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News: 2011-11-03 Health Care Transformation Workgroup Meetings Update 2

Health Care Transformation Workgroup Meetings: Round 2

The week of September 19th, each health care transformation workgroup met to continue their perspective discussions. Each group was given two or three questions to discuss in small groups. The groups then reconvened and discussed their ideas as a body. The next two meetings will be conducted in the same manner.

Global Budgeting Methodology

The Global Budgeting Methodology group discussed how risk ought to be shared between the CCOs and the state. The group identified four main types of risk: transformational risks, execution risks, community risks and actuarial risks, with actuarial risk dominating the bulk of the conversation.
In conversations exploring different risk sharing systems, it was recognized that there is currently no other state that has a program like the one we are trying to implement here in Oregon. Because we are on the forefront there is no viable program to model the CCO’s financial structure after.

It was suggested that CCOs that absorb transformational risk, execution risks and community risks ought to be rewarded with more actuarial rewards. On the other hand, if a CCO is unable to absorb those risks and the state must then step in and assist, their return ought to be less than the state’s return. Also, the members agreed that strong and dependable quality improvement measurements would need to implemented to determine the amount of risk being absorbed by each party.

Medicare/Medicaid Integration of Care and Services

The Medicare/Medicaid Integration group’s discussion focused on how the CCO’s will integrate dually eligible patients into the new system. More specifically, they discussed different domains of accountability that could be utilized to gage the progress and success of each CCO in its integration of dually eligible patients and how those metrics will hold the system accountable for transforming care and services for these patients.

A large focus of the conversation was the patient’s responsibility within the system. The members of the group generally agreed that there needs to be some form of patient accountability for the program to be successful and that the current system does not have such a metric. At the heart of this conversation was the concern that often, the provider can be doing everything correctly, but if the patient is being negligent, the care plan will not succeed. The group generally agreed that there needs to be a metric that accounts for that scenario. Some suggested using the term patient activation rather than accountability. Patient activation is a care plan centered on the self-care behaviors and self-motivated goals, rather than what the provider would like for the patient to achieve.

The group also recognized that a baseline needs to be established in all areas that will be measured for progress of integration to be monitored fully. Most members of the group believed that these metrics ought to be based on hard numbers and statistics rather than intangible ideas.

Coordinated Care Organization Criteria

The two key points taken up by the CCO Criteria group last week were health equity within the CCOs and the CCOs governance structure. The group determined that there needs to be a way to identify health disparities within the community, as well as a network of providers who are able to serve that particular population. It was suggested that CCOs develop relationships with other entities within the community aimed at assisting and improving the health of the at risk population. Also discussed was the use of community health workers and the need for a program centered on ensuring each health care provider has successfully completed cultural competency courses and can implement the principals taught in each course on a daily basis.

There were a variety of governance ideas discussed. Many members suggested that the CCOs should be formed using a checks and balances system, dividing the powers among three separate branches. There was general consensus that, as a public-private partnership, the community should have a place at the governance table, perhaps as an empowered advisory group and representative of the community it serves.

Outcomes, Quality and Efficiency Metrics

The metrics group discussion is based on CCO’s outcomes rather than process. Currently, the proposed areas of measurement include community orientation, prevention, access, equity, cost containment and patient experience. The group recognized that end of life care was not fully represented and suggested that it ought to be included.

The group also grappled with how to determine successful integration of mental health and addiction treatment. Some members of the group suggested that success be based on the utilization of the services and the long term cost savings realized due to successful treatment. This idea lead to a discussion of administration cost and whether the cost of monitoring each process at the CCO level to report back to the care providers will result in enough savings to justify the cost.

It was determined that all metrics ought to be tied to a specific action that can be taken to improve the outcome. For example, although they recognized the importance of measuring a CCO’s integration into the community, they do not believe a valuable metric has been proposed to make measuring this function valuable. Like some of the other groups, they would like to see the measurements based on hard evidence, numbers or existing metrics.

Next Meetings

The workgroups will meet again the week of October 17th. For location information or to read community feedback or get more information, email Jenn at baker@oregonrn.org  

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