Managed Care in
Oregon: the Impact
to Hospice Providers
Jeffrey McWilliams, MD
Medical Director, Bristol Hospice of Oregon
Medical Director, APS Healthcare, Oregon
Objectives
•
Define managed care and its current structure in Oregon.
•
Describe how managed care systems impact health outcomes through population
management.
•
Understand how hospice care operates in a managed care environment
•
Improve interactions with managed care providers.
Definition of Managed Care
•
Managed Care is a health care delivery system organized to manage cost,
utilization, and quality.
•
Medicaid managed care provides for the delivery of Medicaid health benefits
and additional services through contracted arrangements between state
Medicaid agencies and managed care organizations (MCOs) that accept a set
per member per month (capitation)payment for these services.
(Medicaid.gov)
History of Managed Care in the United States
•
1929-Dr. Michael Shadid establishes a health
cooperative in Elk City, Oklahoma selling
shares to build a hospital and annual
membership for health care.
 600 families, PCP, 4 specialists and one dentist
Early HMOs
•
1929-Drs. Donald Ross and Clifford Loos create the Ross-Loos Clinic
 First HMO in America
 Prepaid care for 2000 employees of LA Co. Water and Power
 29 clinics, one large multi-specialty hospital
•
1937-Group Health Association of Washington, DC
•
1942-Kaiser-Permanente Medical Program
•
1947-Health Cooperative of Puget Sound
•
1947-Health Insurance Plan of Greater New York
•
1957-Group Health Plan of Minneapolis
Washington Gets Involved
•
Health Maintenance organization Act of 1973
 Nixon Administration
 $375,000,000 to establish/expand HMOs
 Employers with >25 employees must offer an HMO option
•
1982-Congress caps Medicare hospital rates and creates DRGs
1990's: Growth of Commercial Managed
Care Plans
•
1993-51% of Americans with employer provided insurance are in HMOs
•
Benefit denials and disallowances of medically necessary services lead to
public outcry.
•
Nearly 900 state laws governing managed health practices in the 1990's.
 Right to emergency visits
 "Drive Through Delivery" laws
The Affordable Care Act: Managed Care
Explosion
•
Signed into law on March 23, 2010
 Largest bill ever sent to Congress
 314,900 words
•
Requires most US Citizens and legal residents to have health insurance
•
Created state-based exchanges for purchasing coverage
•
Credits for 133%-400% of FPL
•
Requirements for employer-covered health insurance
•
Expanded Medicaid to all non-Medicare eligible up to 133% of FPL
 1million Oregonians
Managed Care in Oregon
•
1994-The Oregon Health Plan is created
 Prioritized List of Health Services goes live
•
2011-Managed Care Organizations (MCOs) started
•
2012-The CCO (Coordinated Care Organization) era begins.
 Medicaid beneficiaries are assigned to Coordinated Care or Fee for Service
16 CCOs in Oregon
•
AllCare Health Plan
•
Cascade Health Alliance
•
•
•
•
•
•
Columbia Pacific Coordinated Care
Organization
Eastern Oregon Coordinated Care
Organization
Family Care, Inc
Healthshare of Oregon
Intercommunity Health Network
Coordinated Care Organization
•
Pacific Source Community Solutions
CCO, Central Oregon Region
•
Pacific Source Community Solutions
CCO, Columbia Gorge Region
•
Primary Health of Josephine County,
LLC
•
Trillium Community Health Plan
•
Umpqua Health Alliance
•
Western Oregon Advanced Health, LLC
•
Willamette Valley Community Health,
LLC
•
Yamhill Community Care Organization
Jackson Care Connect
Population Management
•
Patient Centered Primary Care Homes (PCPCHs)
•
Metrics and Benchmarks
•
Incentives
•
APS Healthcare as an example
•
Key Attributes for Recognition
 Accessible: Care is available when
patients need it.
 Accountable: Clinics take responsibility for
the population and community they serve
and provide quality, evidence-based care.
 Comprehensive: Patients get the care,
information and services they need to stay
healthy.
 Continuous: Providers know their patients
and work with them to improve their
health over time.
 Coordinated: Care is integrated and clinics
help patients navigate the health care
system to get the care they need in a safe
and timely way.
 Patient & Family Centered: Individuals
and families are the most important part
of a patient’s health care. Care should
draw on a patient’s strengths to set goals
and communication should be culturally
competent and understandable for all.
PCPCHs
PCPCHs
•
More than 500 clinics across Oregon in 34 of 36 Oregon Counties
Accountability
•
2% withhold
•
Metrics and benchmarks
•
Improvement goals
•
Distribution of withholds
Metrics - 2015
•
Access to care (CAHPS)
•
Electronic health record (EHR) adoption
•
Adolescent well-care visits
•
•
Alcohol and other substance misuse screening
(SBIRT)*
Follow-up after hospitalization for mental
illness
•
Ambulatory care: emergency department
utilization
Follow-up for children prescribed ADHD
medication (initiation phase)
•
Mental and physical health assessments
for children in DHS custody
•
Patient-centered primary care home
(PCPCH) enrollment
•
•
Colorectal cancer screening
•
Controlling hypertension
•
Depression screening and follow-up plan*
•
•
Developmental screenings in the first 36 months
of life
Prenatal and postpartum care: timeliness
of prenatal care
•
Satisfaction with care (CAHPS)
•
Diabetes HbA1c poor control*
•
Early elective delivery
Example: APS Healthcare
•
Managed care for the fee-for-service and Dual-eligible Medicaid populations.
