Other states are following Oregon's lead. Colorado has started transitioning Medicaid beneficiaries into regional care collaborative organizations. Alabama this year passed legislation forming community-led networks to coordinate the healthcare of Medicaid members. (See related story, p. 7.) Officials from those states and others have sought advice from Oregon officials on setting up similar systems, said Tina Edlund, chief of policy for the Oregon Health Authority.
Kitzhaber has announced he'd like to see CCOs expand to take on healthcare for public employees. CCOs will be allowed to bid on the 2014 contracts for the state's Public Employees' Benefits Board, and, if successful, will be offered as a plan choice. That has put pressure on physician specialists and hospitals to participate in their local CCO.
Meanwhile, small rural hospitals are bracing for the effect of fewer admissions and the potential loss of the cost-based reimbursement they've received for years from Medicaid.
“I'm supportive of the CCO concept. On the other hand, I am worried,” said Dave Harman, CEO of Wallowa Memorial Hospital, a 25-bed critical-access hospital in Enterprise, a cattle town in eastern Oregon. Medicaid accounts for about 10% of its patient-care revenue. A state law maintains cost-based payment for rural hospitals through July 1, 2014. It's unclear what happens after that.
Wallowa Memorial has no ownership stake or board representation in the Eastern Oregon Coordinated Care Organization. “We are going to have to figure out how to live with whatever payment form they offer,” Harman said. “Honestly, I don't know where it's going to go. We are not willing, at this point, to give up on cost-based reimbursement.”
At larger urban hospitals, executives seem less concerned about reduced admissions, even though Medicaid is a substantial source of revenue for some. Oregon Health & Science University in Portland accounts for 19% of the state's Medicaid spending on inpatient care. But Dr. Joseph Robertson, OHSU's president, said the CCO strategy dovetails with OHSU's efforts to focus on the most complex cases and develop telemedicine and other means of support to help community hospitals avoid unnecessary transfers to tertiary medical centers.
Open disagreements within the CCOs have been rare and haven't stopped them from moving rapidly on some fronts, such as integrating behavioral and physical healthcare. Doctors' offices and clinics across the state have added behavioral health professionals to help care for the many patients who present with physical health complaints that are complicated by depression, mental illness, or alcohol and substance abuse.
Daren Ford, a clinical social worker who joined the staff at the OHSU Richmond Clinic in April, said many of the patients he works with have gone for years without reliable access to healthcare. They've resorted to using the ER because they've seen no other choice. “When we say, 'How can we find a more effective way of getting your needs met?' they are relieved,” he said. “A little of that support goes a long way.”
Robin Henderson, a psychologist at St. Charles Health System in Bend, said patients feel less stigma receiving psychological help at a medical clinic than at a mental health center. She said it's saving money by helping people better manage chronic health conditions and avoid unnecessary ER visits.
In other signs of progress, some CCOs are pushing to integrate dental care ahead of schedule. And a number of CCOs are implementing the primary care-oriented, patient-centered medical home model. Statewide, more than half of CCO members are in medical homes, while in three CCOs, more than 80% of members are in medical homes.