tell us a little bit more about how specifically the state
and local health departments are engaging with the patient centered medical home that
have been established? Lori, do you want me to take this, too? You can. I can also chime in but– Okay. [Inaudible crosstalk] ______ _____ _______ ______. I’ve been talking too much Lori. You start. Okay. So the patient centered medical homes
at least through the metrics are engaged with local health departments because in order
to improve – we have a measure on making sure that children who enter the foster care system
receive a mental and physical health assessment within 60 days. So one area that there’s been
a big focus on is working with the local public health field offices that are handling the
children’s change to foster care and then hooking them up with their primary care provider
and mental health provider to get those assessments. So that would be an example. There’s a number
of other cases where for because the CCOs now are responsible for both mental health
and physical health where there’s needs to coordinate with the local public health and
county public health agencies to make that effectively happen. Finally there is an example of a CCO that
was – the county mental health agency was performing home visits for children that were
at higher risk children and conducting developmental screenings. So they were linking with the
CCO and the primary care providers to get that information that was obtained for the
developmental screening to a child pediatrician so that they could start to organize services
and care. So those are some specific examples. I don’t know Lillian if you have some more. Yeah, I think one of the traditional areas
for public health is home visiting, maternal child health home visiting through targeted
case management which supports a lot of that for Medicaid clients. That money will be going
into the CCOs global budget within the next six months. The CCOs’ executive directors
and medical directors have sat down the local public health to talk about exactly what that
would mean and how do we make sure that it isn’t – that these services are expanded in
a way that allows the local public health authority to visit and work with not just
the CCOs’ membership but the broader community. I think those are some of the examples. Thank you. Operator, any callers on the line? There are none at this time. We’ve gotten a couple questions about metrics
and was just wondering – I know we could probably go through the report but just curious if
you could give us some examples of the behavioral health and dental services measures that you’re
using. So the integration of behavioral and physical
health measures include as I – the one I mentioned to children who come into the foster care
system if they have a physical and mental health assessment within 60 days. Another
is the screening for alcohol and drug misuse. A third is follow-up after hospitalization
for mental illness. The members need to have a follow-up within seven days after being
discharged. Then another is follow-up for children who are prescribed to ADHD medication.
So those are some examples of the behavioral health measures. Okay. I’ll just keep going through the chat
box. Can you tell us more about how the quality improvement organizations are involved with
the CCOs, the QIOs in your state? I’m not sure. I mean we have a couple. They
sit on these committees like the metrics and scoring committees and the quality committee
but I’m not familiar with the context with the question is coming from. Lori, are you
– is this sparking anything? If you’re talking about the state QIOs ours
continues to monitor one of the performance improvement projects and do some validation
with CCOs but they are working in more of a compliance function than real quality improvement
at this time. I don’t know if it helps Monica but there are a couple specific questions
on metrics that I think might be helpful for me to answer. So I’m going to dive right in
if that’s okay. Sure. So somebody asked about that Health Share
of Oregon was awarded nearly $14 million as an incentive award and asked how the decisions
are made within the CCOs to determine how these awards are distributed among partner
agencies. I wanted to say a couple of things. First off, the incentive payments that the
CCOs receive are based on how they perform on the quality metrics and then it’s weighted
by the number of members that they have enrolled. So Health Share of Oregon is the largest CCO
then their quality pool amount is larger and it’s based on the enrollment. The CCOs are
required to report to the health authority annually on how much of the funds are distributed
back to providers and we have heard that there are quite a number of the CCOs now who are
working on alternative payment methodology to incentivize providers to work on the metrics
and improvements and care overall. So we haven’t received the specific reports but we have
in asking and learning about what they’re doing to move quality forward we do know that
a number of the CCOs are paying differently. Also somebody asked whether the CCOs report
on 17 of the 33 metrics and whether they get to pick their measures. The 17 incentive metrics
are part of the 33. The CCOs provide us some information directly but mostly the state,
my office, calculates those metrics and the CCOs do not pick them but the metrics and
scoring committee establish those metrics. So I just wanted to cover some of those details
around metrics. Now I’ll turn it back over to you Monica. There’s a question about whether or how the
CCOs – if the CCOs bear financial responsibility of cost that don’t meet the 2 percent versus
the projection threshold. Yes, they are required to live within their
global budget and for those CCOs that did not receive all of their incentive payments
for example then they hold that risk. I don’t know if you want to add anything Lillian but- No, I mean that – it’s a one sentence. Yes,
they are responsible which is part of forcing the conversations around who else needs to
be at the table whether it’s a community based organized or a local public health authority
to achieve the goals because we’re trying to drive community accountability. There’s a question about the workforce development
area and you reference developing a loan repayment program under that bullet. Can you expand
more on that work? No. I mean we can get back to you on the specifics.
