The New Health Dialogue

Here is my latest contribution to the Altarum Institute's Health Policy Forum, another in my series of "what works" posts. This one is about an innovative Medicaid Managed Care plan in Oregon.

Care Oregon, the state’s main Medicaid managed care plan, had two choices a few years ago, after many commercial partners in the Oregon Health Plan decided to get out of the money-draining business.

It could go broke. Or it could change its world.

It opted for the latter. Today, the Portland-based nonprofit CareOregon is a bit savvier about the business end of its mission. And it’s still trying to change its world.

I started hearing about CareOregon here and there over the last year, and I heard several of its leaders -- including CEO Dave Ford -- speak at IHI events, both about population health (the “Triple Aim” in IHI lingo) and about specific attempts to better serve complex patients with multiple chronic conditions. Medical director David Labby, MD, Ph.D., and I chatted this spring, and he’s updated me recently to refresh my memory. CareOregon’s leaders are quite frank about being a work in progress. But some progress can be discerned.

One question I’m always asking as I write about innovators in health care is about what’s come to be known as “spread.” There are good ideas out there, and good results, but it’s often very isolated.  Good news doesn’t always travel.  In this case, the folks at CareOregon traveled to the good news.  They had heard Doug Eby, vice president of medical services for Southcentral  Foundation in Anchorage (I’ve written about Southcentral here and here) and were intrigued. “Doug is an inspiring speaker. But is it real,” Labby wondered. Thirty people from CareOregon went to Alaska to see for themselves.

It was real. Even if the Southcentral model couldn’t be exported to Oregon wholesale, many of its features, systems, and values could be adapted. Labby came back determined to create a “customer” (aka patient) driven system; proactive, team-based care; greater cultural sensitivity, barrier-free access to care, and a greater integration of behavioral health into primary care. Southcentral, however, is part of an integrated system. CareOregon is the payer working with various providers, large and small, urban and rural, across the state.

CareOregon launched several new programs (including centralized care management, drawing on the Eric Coleman model -- more spread). But we spoke mostly about the reinvented -- and reincentivized -- primary care teams. They call it “Primary Care Renewal” and it’s basically a drive to create patient-centered medical homes within safety-net clinics.

In 2007, CareOregon asked its five largest providers, community health centers that serve about 40 percent of its beneficiaries, to each create one integrated primary care team. CareOregon helped finance the start-up. Every six weeks or so, the various teams got together to learn with and from one another. The idea was to have the teams run for a year, in a sense doubling as an ongoing experiment and a proof of concept.

It spread faster than expected; other providers demanded to be part of similar teams. “They were asking, hey why can’t I do that. They are having more fun,” recalled Labby. By fall of 2009, 63 primary care renewal teams were operating in 15 clinics, covering about a third of CareOregon’s membership. (It’s still hard to spread the model to smaller and/or more isolated practices, a certain volume is required.)

By 2009, CareOregon was shifting the payment model away from pure traditional fee for service to rewards for meeting goals of access, satisfaction, quality, and utilization, a process that was deepened in 2010. Outcomes were measures for such things as well-controlled diabetes and immunization rates.

It was a very different approach than providers were accustomed to, both because they were more anchored in their teams, and because they had to change how they approached care -- and bring their patients along with them.

“Usually, if you want a pill or a test or a diagnosis -- medical services -- you go to the doctor, ask him or her to help you, and you leave. That’s the classic model. It’s acute care. You go away and you are on your own,” he said.

In contrast, said Labby, “We ask, ‘How can I help you between visits to have the best possible health?” Maybe that means a telephone follow-up to touch base and make sure a patient understands what he needs to do, and has the means to do it -- or identifying and removing barriers. Maybe it means a class or a group visit. Maybe help with transportation, or other ways of helping to link medical and social services. It is a shift from what Labby calls the “visit-based economy” to an outcome-one.

If a patient ends up in the ER, because he couldn’t get an appointment with the PCR team fast enough, the team has to take responsibility. Ditto when a patient is admitted to the hospital, for instance, because they aren’t getting or using their medications. (CareOregon hasn’t yet seen a significant drop-off in ER and hospitalization utilization).

“We don’t believe just being more efficient or even creating better access in and of itself will reduce the waste in the health care system. It will reduce some of it…But we need to put new resources into primary care, to develop new resources to address the needs of the chronically ill and complex patients. Primary care practices will have to support them between visits and they are going to need staff and training and information systems. It’s complicated. We believe this is a new clinical practice.”

One goal is to start shifting some of the big chronic disease management from the Portland-based central teams into the primary care teams. Labby recently emailed that they are introducing depression and diabetes management programs (with the depression one drawing on a successful program at the University of Washington. More spread.)

Health reform will help in some ways -- including by simply reducing the number of uninsured patients the clinics see. There will be lots of pilots and demonstrations, although Labby isn’t sure how and when those will roll out in ways that address CareOregon’s specific trajectory. But he knows that if he wants to stay on the road to improvement -- not the road to bankruptcy -- changing the delivery system and the business model is essential

“We started with primary care. Now we are starting to think about specialists, about partnering with hospitals. We believe some of the same lessons we’ve learned in primary care apply throughout the health care system.”

But he doesn’t see health reform as merely a change in finance or structure or practice. It requires a change in culture. How doctors and nurses and social workers and care managers and primary care teams and specialists learn to think about their own interactions, and their relationships with their patients.

“Basically, it comes down to how do we engage in a useful way? How do we join with them in making their health better. Even a person with chronic illness is going to want to have the best possible health. Nobody wants to have the worst possible health.”

(After I met and interviewed David Labby, the Commonwealth Fund also published a 36-page case study. CareOregon: Transforming the Role of a Medicaid Health Plan from Payer to Partner, which I recommend if you want greater detail).