Programmatic gaps in current governmental public health system • These results, when viewed collectively for all foundational programs and capabilities, show that implementation is uneven across the system. PHD LPHAs Extra-Large Large Medium Small Extra-Small P-CDC P-EPH P-PHP P-CPS C-AEP C-EPR C-COM C-PAP C-HEC C-CPD C-LOC Partial Limited Minimal Significant Implementation Implementation Implementation Implementation 23
Programmatic gaps in current governmental public health system • This assessment provides detailed information about programmatic gaps for all 11 foundational programs and capabilities: – E.g., environmental health : POPULATION BY LEVEL OF SERVICE State Activities Local Activities Limited Environmental Public Health 19% 71% 9% 19% 71% 9% 0% Implementation Identify and Prevent Environmental Health Hazards 3% 43% 36% 19% 3% 43% 36% 19% 73% 26% 1% Conduct Mandated Inspections 73% 26% 1% 0% 38% 32% 29% 2% Promote Land Use Planning 38% 32% 29% 2% Significant Partial Limited Minimal 24
Full implementation cost findings Annual current spending on foundational programs and capabilities: $209M Preliminary annual additional increment of cost of full implementation of foundational programs and capabilities: $105M This is a preliminary point-in-time, $1M in current planning-level estimate for spending implementation under the current governmental public health system $1M in additional and does not represent the final cost increment of cost of needed to fully implement public full implementation health modernization. This cost estimate will be revised over time as efficiencies in public health system are implemented. 25
Criteria for selecting priorities The Public Health Advisory Board used the public health modernization and the following criteria to identify priorities for public health modernization for the 2017-19 biennium: 1. Health impact 2. Service dependency 3. Equity 4. Population coverage 26
Recommended priorities for 2017-19 • Communicable diseases • Environmental health • Emergency preparedness • Health equity • Population health data • Public health modernization planning 27
Public Health Modernization Framework 28
Implementation efforts Local public health authority funding formula: HB 3100 requires a formula for the equitable distribution of funds. Initial formula includes the following variables: • Population size • Disease burden • Health status • Racial and ethnic diversity • Poverty • Limited English Proficiency The funding formula also includes matching funds for local investment and a quality pool. 29
Implementation efforts Accountability metrics: HB 3100 requires the use of incentives to encourage effective provision of public health services. To the extent feasible, the final public health quality measure set will align with the work of: • Statewide public health initiatives (e.g., Oregon’s State Health Improvement Plan) • National public health initiatives (e.g., CDC’s Winnable Battles) • Coordinated care organizations • Early learning hubs 30
Implementation efforts Regional public health modernization meetings: Using funding from the Robert Wood Johnson Foundation, regional public health modernization planning meetings will be convened from September 2016-January 2017. The purpose of these meetings is to: • Engage elected officials, CCOs, early learning hubs, community-based organizations and other stakeholders in moving forward a new model for public health • Identify barriers and opportunities for collaboration across jurisdictions • Begin the process of developing local public health modernization plans 31
For more information Cara Biddlecom, Interim Policy Officer (971) 673-2284 cara.m.biddlecom@state.or.us healthoregon.org/modernization 32
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CCO Metrics 2015 Performance Report Medicaid Advisory Committee July 27, 2016 Sarah Bartelmann Office of Health Analytics
• Includes state and CCO level performance on 50 metrics • Measures reported for members with disability, with mental health diagnosis, and with severe and persistent mental illness. www.oregon.gov/oha/Metrics/Pages/HST-Reports.aspx 35
Oregon Health Plan Population
Oregon Health Authority Quality & Accountability Core Performance Measures • From Oregon's 1115 waiver - some focus on population health. • No financial incentives or penalties associated with them. State Performance Measures • Annual assessment of statewide performance on 33 measures. • Financial penalties to the state if quality goals are not achieved. CCO Incentive Measures • Annual assessment of CCO performance on 17 measures. • Quality pool paid to CCOs for performance. • Compare performance to prior year.
2015 Quality Pool Distribution To earn their full quality pool payment , CCOs had to: Meet the benchmark or improvement target on at least 12 of the 17 measures (including EHR adoption); and Have at least 60 percent of their members enrolled in a patient-centered primary care home (PCPCH). Money left over from quality pool went to the challenge pool . To earn challenge pool payments, CCOs had to: Meet the benchmark or improvement target on the four challenge pool measures: depression screening, diabetes HbA1c control, SBIRT, and PCPCH enrollment.