It’s just in the developmental stages particularly for what I would call new professions. I can elaborate a little bit. The Office of
Equity and Inclusion has been involved in working on expanding the role of traditional
health workers and that would be part of the workforce development piece. So they’re working
to promote the use and the ability to pay community health workers or traditional health
workers as part of the CCO. So that as Lillian said it’s underway and new but it is moving
forward particularly with the focus from the Office of Equity and Inclusion. Thank you for that additional context for
that particular question. I actually do think that that’s a topic that a lot of the callers
and other members would be interested in hearing more about. Just a reminder, we will be posting
the Q&A online along with this webinar and copies of the slides. Operator, one last chance
for any live questions out there. You have a question on the line of Robert
______. Madam that was my question on workforce. Anything
regarding the loan repayment program would also be of interest. Thank you. So the Oregon legislature did establish a
program within the state. It’s called Scholars for a Healthy Oregon. Rather than loan repayment
it actually pays tuition for physician assistance, dentists, medical students and I think nursing
as well. The payment is made for tuition and then the students have to agree to work in
a rural part of Oregon for each year that they have their tuition paid. That program
is underway and being part of the health authority is administering it. In terms of additional
loan payment programs though I would have to look to find out what else there is. There’s a couple of questions about gender
distribution. So I’ll go ahead and ask this. I’m not sure if it’s – so I’ll go ahead and
ask it as it reads. The question is, “What is the gender percentage distribution for
the respective organization?” I can answer that sort of. So the CCOs in
2013 were more heavily weighted with women and definitely children and the 17 incentive
metrics reflect that. There’s a focus on maternal and child health. We have been – I didn’t
provide it in the slides but when we look at the new enrollees for the Medicaid expansion
the proportion of men enrolled is increasing. So it’s something that we’re going to be thinking
about because the distribution for males is increasing on the adult side. So more to come
on that. Thanks. Two more questions I’m going to try
to squeeze in. How are participants enrolled with a CCO? Are they placed within a CCO or
do they have an option to select which one they want to enroll with? Lillian, do you want me to take this one? Oh yeah, sure. I was ______ you were keep
going. I feel like I’m talking too much. No.
Members are allowed to choose. In many cases if they live in an area where there’s just
coverage for one CCO unless they’re willing to travel, they don’t have as much choice.
There are areas of the state, both the Portland metro area and then the southern part of the
state where there are multiple CCOs and then the members can select. Can I just add a little bit to that? Remember
the CCO is just the organizational structure and the participant who chooses a CCO or if
they’re in an area doesn’t have it they very often get to choose their provider or the
provider system within that CCO that they wish to remain with or to begin with. So you
might get assigned to a CCO and then you want to go to – I’m trying to think here – like
the Richmond Center of Oregon Health Sciences University or you may want to choose to be
in one of the Providence clinics or stay with a clinic that you’ve been in. So we try to
have as much patient choice as is feasible within the constraints of capacity. Thank you Lillian and Lori. Unfortunately
we are at the top of the hour so we’ll need to wrap up this webinar and the Q&A session.
We will be taking all of the questions that we weren’t able to answer and following up
with Lillian and Lori to get responses to those questions that we weren’t able to cover
on this afternoon’s webinar. So I want to thank everyone for joining us today. As we
mentioned at the beginning of the call you’ll be immediately directed to an evaluation at
the end of the webinar. Please take a few minutes to complete the survey. I’d also like
to thank Lillian and Lori for presenting on the webinar today and also thank the CDC for
sponsoring this afternoon’s webinar. A recording of all the slides and Q&A will be available
on our website within a few days. The Web address is on your screen now. We hope that
you will use this webinar as a resource and share the link with others once it’s available.
Thank you everyone. Thank you very much. Many thanks. [End of Audio]

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