Has serendipity created a transformational moment in Oregon health care?

Sometimes, health care transformation happens with intention.

That was certainly the case in Oregon with the development of Oregon’s Prioritized List in the early 1990s.  The development helped to bring quality and efficacy to health care by using empirical data to determine a ranked order of medical effectiveness.

From the Oregon website discussing the approach:

The Oregon Health Evidence Review Commission (HERC) ranks health care condition and treatment pairs in order of clinical effectiveness and cost-effectiveness.

The Prioritized List emphasizes prevention and patient education. In general:

      – Treatments that help prevent illness are ranked higher than services that treat illness after it occurs.

      – OHP covers treatments that are ranked on a covered Prioritized List line for the client’s reported medical condition.

Intentional transformation was also the case in 2012 with Oregon’s CCO project.  There, the idea was to integrate physical and behavioral health in a model that allowed for community and stakeholder governance.

Other states have clearly been intentional about their transformation projects as well.

Sometimes, however, serendipity strikes.  And, it may be the case that such serendipity is about to strike Oregon which has otherwise been very visionary about the reform of the health care system there.

Here’s what I mean.

The Oregon Health Authority has developed its new RFA for the 2.0 version of CCOs, a document that has been out since January.  This was a product developed in part from significant public input.  That input elevated the importance of social determinants, and called for the CCO 2.0 RFA to require CCOs to address those determinants in a more formal way than they had previously.

From the Executive Summary of the OHA’s approach to re-procurement.

Over the next five years, CCOs will increase their investments in strategies to address social determinants of health and health equity. CCOs will build stronger relationships with members, nonprofit organizations, hospitals, schools, and local public health departments. CCOs will align goals at the state and local level to improve health outcomes and advance health equity.  OHA will develop measurement and evaluation strategies to increase understanding of spending in this area and track outcomes.

The RFA itself spends five pages on new requirements for CCOs to address social determinants.  Attachment 10 outlines incentive payments, priority targets, and some spending flexibility.

Beginning CY 2020, CCOs will be required to spend a portion of end-of-year surplus, derived from annual net income or excess reserves, on Health Disparities and the social determinants of health…

Further, OHA intends to establish a two-year incentive arrangement… to offer bonus payments above and beyond the capitation rate to CCOs that meet SDOH-HE-related performance milestones.

It’s clear from the RFA that Oregon Medicaid believes that social determinants can impact health in a meaningful way, and that the OHA will require some portion of capitated payments – payments that operate under the State Medicaid Plan agreement with the feds, which are subject to FMAP and statutory restrictions for use – to be used for social determinants.  The OHA directs that this process prioritizes housing.

Here’s where serendipity comes in.

If Medicaid dollars – whether they are direct service dollars or surplus – are being spent on social determinants, and that spend is meant to address a diagnosis and to improve health, shouldn’t those expenditures be put onto the Prioritized List and measured for efficacy?

After all, the Prioritized List is specifically interested in “treatments that help prevent illness.”  Housing qualifies.  The list is specifically interested in efficacious and high value treatments for disease states.  Housing qualifies there, too.

As we now commonly recognize, you can’t get someone well that isn’t housing secure.  In fact, it’s so well known that stakeholders in Oregon spoke to this clearly, and the OHA included housing as a priority in health care spending for the CCO 2.0 model.

In other words, the logic of the Prioritized List, of the CCO model, and of Oregon Medicaid itself, suggests that social determinants should now be included for consideration on the Prioritized List.

So, what might we expect will happen when that occurs?

The list already recognizes that physical therapy is often more efficacious than surgery for lower back pain.  Wouldn’t we expect that moving someone from sleeping on a sidewalk into a safe and secure bedroom is likely to be more efficacious than surgery as well?  Maybe more efficacious than physical therapy too?

In other words, its reasonable to think that including treatments to address social determinants that lead to poor health outcomes will be among the most efficient, value-added strategies that can be employed in Oregon Medicaid.

They will be at the top of the Prioritized List.

Oregon health care leaders are starting to imagine a world where the Prioritized List measures efficacy of housing against back surgery.  That wasn’t the goal of CCO 2.0, and it hasn’t been a vision adopted by the OHA or Oregon Health Policy Board just yet, but the conversation is on the horizon.

And, just as you might imagine, that conversation could turn health and health care in Oregon – indeed the whole country – on its head.