•
Oregon Health Plan Care Coordination Program
APS Healthcare’s Client-Centered Model for the
Oregon Health Plan Care Coordination Program
OHPCC Serves Clients in all Counties in Oregon
OHPCC Serves >120K FFS & FFS Dual-Eligible Clients
Out of ~ 1 Million Medicaid Clients in Oregon
OHPCC Program Activities & Functions Focus on the
Triple Aim With People Who are Served at the Center
OHPCC’s Program
Flow is Made to
Look Simple in This
Diagram…
But, the Following
Slide Shows the
Complexity of the
OHPCC Workflow
Process…
% of Healthcare Costs for % of Population
100
% of Healthcare Costs
90
80
70
60
Population Health Principle:
A small % of any population
experiences the majority of the
healthcare costs
(e.g., 20%:70% or 5%:50%)
50
40
30
20
10
0
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
% of Population
75
80
85
90
95
100
APS Healthcare’s Systematic Approach to OHPCC
Client Selection, Referral & Engagement
We Tailor Interventions for Risk Levels
Lowest 80% (No Acuity Rating)
Clients in this cohort have low rates of chronic conditions and very
low rates of uncoordinated care.
Population interventions include screening and referral for wellness
care, encouraging early access to prenatal care, and promotion of the
Nurse Advice Line to address rates of avoidable ER utilization.
We Tailor Interventions for Risk Levels
Moderate 15% (Acuity 1, 2 or 3)
Clients in this cohort have similar chronic primary and co-occurring
conditions, and lower rates of uncoordinated care. They are “at risk
to become high-risk.”
Interventions for this group emphasize engagement with a medical
home and development of health literacy and self-management
skills.
We Tailor Interventions for Risk Levels
Highest 5% (Acuity 4-5)
High-risk clients use facility-based care, are reliant on ER for
services, and have high rates of readmission.
Interventions focus on face-to-face interaction, identification of
unmet needs and gaps in care, and access to social services/home and
community-based services to protect community tenure, improve
health literacy and self-management skill, and establish “medical
homes” for clients.
APS Healthcare’s Systematic Approach to
OHPCC Client Selection, Referral & Engagement
OHPCC Services to Clients
OHPCC Specific Metrics
Clinical Metric
Benchmark
FFS Result
Dual Result
All Cause Readmissions
10.5%
14.3%
24.1%
ED Utilization
41.3%
37.1%
48.2%
Outpatient
Utilization
439
209.1
461
Comprehensive Diabetic Care: Hemoglobin
A1c Testing
86%
63.5%
73.9%
Diabetic Short Term Complication
Admission Rate PQI-1
203.4
97.9
95.1
COPD/Asthma Older Adult Admission Rate
PQI-5
329.5
634.8
676.3
Ambulatory Care:
CHF Admission Rates
per 100k
PQI-8
238.5
367
616.4
Young Adult Asthma
Admission
PQI-15
35.9
33.2
93.3
OHPCC Reduces Costs for the State of Oregon &
Provides a Positive ROI > 3:1
OHPCC Program Savings &
ROI for
Each of 5 Program Years
(2009-14)
Hospice and Managed Medicare
•
After beneficiary makes hospice election:
 Medicare pays for hospice services
 Medicare pays for services of managed care attending physician
 Medicare pays for services not related to the terminal illness through the
fee-for-service system
 A managed care patient may choose a provider outside his/her MCO
•
Fee-for-service Medicare after hospice election
•
Upon discharge or revocation, FFS continues through the end of the
month that the discharge or revocation occurred
Hospice and Managed Medicaid
•
States must pay for hospice care in amounts no lower than the amounts used
under Medicare Part A
•
Medicaid hospice rates do not include a co-pay for repite care or medications
•
Concurrent care for children is available
Medicaid Dual Eligible Demonstrations
•
Fifteen states
 California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York,
North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington,
and Wisconsin.
•
To design new approaches to better coordinate care for dual-eligible individuals
•
Goal is to identify and validate delivery system and payment coordination
models that can be tested and replicated.
•
Oregon's demonstration is for managed fee-for-service duals via contract with
APS Healthcare
What's in it for the CCOs?
•
New partnerships
•
Allies in cost control and population management
•
Improved end of life centered metrics
•
Contracting opportunities
•
Possibility of bundled payments, sharing of risk, etc.
•
Shifting the cost of end of life care out of the CCO to Medicare
Interacting with CCOs
•
Establish referral process
•
•
Determine if hospice is a carvein or carve-out for the CCO
How does the CCO determine
hospice eligibility?
•
Are there medication limits?
Can they be waived?
•
Clarify the CCO's billing
process
•
IT systems information
•
Provider and beneficiary
appeal rights and process
•
Define quality measures and
accountability
•
•
•
Obtain a list of what is inside
the plan and what is fee-forservice
Good relationship with
Provider Relations contact(s)
If contract negotiations, be
specific about who pays for
items like transfusion, certain
drugs
Future Directions
•
Hospice Referal as a metric
•
Concurrent care model
•
Hospices as PCPCHs?
•
Hospice-specific metrics
Conclusions
•
Systems of delivery of medical care continue to get more complex
•
The recent Medicaid expansion has increased the number of individuals cared for in
a managed care environment
•
Partnerships with hospice agencies can be very beneficial to CCOs
•
The current managed health care environment has the potential to spawn innovative
approaches to the delivery of end of life care
Questions?