As a physician, I’ve always felt confident in my knowledge, skills, and ability to diagnose, treat, and manage disease on the individual patient level. However, after about 8 years of practice, I began to realize that my efforts could only go so far in helping my community as a whole. It was clear that the actual medical care I was administering was just a small part of the equation. The quality of a patient’s health and the overall medical care they receive is largely affected by other determinants, such as their lifestyle choices, socioeconomic status, level of education, and genetics. However, seeing only a single patient at a time, I had little ability and almost no platform for addressing these other determinants of health at the community level.
As a radiologist, I could, for instance, help develop large-scale breast-screening programs using mammography. These efforts could help the population but did little to help connect the other community organizations involved in addressing the determinants of health. What was desperately needed, in my eyes, was a way to connect and coordinate my efforts with other parts of the community not typically included in healthcare conversations and strategies. Fortunately, the State of Oregon also saw a need for better coordination of health services, mainly as a way to help manage costs.
The state was facing a budget deficit driven by spending on Medicaid. Typically, when states try to manage deficits related to Medicaid, they employ a combination of three strategies:
- Decrease reimbursement rates to hospitals and providers. This does not work very well because, ultimately, clinics will need to limit the number of Medicaid members they see since they are not financially viable, in turn creating access issues for patients.
- Restrict the number and types of covered services. In Oregon, we had already employed the Prioritized List for more than 20 years, which served as an evidence-based approach to prioritizing and limiting the availability of healthcare services. Limiting what was already on the list would not have been possible without denying many essential services.
- Decrease the number of individuals enrolled in Medicaid. This was not an option either, as Oregon was going to be an expansion state under the Affordable Care Act and would see its Medicaid population grow from 600,000 to a little over 1 million members within just a short time.
Oregon’s approach was to take a fourth path and develop a new model to deliver Medicaid benefits: the coordinated care model. Under this model, the state would pass legislation and receive Section 1115 Medicaid expansion waiver from the federal government, which allowed it to create new community-governed health insurance plans for the Medicaid population called coordinated care organizations (CCOs). Medicaid members enrolled in CCOs reside within a defined geographic region and receive funding for their medical, behavioral, and dental care benefits by a single global budget that the state defined.
A significant component of the CCOs was the focus on community governance. The board of the CCO needed to have a local primary care physician still in practice, a behavioral health provider, a representative from local public health departments, as well as several local elected officials. Additionally, each CCO could have a clinical advisory panel made up of various actively practicing physicians, social workers, dentists, and other healthcare professionals.
As a physician, I saw the CCO framework as a way for me to finally have a formal way to work with others in my community on addressing population health and the various determinants of health. As a result, I helped my community apply for and become recognized as one of 16 CCOs in Oregon.
The CCO then provided me with a number of opportunities and a community-wide platform to improve the community’s health. For example, as a result of conversations in the CCO, we realized as a community that one of our local fire departments had extra capacity with its paramedics and ambulances. They were looking for work and additional revenue. Thus, we proposed incorporating them both into a transition of care strategy for Medicaid members discharged from the hospital. When transitioning back home, the last thing I wanted was to see them re-admitted, especially when it could have been prevented. Under the so-called paramedicine program, paramedics could perform non-emergency visits to Medicaid members’ homes following hospital discharge, helping with medication reconciliation, laboratory specimen collection, safety checks, and more. The CCO was able to fund this initiative after input and approval from the governing board and clinical advisory panel. Not only were patients’ lives improved, but the local economy was also stimulated.
Ultimately, the structure of the CCO allowed me and other physicians to have tangible, impactful input in helping our patients outside the hospital’s four walls, improving their health as well as the health of our entire community. The coordinated care model has proven tremendously successful for Oregon and has enabled both providers and members to have a voice in the governance of healthcare. Making a change took time and resources, but seeing the results first-hand made every ounce of effort worth it.