Janeece Cook popped in to the county health clinic on Northwest 27th Street in Corvallis Friday morning for a checkup.
She wasn’t sick, and it wasn’t time for her annual physical, but she was a little worried she might have been exposed to the flu. The doctor checked Cook’s pulse and blood pressure, listened to her breathing, asked some questions about her overall health and arranged for her to get a flu shot.
But the clinic won’t be sending Cook a bill for the office visit — it’s already covered.
Starting this month, the Community Health Centers of Benton and Linn Counties are taking part in a one-year pilot program that pays them a flat monthly rate for providing a full range of services to the 6,322 Oregon Health Plan members assigned to the county-run clinics in Corvallis, Monroe and Lebanon.
Rather than billing OHP (Oregon’s version of Medicaid, the federal insurance program for the poor and disabled) on a fee-for-service basis, the Community Health Centers will receive a single payment each month from the InterCommunity Health Network, the regional coordinated care organization for Linn, Benton and Lincoln counties.
The clinics are to receive payments ranging from $15 to $86.36 a month for each assigned patient, depending on which risk-weighted rate group the patient falls into. The estimated revenue for the clinic is $170,041 a month, or just over $2 million for the year, though the amount will be adjusted periodically as the numbers and types of OHP patients change.
IHN is providing an additional $400,000 or so to cover most of the cost of salary and benefits ($408,000) to add the equivalent of five full-time staff members for the clinics, and the two parties have agreed to a set of benchmarks to measure how well the system is meeting goals for access, quality of care and utilization.
The coordinated care organization is piloting a similar arrangement with two other medical groups in its region, Samaritan Internal Medicine in Corvallis and Coastal Health Practitioners in Lincoln City.
If the new alternative payment methodology (APM for short) works as intended, all of the Oregon Health Plan members assigned to those three primary care providers will do what Janeece Cook did — come in for preventive care so any potential problems can be detected early, chronic conditions can be managed effectively and those who need help can get it quickly.
“It’s going to allow us to provide the kind of care we all want to provide and have wanted to provide for a long while to our patients,” said Dr. Kristin Bradford, the medical director for the Community Health Centers of Benton and Linn Counties and the physician who examined Cook on Friday.
Trying new things
Under Oregon’s health care transformation initiative, the coordinated care organization for each region of the state gets a global budget from Medicaid, a single pot of money to serve the medical, dental and mental health needs of all the Oregon Health Plan members in its coverage area. Gov. John Kitzhaber, who championed the transformation plan, wants to bring other groups of people, such as public employees, into the fold as well.
Each CCO’s mission is to improve the health of its member population while maintaining quality standards and lowering, or at least controlling, overall costs. And while the individual care organizations are overseen by the Oregon Health Authority, they have a considerable amount of autonomy in how they achieve the benchmarks set by the state.
One thing all 16 CCOs are being encouraged to do is to set up and implement alternative payment methodologies. Many, if not most, are already test-driving some variation on the approach IHN is trying, known as PMPM (per member per month) capitation.
“Some CCOs are doing a lot of capitation of services, including hospital services,” said Kelly Ballas, the Oregon Health Authority’s chief financial officer. “Others are capitating only primary care services, and others might do it just for certain kinds of services, like mental health services.”
Each alternative payment plan is tailored to the needs of the communities it serves as well as participating health care providers. After the pilot programs are over, the ouctomes will be evaluated and CCOs will compare notes to determine what went well and what didn’t. That information will be used to inform future payment strategies.
“I wouldn’t use the word ‘experiment’ because that implies you don’t know what the outcome is going to be; I would use the word ‘demonstration,’” Ballas said. “We’re trying to learn everything we can about what works best ... for the triple aim.”
Three ways to win
The triple aim is the holy grail of health care reform: greater access to services, improved health outcomes for patients and lower overall costs for health care. The theory behind IHN’s alternative payment pilot program is that it will address all three of those aims by taking care of patients early on so that little, inexpensive problems don’t turn into big, costly ones.
“In the grand scheme of things, it’s a lot cheaper to treat somebody in the clinic than it is to treat them in the hospital after they get sick,” said Eric Owen, deputy director of the Community Health Centers of Benton and Linn Counties.
A big component of the alternative payment pilot program — and the reason for the additional staffing — is making sure as many people as possible access a full range of services, from regular checkups to wellness coaching to management of chronic conditions such as diabetes, asthma and high blood pressure.
One of the keys to making that happen is a team of registered nurses who act as care coordinators. Part of the job is serving as a sort of concierge, orchestrating visits to primary care docs, medical specialists, mental health practitioners or behaviorists.
They also perform a wide variety of other functions, sometimes making outreach calls to patients who haven’t been in for awhile, educating people on self-management, checking up on medication use or keeping tabs on follow-up care after surgical procedures.
“That’s why they call us a medical home versus just a clinic,” said care coordinator Carol Oldshield.
Follow the money
While the Community Health Centers system was designed to function on the patient-centered primary care home model, fee-for-service billing hasn’t provided sufficient revenue to make it function as intended. Medicaid expansion under the Affordable Care Act has helped alleviate that problem by enrolling more people in the Oregon Health Plan, which reduced the number of uninsured people in the patient mix.
Community Health Centers director Sherlyn Dahl thinks the new alternative payment plan will provide another big boost to the system’s bottom line.
“The main thing it does for us is it takes away the volatility or uncertainty of the provider visit-based system,” she said.
“This allows us to have a full team (of providers), but even more important for us is it allows us to interact with the patient and change their health.”
Kim Whitley, the chief operating officer for IHN, acknowledges it may seem counterintuitive to try to save money on health care costs by encouraging people to access more services. But by getting people the help they need early in the game, she believes the new approach can help keep minor ailments from turning into serious — and costly — diseases, resulting in a healthier population and keeping overall costs in check.
“I could decrease costs today (by restricting access), but I’m just shooting myself in the foot for tomorrow,” Whitley said.
“We’re realizing there’s a lot of costs we don’t see in the traditional system,”she added. “It’s just a different way of looking at it, but there’s just so many options for cost saving in our tri-county area when you bring all these people together.”