By Lily Raff McCaulou
PORTLAND — First, the good news: Oregon Health Plan patients made 13 percent fewer visits to the emergency room during the first nine months of 2013 than in 2011, which suggests a massive effort to reform the state’s version of Medicaid is cutting down on costly hospitalizations.
But here’s the bad news: The state still has to make strides in other areas, for example, increasing the rate of outpatient services such as counseling, doctor’s office visits and screenings. In 2015, the state could face significant fines if the Oregon Health Plan hasn’t shown improvement in 33 categories.
This week, the state released its third-ever quarterly report on how its efforts to reform the Oregon Health Plan measure up to its lofty goals, set in a contract between the state and the federal Centers for Medicare and Medicaid Services. So far, results are mixed. But officials warn it’s still very early in the reform process.
In 2012, the federal government gave Oregon $2 billion to fill a short-term budget gap in return for the state’s long-term promise to reform Medicaid by improving health care quality and lowering costs. Oregon’s reform strategy, which went into effect gradually throughout 2013, hinges on 16 Coordinated Care Organizations. Called CCOs, these are regional entities that have increased flexibility in terms of how they spend Medicaid dollars. The hope is that this flexibility will lead to more coordinated care and less waste. Many CCOs, for example, have hired caseworkers to encourage cost-effective preventive care and reduce expensive emergency room visits.
“The general feeling here is that we are headed in the right direction,” said Alissa Robbins, a spokeswoman for the Oregon Health Authority, the agency overseeing the reform effort. “Especially because two of the primary measures — decreased emergency room use and increased primary care visits — really speak to the foundation of the coordinated care model.”
Spending on primary care is up 18 percent, according to the new report, and enrollment in what the state calls “patient-centered primary care homes” is up 51 percent since 2012.
Officials also touted increased screening of young children for developmental delays. The percentage of children younger than 3 who were screened for developmental, behavioral and social delays increased from 20.9 percent in 2011 to 31.7 percent in the first nine months of 2013.
“That can make a big difference, because an early intervention can have lifelong health benefits, as well as early learning developments,” Robbins said.
That doesn’t mean that all of the trends reported this week are positive.
Only 21 percent of adolescents under the Oregon Health Plan went in for a “well-check” visit during the first nine months of 2013, compared with 27 percent in all of 2011. Officials warned, however, that these results shouldn’t be compared until the 2013 fourth-quarter data have been reported, because the total percentage accumulates throughout the year, as eligible teens visit their doctors.
The percentage of children with sore throats who were tested for strep before being prescribed antibiotics reportedly fell 1 percentage point, from about 74 percent in 2011 to 73 percent in 2013. The over-prescription of antibiotics is widely viewed as a public health threat, and although antibiotics are effective in treating strep throat, they are not effective in treating viral causes of a sore throat.
The rate of outpatient treatment, such as office visits, screening and counseling, fell from 2011, instead of rising as the state had hoped, according to the report. Cervical cancer screening also reportedly is down, though state officials said, again in this case, results shouldn’t be compared until a full year of data have been released.
Some of the measures were reported for the individual CCOs, too.
Kate Wells, director of community health development for Central Oregon’s CCO, PacificSource, said the general feeling about the most recent report was one of cautious optimism. The local CCO scored high marks in some categories where the rest of the state lagged, such as strep throat testing.
In the past year, she said, local caregivers have had a lot to learn about the new Medicaid system. Some of the metrics that are being reported weren’t finalized until midway through 2013, she said.
“One big ‘ah-ha’ moment was when we realized that adolescents aren’t really used to accessing annual preventive care … the way that younger kids are,” she said. “But if you think about that population, it’s one of our highest risk populations. So how do we change that norm in our community?”
For this type of quality measure, Wells said, the CCO is working with other groups to find “a community-minded approach.”
The data are about to become even more important to the CCOs themselves, which contract with the hospitals and clinics that treat Oregon Health Plan patients. Beginning in June, once a full year of data have been released, some of the state’s funding of CCOs will be tied to how well they do — or don’t — measure up in 17 categories.
The data could eventually have repercussions for all Oregonians.
In 2015, if the state is not showing improvement in each category over its pre-reform performance, it could have to begin paying penalties to the federal government.
To read the full report, visit www.oregon.gov/oha/Metrics/Documents report-february-2014.pdf
—Reporter: 541-410-9207; firstname.lastname@example.org
Editor’s note: This story has been corrected. In the original version, the agreement between Oregon and the federal Centers for Medicare and Medicaid Services was mischaracterized. In 2015, the state faces fines if the Oregon Health Plan has not shown improvements in 33 categories beyond its “baseline” measurements, most of which reflect data from 2011, the year before the reform effort took effect. The Bulletin regrets the error.