Oregon Health Care Reform

"Letting Go of the Rope"

Timothy L Keenen, MDOrthopedic Spine

SurgeonTualatin, OR

Timothy L Keenen, MDOrthopedic Spine

SurgeonTualatin, OR

AAOS Fall Meeting

October 20, 2012Philadelphia, PA

AAOS Fall Meeting

October 20, 2012Philadelphia, PA

US Health Care Spending

18 % of GDP 25% by 2037

25% of Federal Spending 40% by 2037

Accountable Care Organization(ACO)

Fee for Service

3,800,000

2,000,000

40% D

30% R

25/5 %

20123,800,000

600,000 Medicaid

300,000 public employees / teachers

25% state funding for health care

16 % budget

Oregon Health Plan 1993 waiver from Bill Clinton

2,900,000240,000 medicaid oregonians

John Kitzhaber, MDState Legislator 1978-1993

(President of State Senate 1985-1993)

Governor 1995- 2003Archimedes Movement 2006

Governor 2011-present

US health care assumes that the public sector and private employers

will continue to fund the medical inflation rate faster than CPI and

that this will continue to be funded without evidence of positive

outcomes.

Gov. John Kitzhaber

Three strategies

1. Decrease provider reimbursement

2. Decrease number of patients covered

3. Decrease patient benefits

The new rope we are grabbing onto…..

“Outside” fee for service

Global Payment

Bundled Payment

Pay for Performance

“Outside” hospital and doctor office

Flexibility

Technology

Coordinated Care OrganizaionCCO

Local Flexibility Cost / Outcome Management

2007Oregon Health Fund Board

(OHFB)

2009Oregon Health Authority

(OHA)

Oregon Health Policy Board (OHPB)

2007Oregon Health Fund Board

(OHFB)

2009Oregon Health Authority

(OHA)

Oregon Health Policy Board (OHPB)

Oregon SB 99(June 2011)

State Health Insurance Exchange

•Market place for apples to apples comparisons for insurance

•Central elements to move from Medicaid into the private market

:

3650 HBJune 2011

 

Coordinated Care Organizations(CCO)

•A service integration, care coordination, focus on wellness, prevention and community based management of chronic conditions  medical care.•Population health rather than simply the delivery of medical care

•Risk adjusted global budget that grows at a fixed rate

•Accountability for performance standards around access, around clinical outcomes, and around metrics for improving population health

SB 1580 February 2012

Senate 16-14 vote (16D 14R)House 53-7 vote  (30D  30R)

•CCO adopted as a plan •Established application / certification process

•Tort Reform deferred to 2013

Differences

Commonalities•Reduce incentive for providers to earn more by treating more•Improve coordination / integration of care•Focus on use of Information Technology

ACO Accountable Care Organization

PCMH Patient Centered Medical Home

CCO Coordinated Care Organization

May 1, 2012Federal Waiver

Payment:$1.9 billion dollars from HHS over 5 years

Federal requirement:2% decrease in the Medicaid per member inflation rate trend by the end of the second year (down to 3.5%)

Savings:$ 1.9 billion over 5 years$11 billion over 10 years

The grand bargain was they give us the flexibility, they give us $1.9 billion, we reduce

the Medicaid cost trend by 2 percent points per member by the end of the second year and improve health outcomes. That’s the grand

bargain.

Health Evidence Review Commission (HERC)

Health Technology Assessment Subcommittee

SK: How will the administration measure what counts as higher quality care? How do you safeguard

against providers skimping on care?JK: There are metrics we’re developing with [the

Center for Medicare Services] about patient outcomes and population health metrics. So this is

clearly unlike an old HMO, which could save costs by skimping on care.

ReimbursementFee for ServiceGlobal PaymentBundled Payment

Contract ?Strategic Pathway ?

RCT basedPatient Registry based

Treatment Outcome Measure?Pay for performance

What can I do?