Jeremey Vandehey, Health Care Policy Advisor to the Governor, says they have had a number of positive conversations about the waiver with CMS.
Vandehey says CMS sees Oregon’s CCO model as a promising model nationally. He said key elements in the new waiver request include:
Leslie Clement, Director, Health Policy and Analytics, Oregon Health Authority (OHA), reports that, “We have significant issues with people with mental health issues over-utilizing emergency departments. As an aggregate we are doing a good job decreasing ED visits, however when you look at this specific subset, it is clear we have more work to do.” Susan Otter, Director of Health IT, OHA, said CCOs are now able to review ED visits via pre-manage that has access to the EDIE.
Clement also talked about moving more OHP patients into the CCOs including the dual eligibles (those eligible for both Medicare and Medicaid). Currently the dual eligibiles have to opt in to CCO coverage. One of the proposed changes in the new Medicaid waiver would change that so dual eligibles would be assigned to CCOs unless they opt out.
Clement said OHA is concerned about each CCO maintaining significant reserves. House Health Committee chair Rep. Mitch Greenlick (D-Portland) said there is now $923 million in the CCO reserves. “This money belongs to the community they are serving not the individual organization. That money seems very much at risk…” he said.
They also noted that there will be a full Provider Directory by end of 2017 and are in the procurement process for a Clinical Quality Metrics Registry—which would collect clinical data from clinics for Oregon’s CCO metrics.
Health Insurance Marketplace Update
Pat Allen, Director of the Department of Consumer and Business Services (DCBS), told the House Health Committee the Marketplace’s goal when open enrollment begins is to maintain market share in the face of large rate increases. They had the same goal last year and actually increased enrollment by 31
He said they will not be using mass media advertising this year. Instead, they will be micro targeting millennials and the Hispanic community. Both groups have higher than average uninsurance rates.
Allen said they will do outreach through community partners and agents, “who are a very important part of this effort. Navigating dozens of choices is challenging and agents help them make better choices.”
After the failure of Oregon Health Insurance Coop, Allen said 70% - 75% were placed in alternative coverage. Those new insurers honored Coop policyholders’ out-of-pocket expenditures, with the exception of ZoomCare and Lifewise. He said the Insurance Division issued an order requiring them to comply.
Allen flagged the issue of out-of-pocket carry over when a policyholder switches from one policy to another with the same carrier in situations like a mid-year job change.
The Senate and House Health Committees heard informational testimony on the Comprehensive Primary Care Plus (CPC+) program. Ron Stock, Clinical Innovation Advisor, ORPRN, says the goal of Comprehensive Primary Care Plus is to lower costs and increase quality by providing comprehensive care that meets patient’s needs.
Jane Conley, clinic administrator at Springfield Family Physicians, says they received about $250,000 per year under the predecessor to CPC+. “It is important for you to understand that all of this money went toward patients. None of it went toward boosting doctors pay.” They used the money to hire an RN, mental health experts and medical assistants. As a result, they:
Bob Gluckman, MD, Chief Medical Officer, Providence Health Plans, said, “We are concerned about the uneven participation of payers. There are multiple payers that have more than 5% of market share, yet Providence is the only one to participate in both CPCI and CPC+.” Gluckman said there shouldn’t be “freeloaders.” “Right now, payers who are not participating are still receiving the benefits.”
Both committees said they want to know why some insurers are not participating in CPC+.
Behavioral Health Collaborative
Lynne Saxton, Director, OHA, told the Health Committees they presented a “controversial” straw model to the 50 member Behavioral Health Collaborative to start the conversation about the future of behavioral health in Oregon. She said the OHA does not have preconceived notions about how to move forward but that, “We are working to increase efficiency within the system.”
She says they also have begun to address the US DOJ agreement to address those 30,000 people in Oregon with serious and persistent mental illness (SPMI). “We have had some fairly heated conversations so far and we hope to have more in the future.”
Bob Joondeph, Executive Director of Disability Rights Oregon, spoke next saying “there has been a lot of frustration in understanding what Oregonians are receiving for their mental health dollar. Mental health was moved into the physical health realm through the process called integration, understanding that they are related. What we have seen from the consumer is that in some areas things have moved forward; in others they have not moved forward at all. We have a longstanding policy of moving money to counties to address our different issues. Is that the most effective place to move our money?”
The Senate Health Committee was mostly quiet during this informational hearing. Sen. Elizabeth Steiner Hayward (D-Portland) commented, “One of the issues I think we need to consider is how previous interactions with the justice system affect people’s ability to access care.”
Margaret Shield from Community Environmental Health Strategies in Seattle told the House Health Committee that one-third of prescription drugs go unused and Rx take-back programs are the best way to deal with them. A take-back event in Lane County in 2015 took in 450 lbs of drugs.
She said flushing or throwing drugs in the trash contributes to environmental pollution. Unfortunately, she said, 380 drug manufacturers formed MED-Project, which is still telling consumers to throw Rx in the trash.
France, Canada, Mexico, Brazil, Columbia, Hungary and Spain all have well-established take-back programs paid for by pharmaceutical companies. She said Walgreens and local hospitals are already stepping up and starting these programs.
Shield estimates it costs about 1-cent per $10 of Rx to finance a take-back program.
Kathy Gunter, OSU, says several recent studies in Oregon have provided very consistent data statewide that between Kindergarten and 6th grade, the rate of childhood obesity doubles.
Federal guidelines say kids need a minimum of 60 minutes of physical activity each day, but that on average, kids are getting less than 20 minutes of exercise in a 6-7 hour day.
Dr. Craig Gunderson, University of Illinois, spoke about common programs used to combat childhood obesity such as a soda tax and the Supplemental Nutrition Assistance Program (SNAP).
The data, he says, is counterintuitive. He says that a soda tax is effective at raising revenue but not effective at decreasing obesity. He also refuted the perception that SNAP recipients are more likely to be obese. “This is false”, he says. According to Gunderson, SNAP is a very effective hunger relief program, as well as an effective anti-obesity program, and that the rates of obesity in the SNAP population are comparable to, if not lower than, those of the general population. He also says there is no evidence that restrictions on SNAP purchases, such as prohibiting junk food, would promote better health.
School Nursing Update
Nina Fekaris, chair of the Oregon School Nursing Association, says some 30,000 students do not have adequate access to a school nurse in Oregon. She noted that chronic health conditions, including mental health issues, require ongoing care, and that a school nurse is an optimal provider to treat these conditions.
Sen. Elizabeth Steiner Hayward (D-Portland) commented, “I have long been baffled that school nurses come out of the [education] budget. This is a health issue. This is a function that should be a community supported medical issue.”
Surprise Billing - LC 707
The Insurance Division has received more than 300 consumer complaints since January 2014 for “surprise billing.” This happens when a consumer goes to a hospital or clinic that is “in network” only to receive a “surprise bill” after the fact because one of the physicians, surgeons or nurses is “out of network.”
A Stakeholder Group met with the Insurance Division to talk about possible solutions. The Insurance Division’s original idea, in LC 707, was thought to be too complicated and did not kick in until after the consumer already had a bad experience with a surprise bill. Insurers said they want to find a solution “further up stream.”
One idea is to find a benchmark rate, e.g., 125% of Medicare, that out-of-network providers would be paid when they provided a service to an in-network patient at an in-network facility, and the out-of-network provider would be prohibited from balance billing the patient.
The Insurance Division plans to bring the Stakeholder Group back together later this fall. Expect one or more bills on this topic in the 2017 session.
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