About
• Non-profit, public benefit corporation that manages
Medicare and Medicaid services
• More than 200,00 OHP and 13,000 Medicare
Advantage members
– ~25% of the total Medicaid population in Oregon
– Most CareOregon Advantage (Medicare) members are
enrolled in our Special Needs Plan for dually-eligible
members
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76% of members live in the Portland metro area
54% of members are female
26% do not speak English as their first language
46% self identify as non-Caucasian
Legislative History Leading to
Oregon’s Healthcare Transformation
• 2009 Oregon Legislature
– HB 2009 “Healthy Oregon Act”
• 2010 U.S. Congress
– Patient Protection & Accountable Care Act (PPACA or ACA), aka
“Obamacare”
• 2011 Oregon Legislature
– HB 3650 – Health Care Transformation
– Created concept of a CCO
– Charged the Oregon Health Policy Board with coming up with a plan
for CCO implementation
• 2012 Oregon Legislature
– SB 1580 – Coordinated Care Organizations
– Essentially endorsed OHPB’s plan for CCO implementation
Vision of HB 3650 and CCO Implementation
(2011 Legislative Session, Oregon Legislature)
Integration &
coordination of
benefits & services
Local
accountability
for health &
resource allocation
Standards for safe
& effective care
Global budget
indexed to
sustainable growth
[A CCO]
Redesigned
Delivery
System
Healthier
population
Improved
Outcomes
Reduced Costs
[The Triple Aim]
What is a Coordinated Care Organization
(CCO)?
• A CCO is a single organization that accepts responsibility for the
cost of health care within a global budget and for delivery,
management and quality of care delivered to the specific
population of patients enrolled with the organization.
CCO
MCO, DCO, MHO, Rx, County
Programs, Medicare, Medicaid,
Specialty, Hospital, PCPCH
Shared Systems &
Learning
Coordination &
Communication
Local Accountability
Global Budget
Fragmented, Siloed System
Coordinated “Commons”
System
Key Principles for Governing the Commons:
Commons as metaphor for Coordinated Care
1. Individuals know the boundaries and limits
–
–
2.
3.
4.
5.
6.
7.
8.
Of the resource (“Common Pool Resource”)
Of the community of users (“Appropriators”)
Rules are locally made and adapted to context
Decisions are made together
Active measurement and monitoring
Effective sanctions
Mechanisms for conflict resolution
Latitude from higher authorities to act locally
Nested Commons
Source: Elinor Ostrom quote by Don Berwick in 2009 IHI Forum Plenary
CCO Theory
CCO
Shared Systems &
Learning
Coordination &
Communication
Local Accountability
Global Budget
• Demands a more horizontal
approach
– Democratizing systems that promote
health, not just health care
• Dependent on a network model
– Interdependent / Inter-independent
agents
• Requires involvement and input of a multitude of
stakeholders
– Is accountable to those stakeholders
• Is a community solution, as opposed to an industry
solution
– No longer every man (organization) for itself
Key Components of CCO Development
• Geographic/Demographic • Model of Care
Scope
– Physical, mental, oral health
• Business & Operations
–
–
–
–
–
–
Information Systems
Utilization Management
Administration
Claims Processing
Customer Relations
Workforce Development
• Local Governance
– Board of Directors
– Community Advisory Council
integration
– Social service
networking/integration
– Delivery system
transformation
– Keeping people healthy
• Financing
–
–
–
–
–
Global Budget
Capitalization
Risk
Revenue
Alternative Payment
Methodologies
Why would Oregon’s health systems
agree to do all this just for Medicaid?
• Post-ACA, 25% of Oregonians are enrolled in Medicaid
• $1.9 Billion in federal investment  accounts for 19%
of the state’s Medicaid budget in the ‘13-’15 biennium
– Unclear what the expiration of this investment will do
• The CCO Metrics dollars are real money
• Policymakers are pushing to fold all publicly-funded
health coverage into the CCO model
– PEBB & OEBB
– If that happened, ~40% of Oregonians would have care paid
for and coordinated by CCOs