Solutions from the Outside

1. Solutions from the Outside Who Asked You?

2. CONTEXT

3. Health Care Reform • Reform is not about health care – it is about money and politics. • Health Care costs are between 17-18% of GDP • They should be around 11% • No health care entity will willingly give up revenue or profit. • Health outcomes are what will be achieved after money and politics are decided.

4. Health Care Triangle

5. Health Care Reform • Demand – Causes • Genetics, environment, economic status, education....... • Access – How one gets into the system • Finance – Who gets paid what • Price – Controlling the market • Cost – Budget • Quality – How good we want the system to be

6. Oregon’s Managed Care History • Began in 1985 with PPO risk model for Medicaid • Legislature authorized Oregon Health Plan in 1989 • Full HMO Model • Full integration of all health services except LTC • Cost based provider reimbursement • Prioritized list of covered services • Guaranteed access to providers • Implemented in 1995 W/O Mental Health • Added Mental Health in 1997, partial success • Cost based reimbursement lost in 2003

7. Key Results of OHP • Most comprehensive evidence based benefit list in the US. • 14 Fully Capitated Health Plans • 2 Insurance companies • 12 community based managed care organizations • All are full HMO operations • 500,000 Clients with guaranteed timely access to care • All Clients have a primary care provider • Approximate 12% savings per managed care client per year • $15 Billion over 16 years

8. 2012 Health Reform • Legislature passed Health Transformation act in 2009 • Integration of Mental Health and Dentistry • Modified Act in 2011 • Protected existing MCO’s • Set rules for Governance • Transparency in Government payments (sort of) • CCO’s began operation in August, 2012

9. What’s a CCO? • CCO’s are fully integrated health plans responsible physical, mental, alcohol and drug, and dental care. • CCO’s are given a global budget, paid by a monthly premium, that covers full risk for all services. • CCO’s are viewed as community based organizations and are required to have community representation regardless of their corporate structure. • CCOs are held accountable by reporting performance on quality measures such as prevention, disease identification, ongoing intervention, patient satisfaction and total cost of care.

10. What is changing? • Practitioners across the disciplines are talking to each other • CCO Insurers are changing their business models • Traditional silos: Claims, Customer service, R&A, Care Coordinators, etc. • New model: Integrated customer teams – Navigators, referral and social service coordinators for providers, care coordinators and patient mentors. • Redistribution of money and services • PCP’s paid more and used more. • Specialty utilization is down • Outpatient and ER services are declining • Hospital reimbursement is tied to Medicare methodology and rates are capped • Long term cost trends ??

11. What is being accomplished? • Health care is a community effort • Integration of health care services is happening • Integration of health care, social, housing and food services is being designed and implemented. • Community Health discussions now involve • Health care providers • Social Services • Schools • Public safety

12. What Does Alaska Do? • Medicaid Expansion • You pay the Bill either way • Reform or not • Where do you want your money to go? • Health care or other areas? • Education, roads, sewers, economic development • You get to choose or not choose • If you don’t, someone else will