“We're about 40% of the Medicaid population in the state of Oregon,” said Dr. George Brown, president and CEO of five-hospital Legacy Health. “We have a large center of gravity, so it's important that we do succeed—all the organizations involved are quite cognizant of that fact.”
Because they're trying things that haven't been tried before, Brown said, “The biggest concern that I have is the unknown,” but he remains optimistic for success, in part because he has no other choice.
“The inconvenient truth, if I can borrow a phrase from Vice President Al Gore, is that we can't afford the current system we have,” he said. “My prediction is that we will be successful. It will be a lot of hard work, but if we're not, it will be much worse. There is a commitment that this is in the best interests of the community.”
Brown noted that one sign of this commitment is an agreement that, if one healthcare organization within the CCO is producing better patient outcomes, that organization will share information on how those outcomes are being achieved.
Dr. Craig Wright, chief executive for physicians and clinical services at 26-hospital Providence Health & Services, echoed Brown's remarks on competitors committing to collaborating on CCOs.
“Healthcare is complex, making transformation a difficult job,” Craig said in an e-mail while traveling. “As we change direction from competition to collaboration, one of the keys to success is open and honest communication among the partners.”
Andy Van Pelt, spokesman for the Oregon Association of Hospitals and Health Systems, noted that collaboration is mandatory. “This is forcing collaboration among what traditionally have been competitors,” Van Pelt said. “Is this going to work? We sure hope so.”
Such intimate cooperation ordinarily would raise significant antitrust issues, which Oregon lawmakers sought to address in the legislation, declaring it “in the best interest of the public” and their “intent to exempt from state antitrust laws, and to provide immunity from federal antitrust laws through the state action doctrine.”
Van Pelt said that a main concern of his is that the state budget was balanced on an assumption that Medicaid care providers will somehow find a way to save $239 million this year—outside of the CCO program. And, if that level of savings is not achieved, he said it could affect how much federal money the program receives, so a total of $650 million in Medicaid funding is at risk.
The $1.9 billion Oregon is receiving from the CMS for its CCO program will be spread out over five years with $620 million coming in July and roughly $320 million in years two through five of the grant. “We don't know yet what is attached to those dollars,” Van Pelt said. “I know it can't be used to backfill the budget.”
In his e-mail, Wright said the projected efficiency savings “will be a challenge, particularly in the first years of CCO operation,” because of the time and money needed to restructure a new delivery system, but he noted that an independent analysis confirmed the state's projections that CCOs could produce savings of approximately $50 million to $60 million in 2012 and 2013.
Dr. Evan Saulino, president-elect of the Oregon Academy of Family Physicians, believes there is enough low-hanging fruit to achieve the necessary savings—but he's still concerned.
“I'm a big believer in that, if we give people better care, we will save money,” Saulino said. “But it could be a catastrophe if people make bad decisions for short-term gain and just push the risk downstream.” He recalled that in 2003, the state sought to save on Medicaid costs by removing 150,000 people from the program.
“These people still got sick and they still went to the emergency room,” Saulino said. “We have to innovate out of the problem, so the OAFP and myself welcome the idea and effort we're pursuing in Oregon.”