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Inside a ‘transformation’

At the Coordinated Care workshop in Portland/Randy Stapilus


The word that has been bandied around is “tranformation” – as in, transformation of Oregon’s health care system. And what the new coordinated care organizations (CCos) are trying to do is major, and – if they work more or less as planned – they could lead to a big shift in the way health care is delivered, and how much it costs. Less, hopefully.

What some of this translates to as a more practical matter came a little clearer at the August 8 CCO workshop in Portland, led by the FamilyCare Health Plans, a local nonprofit which in its self-descriptions says it is “dedicated to creating healthy individuals through innovative systems. We offer affordable, high quality, patient-centered health plans to Oregonians receiving benefits through Medicare or the Oregon Health Plan.”

That’s what’s involved at this stage: Not all Oregonians but rather those using Medicare and the Oregon Health Plan. But a lot of them will be getting their health services this way, an estimated 81% of Medicare patients by September 1. The idea is that, instead of each medical provider being paid for whatever goods or services they bill for, a large lump sum will be spent on the system, apportioned out, with the idea of using it efficiently to do whatever’s needed to keep people healthier and out of emergency rooms.

Speaker after speaker, including legislators, state officials and care organization leaders: “There will be no turning back.”

Speakers referred several times to the walls between various types of providers, different organizations and types of organizations, different medical specialties, physical and mental health, and more. The CCOs are intended to serve as a central communications hub, bringing together the various groups in work for specific patients.

It’s a concept easier to grasp through example than description. One example raised was of an eight-year-old boy who had asthma, who experienced attacks that every other week, for months, sent him to an emergency room. Finally, a team of physicians and other social and health workers got together and worked out a set of changes that allowed him to better manage his problem; he stayed out of emergency rooms thereafter. The estimate has been been that 20% or so of patients – like this boy – account for 80% of health care costs (and some guesstimate, informally, about a 5%/50% ratio); catching those chronic cases in the early stages is a big part of what the new CCOs are supposed to do.

How exactly that will happen still seems to be a matter under development. The developers, like Bruce Goldberg, the director of the Oregon Health Authority, seemed to acknowledge as much, but stressed that a lot of what’s hoped for is emphasis on health outcomes rather than on process.

Sitting around a lunch table (as opposed to the head table’s speakers) with some of the people working in provider offices – the technicians, nurses, billing managers who work in the guts of the system’s bureaucracy, you hear some skepticism. There’s already been heavy paperwork so far this year, they point out. (Everyone acknowledges a work crunch this year, since legislation creating the change was passed in February, and the first CCO’s, like FamilyCare’s, cranked up August 1.) The paperwork will rise, they suggested.

The speakers, though, like Goldberg and FamilyCare CEO Jeff Heatherington, said that if the new system works as intended, the amount of paperwork will go down, as will be number of rules and rulemaking, and even the detailed state oversight, which would focus more on outcomes (and tracking the money) than on following the process. Goldberg said that there’ll still be accountability, but said the new law has a key insight built in: You can fill out a form perfectly and still have a terrible patient outcome.

“There’s no roadmap,” he said.

A specific part of the plan – a requirement for getting the substantial federal money that’s now been promised for the next five years – is that while health outcomes improve, less money is spent, or at least, the growth of spending slows.

And on that front, there were some blunt words. Heatherington: “The truth of the matter is that some people are not going to make as much money as they did before. That’s the only way you bend the curve.” There are too many specialist and not enough primary care physicians, he said.

So it has worked, through the market system: For example, specialists make more money than primaries. But if a system is developed in which money is apportioned based on the specific needs of specific patients, that money might be apportioned in some very different ways.

There are organizations, FamilyCare for one, which for some time have been using approaches like this in health care. (Oregon isn’t developing this completely from scratch, though it may wind up a leader in health care for such a large and varied jurisdiction.) Several speakers, like Heatherington, said it is more evolution than revolution.

All the same, a year from now a large part of Oregon’s health system may be forcibly wrenching into some very new – maybe much more practical and less costly – patterns. And if that happens, the spread beyond may in fact be irreversible, because the benefits may be too hard to deny.

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