Eligible Patient Population: Nearly all Oregon Health Plan enrollees, including Medicaid beneficiaries who are dually eligible for Medicare will be enrolled in Coordinated Care Organizations (CCO)s. The only Oregon Health Plan enrollees not subject to mandatory enrollment requirements are: noncitizens, American Indians/Alaska Natives, dual eligibles enrolled in a PACE program, enrollees who receive an exemption, and individuals who reside in an area not served by a CCO.
Under the State Innovation Model grant received by Oregon in early 2013, the model will be expanded beyond the Oregon Health Plan to public employees covered through the Public Employees Benefit Board, Medicare for dual eligibles, and commercial payers.
Scope of services: CCOs are responsible for integrating and coordinating physical, mental, behavioral and dental health care for enrollees. Oregon Department of Human Services Medicaid-funded long-term care services will not be provided by CCOs.
Attribution: Administrative rules governing the project stipulate that Oregon Health Plan beneficiaries choose the Coordinated Care Organization into which they would like to enroll. Beneficiaries that fail to choose a CCO will be assigned to a CCO that is open for enrollment, services the county in which the beneficiary resides, and has practitioners located within the community-standard distance for average travel time for the beneficiary.
The Oregon Integrated and Coordinated Health Care Delivery System was authorized by the Oregon legislature in 2011 through House Bill 3650. A second piece of legislation passed in 2012, SB 1580, approved follow-up proposals for Coordinated Care Organization (CCOs) qualification criteria and global budgeting processes developed by the Oregon Health Authority.
Section 15 of House Bill 3650 declared the Oregon Legislature’s intent to exempt CCOs from state antitrust laws, and to provide immunity from federal antitrust laws through the state action doctrine.
Oregon submitted to the Centers for Medicare & Medicaid Services a Request for Waiver Amendment to the 1115 Demonstration Waiver under which the Oregon Health Plan operates. The state requested a three-year extension of the waiver through October 31, 2016 and sought to maintain authorities included in its existing waiver, such as the authority to contract with managed care entities and to mandatorily enroll and auto-enroll individuals within managed care. The waiver request was approved in July 2012.
The state received a State Innovation Model grant from the Center for Medicare & Medicaid Innovation in early 2013 to expand its model.
Coordinated Care Organizations (CCOs) must ensure their governance structure makeup reflects community needs and supports the goals of health care transformation and meets governance structure criteria from ORS 414.625. The law requires that each CCO’s governance structure include a majority interest consisting of the persons that share financial risk of the organization. Major components of the of the health care delivery system and the community at large must also be represented.
CCOs are also required to convene regular meetings of community advisory councils (CACs) to obtain community perspectives. These councils include representatives of the community and of county government, but with consumers making up a majority of the membership.
|Criteria for Participation||
The Oregon Health Authority established certification criteria for Coordinated Care Organizations in March 2012 through administrative rules. Applicants are required to demonstrate capacity for:
Engaging community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the entity’s enrollees and the entity’s community
As described in the state’s 1115 waiver request narrative, Coordinated Care Organizations (CCOs) receive a fixed global budget from the state. These global budgets include:
CCOs are expected to move beyond fee-for-service payment mechanisms for compensating health care services providers. CCO applicants must be able to demonstrate experience and capacity for “Developing and implementing alternative payment methodologies that are based on health care quality and improved health outcomes.” Alternative payment methodologies include, but are not limited to: shared savings arrangements, bundled payments, payments based on episodes, and payments based on a global budgeting system.
A Transformation Center will be formed under Oregon’s State Innovation Model Grant to provide technical assistance to promote alternate payment methodologies. The Center will offer implementation tools for a “start set” of promising payment models, which will include:
|Support for Infrastructure||
Each Coordinated Care Organization (CCO) is required by regulation to participate in a learning collaborative established (in ORS 442.210) by the Office for Oregon Health Policy and Research as part of the state’s patient-centered primary care home program.
Under its State Innovation Model award, Oregon plans to create a Transformation Center to support a statewide “Rapid Learning Health System” that facilitates the spread of the state’s model to other payers. A Patient-Centered Primary Care Home Technical Assistance Institute will reside under the Transformation Center is planned for launch in the fall of 2013.
An incentive pool for rewarding CCO performance on quality, access, and efficiency will be implemented by the middle of 2013.
The Oregon Health Authority’s Office of Health Analytics will support the Transformation Center that will be established under Oregon’s State Innovation Model grant. The Office of Health Analytics has access to health-related data sets containing claims or encounters, data on long-term services and supports outside of CCOs, surveys (including the Consumer Assessment of Healthcare Providers and Systems survey), the state’s All-Payer All-Claims database, and a Client Process Monitoring System that contains clinical information on mental health/chemical dependency services. The office will use this data to support the improving and targeting of services, performance measurement, and communication on performance.
|Measurement and Evaluation||
No evaluations have been produced yet. The Oregon Health Authority is required to regularly report to the Oregon Health Policy Board, the Governor, and the Legislative Assembly on its progress in implementing Coordinated Care Organizations, including:
A set of Year 1 CCO Accountability Metrics will be for reporting purposes only in Year 1.
A quarterly report released in November 2013 found the following results for beneficiaries served by CCOs: