States developing accountable health models often look to Oregon for inspiration. Oregon established its Coordinated Care Organizations (CCOs) in 2012, pursuant to a Medicaid Section 1115 demonstration waiver. CCOs are local networks of all types of health care providers — including physical, behavioral, and oral health providers — that the state pays a global capitated rate to provide integrated care to Medicaid beneficiaries. This capitation model gives the CCOs flexibility to provide both health and health-related services as appropriate for:
- Individuals, such as supplemental food, athletic shoes, or air conditioners, and
- The community, such as supporting farmers’ markets or workforce development programs.
A percentage of the global budget is set aside each year for CCOs to earn based on their performance on quality incentive measures, some of which measure progress toward addressing upstream health factors such as smoking prevalence or effective contraceptive use.
The Oregon Health Authority (OHA) is in the process of selecting CCOs to serve Medicaid beneficiaries for a second five-year period, beginning in 2020. The state recently announced that it received 20 letters of intent, with full applications due in late April 2019. As part of this re-procurement process, known as CCO 2.0, the OHA developed a request for applications (RFA) that reflects Gov. Kate Brown’s commitment to health equity and to addressing the social, economic, and life conditions that affect health.
The process also builds on a comprehensive evaluation of the CCO model’s first five years. For example, the evaluation found that the financial incentives built into the CCO model were associated with improvements in the incentive metrics. It also suggested that the state require CCOs to invest a portion of their global budget in the social determinants of health, to ensure CCOs address non-clinical factors affecting health. CCO 2.0 incorporates these and other lessons from the first five years, to help the model build on its strengths and learn from experience.
Oregon recently shared updates on its CCO 2.0 contracting process with states participating in the National Academy for State Health Policy’s workgroup for states with accountable health entities. States seeking to improve health equity and address health-related needs through accountable health models could learn a number of lessons from Oregon’s experience.
- Convene without usurping. States and accountable entities can use their convening authority to raise the profile of health equity and health-related social and economic needs. Because accountable entities are locally driven, states can expect them to bring together stakeholders representing a range of community perspectives for focused conversations about community needs. The OHA oversaw an extensive stakeholder engagement process as part of CCO 2.0 that culminated in soliciting public comments on the RFA.
Requiring accountable entities to take on a convening role with diverse stakeholder representation can also help ensure that they are not entering the health equity space by taking over work currently performed by community partners. Instead, accountable entities can identify and build upon the good work already taking place in a community and supplementing it.
- Pay for priorities and pay partners. The Oregon legislature codified the state’s commitment to health equity and the social determinants of health by requiring CCOs to direct a portion of their spending to “services designed to address health disparities and the social determinants of health,” consistent with the CCOs’ community health improvement plans. Oregon’s CCOs work with a range of community partners — such as social service organizations, housing service providers, and public health professionals — to improve health equity and meet health-related social needs. Recognizing that the work of these partners helps CCOs earn quality incentive payments, one of the adopted CCO 2.0 policy recommendations encourages CCOs to spend a portion of their funds on the community partners who help them reach their goals.
Even accountable health entities that do not receive global payments or incentives for meeting quality measures could consider acknowledging the importance of their community partners to their work, whether through monetary appreciation or other means.
- Align assessments. Accountable entities play a key role in identifying and meeting the health and health-related needs of people in their local communities. At the same time, non-profit hospitals’ community health needs assessments, state health improvement plans, and local health department needs assessments also gauge the needs of their communities, often to fulfill federal, state, or other requirements or expectations. To ensure that these assessments complement one another without duplication, accountable entities can work to bring the parties together to discuss sharing data and information, aligning due dates where possible, sharing tools and resources, and seeking to fill gaps.
Oregon’s CCOs are required to develop local Community Health Improvement Plans (CHPs) and Assessments (CHAs). As laid out in in the adopted CCO 2.0 policies, the OHA requires CCOs to share their CHAs with local hospitals, tribes, public health authorities, and other CCOs that serve those same communities. It also requires the CHPs to address two priorities identified in the state health improvement plans and requires each CCO to submit its CHA to the OHA. This helps integrate state and local priorities, and ensures that policymakers have an understanding of local and regional needs.
- Govern with the community. In Oregon, community voices are built into the structure of CCOs. Each CCO is guided by a community advisory council (CAC) made up of community members. In addition, each CCO has a governing body that by statute must include a member of the CAC, and at least two members of the community at large. This requirement is meant “to ensure that the organization’s decision-making is consistent with the values of the members and the community.” As part of CCO 2.0, CCOs are expected to have at least two CAC members, at least one of whom is a Medicaid beneficiary, on their governing boards.
While many state accountable health entities require community representation in their governing bodies, it can sometimes be challenging to ensure that the full diversity of community voices are heard. Some states use statutory language or guidance to enumerate the types of community organizations or perspectives that accountable entities must include. Oregon goes a step further: CCO 2.0 will require CCOs to report on the composition of their CACs, and on how closely the representation on the councils aligns with the demographic composition of their communities and with the community’s health priorities. This helps ensure that CCOs will engage community members who are in touch with the community’s health priorities, and can provide appropriate insight and guidance.
All eyes are on Oregon as it addresses non-clinical health needs at the individual and community level, and builds health equity into the contracting requirements for its CCOs. Even states whose accountable health models look very different from Oregon’s CCOs, or whose work on community health and health equity is in early stages, may draw on these lessons to inform their next steps. As Oregon’s example shows, states have the levers and expertise to help accountable health entities improve health and well-being in their communities and ensure that community voices are heard in the process.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.