Report details key findings about Oregon’s Medicaid delivery system and impact of CCOs

Oregon’s Medicaid delivery system has undergone many changes in the past decade, and state health officials continue to try and improve it.

 

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The state transformed its Medicaid program in 2012 by establishing coordinated care organizations (CCOs) under a federal Medicaid demonstration waiver to provide care for its Medicaid population. The state executed a 5-year renewal of the 1115 Medicaid waiver with CMS in 2017, and Oregon Health & Science University (OHSU) was selected to conduct an evaluation of the waiver renewal. OHSU released an interim report in October 2021 that reflects data capturing the initiation of Oregon’s CCO model under the 2012-2017 waiver, and 3 years of experience from 2017-2019 under the renewal. A final report is expected to be available in December 2023.

The evaluation focused on behavioral health integration, oral health integration, health-related services, and people eligible for both Medicare and Medicaid.

OHSU Health Economist K. John McConnell, PhD, directs the university’s Center for Health Systems Effectiveness (CHSE), which released the interim report and is compiling the final version.

“At the time of the report, progress on behavioral health integration looked to have slowed or stalled,” McConnell said. “I believe the state has worked to remedy that, but it may still be an area requiring greater investment, definition, and measurement by the state. Oregon is a leader in figuring out how to use managed care entities to address social determinants of health through its Health Related Services program. The program has grown but there are still some kinks to work out.”

Behavioral health integration

Behavioral health integration was a priority in the waiver renewal, and the report states that progress has been mixed. Throughout 2017-2019, Oregon and its CCOs engaged in several activities focused on behavioral health integration. The state participated in the Substance Abuse and Mental Health Services Administration’s Certified Community Behavioral Health Clinics demonstration project, supported a Behavioral Health Collaborative, and created a Behavioral Health Information Technology Workgroup. The state made substantial changes to its contracting mechanism in an effort to reduce the separation of behavioral health and physical health financing. 

Despite these initiatives, it is difficult to develop a strategy for implementing behavioral health integration. Many of the activities focused on behavioral health integration do not appear to be coordinated across the state, the report states.

Between 2016-2019, care coordination and access for non-English speaking individuals with behavioral health conditions worsened relative to English-speaking individuals with behavioral health conditions, according to the report. But the CCOs have adopted a new incentive metric: Meaningful language access to culturally responsive health care services, which McConnell said could help address the issue.

Oral health integration

The 2017-2022 waiver called on CCOs to implement recommendations from the state’s 2016 Oral Health Roadmap, including integrating oral health into Patient Centered Primary Care Home standards and practices (PCPCH), and improving coordination on oral health with the state’s Health Care Authority (HCA).

During the first 3 years of the renewal, OHA worked to address barriers associated with oral health provider shortages and member awareness of dental benefits, according to the report. In 2019, OHA worked with staff at PCPCHs to develop standards for oral health integration, and OHA’s Transformation Center assisted CCOs in implementing oral health integration pilot projects.

Measures of access to dental services and utilization of dental procedures improved between 2016-2019, according to the report. 

“The percentage of members with at least one dental visit increased by 2.2%,” McConnell said. “If we assume about 900,000 enrollees, that would be approximately 19,800 more enrollees who received services.”

Health-related services

During the first 3 years of the waiver renewal, the state issued additional guidance on the types of spending that could qualify as health-related services and how CCOs could use that to address social determinants of health, the report states.

Oregon began developing adjustments to capitation rate setting to mitigate premium slide (a scenario in which increased spending on health-related services might lead to lower capitation rates). The state also implemented the Supporting Health for All through Reinvestment (SHARE) Initiative, which requires a portion of CCOs’ profits to be spent on social determinants of health domains. SHARE launched with CCOs reporting their 2020 expenditures, CHSE Associate Director Ruth Rowland, MA, said.

“CCOs that reported net revenues for 2020 ‘designated’ a portion of them for SHARE spending, an amount which was voluntary for 2020 and 2021, but will be determined by an OHA formula from 2022 onward,” Rowland said. “CCOs designating funds for SHARE submitted SHARE plans to show how they intended to use funds to address social determinants of health.”

Members eligible for both Medicaid and Medicare

The waiver renewal aimed to simplify coverage and choices for beneficiaries who are dually eligible for Medicare and Medicaid through passive enrollment in CCOs, with the option to opt out and return to the state’s Fee-For-Service (FFS) program at any point.

Oregon implemented passive enrollment in CCOs for dual-eligible members in 2019. Prior to that, dual-eligible members were enrolled in FFS coverage by default but could choose to enroll in a CCO.

Results for measures of health care access, quality, and spending suggest that care for dual-eligible members did not change substantially from 2016-2018, according to the report. Outpatient visits increased, particularly for behavioral health, but access to primary and preventive care were relatively flat. Declines in emergency department utilization and avoidable emergency department visits were limited to dual-eligible members residing in urban areas. Total spending increased from 2016 to 2018 for dual-eligible members in isolated and rural areas.