Meeting goals and what they mean The Metrics and Scoring Committee establishes a benchmark and/or improvement target for each incentive measure. The Committee reviews measures and targets each year. Benchmarks: These are national-level benchmarks, set for exceptionally high achieving Medicaid programs. We expect these to be reached in the long term, rather than short term (5 to 10 years.) They may shift slightly year to year as national performance shifts or be increased as needed. Improvement targets: In addition to the benchmark, an improvement target is calculated for each incentive measure. The improvement target is unique for each CCO and focuses on reducing the gap between the CCO’s prior year performance and the benchmark by 10%.
How did CCOs do?
New! CCO Summary Reports
New measure
New measure
Modified measure
Next steps • Expand analysis and reporting of data stratified by disability and mental health diagnoses. • Mid-year progress report will be published January 2017 • New incentive measures in 2016 – Cigarette smoking prevalence – Childhood immunization status • 2017: No changes to measure set • Committee is considering adding more transformational measures for 2018
For more information 2015 Performance Report www.oregon.gov/oha/Metrics/ Measure Specifications www.oregon.gov/oha/analytics/Pages/CCO-Baseline-Data.aspx Contact us at metrics.questions@state.or.us
Oregon FFS Access Monitoring Review Plan (DRAFT) July 27 th 2016 Jamal Furqan, Health Systems Division
Access Monitoring Review Plan Requirements Data, sources, methodologies, baselines, assumptions, trends and factors, and thresholds that analyze and inform determinations of the sufficiency of access to care, which may vary by geographic location within the state and will be used to inform state policies affecting access to Medicaid services such as provider payment rates. (42 C.F.R. §447.203(b)(1)) 81
7 Regions 82
Monitoring Specific Service Categories Primary Care (including dental) Physician Behavioral Specialty Health Services Access to Care Home Health Obstetrics Other? 83
Oregon must complete a regional study of the following components Comparative Access Rates & Measurements Reimbursement & Metrics Analysis (HPA) (ASU) Beneficiary & Characteristics Provider of the Complaints Beneficiary Analysis Population (HSD) (HPA) 84
Criteria for Open Card OHP Eligibility • Dual eligible members (Medicare and Medicaid) have option • American Indian/Alaskan Native Tribal members have option • Non-citizens with CAWEM eligibility always FFS • Children in DHS custody have option • Newly eligible members admitted as an inpatient at hospital are FFS • Medically fragile children 19 and younger have option • Newly eligible members needing organ transplant have option • Continuity of Care Exemptions – Pregnant members have option – Provider request for member to be open card - OHA review – No other reasonable alternative as determined by OHA • Member has major medical private insurance (third party liability) – Always FFS 85
The FFS Population Total Open Card Members 4233 Central Oregon 12761 Columbia Gorge 13844 10482 65425 Eastern Oregon North Coast 36080 Southwest 1545 Tri-County Unknown 76846 Willamette Valley Percent of Oregon Health Plan Population on Open Card by Region, February 2016 Central Eastern Gorge North Coast Southwest Tricounties Willamette Valley State Avg 19% 22% 23% 21% 18% 18% 19% 19% 12,563 13,893 4,224 10,276 34,787 75,582 63,784 216,517* *There were 1,545 persons with an unknown, missing or out of state 86 residence.
FFS population continued… Age Open Card Managed Care Total Pct Open Card < 1 1,807 24,353 26,160 7% 01-5 11,180 109,997 121,177 9% 06-12 18,452 145,710 164,162 11% FFS members by age group 13-18 18,295 103,552 121,847 15% 19-21 8,858 40,230 49,088 18% 22-35 51,872 201,615 253,487 20% 36-50 47,119 149,821 196,940 24% 51-64 28,356 128,720 157,076 18% 65+ 30,578 26,425 57,003 54% Total 216,517 930,423 1,146,940 19% Percent of Oregon Health Plan Population on Open Card 54% FFS members by 26% 24% race/ethnicity 17% 16% 12% State Average = 19% Open African American Asian or Pacific Caucasian Hispanic Other / American Indian or Islander Unknown Alaskan Native 87
FFS Reimbursement Rate Comparisons Primary Care Willamette/ Central/ South Tri-County All Regions North Coast Eastern west FFS vs CCO -34.6% -24.3% -8.2% -17.9% -24.2% FFS vs Medicare -30.7% -29.6% -30.2% -28.7% -29.8% Specialist Services Willamette/ Central/ South Tri-County All Regions North Coast Eastern west FFS vs CCO -14.0% 3.5% -5.0% -15.3% -7.1% FFS vs Medicare -16.7% 3.8% -12.1% -25.6% -12.1% Obstetric and Neonatal Services Willamette/ Central/ South Tri-County All Regions North Coast Eastern west FFS vs CCO -14.1% -14.8% -5.8% -5.5% -11.6% FFS vs Medicare -5.3% -6.6% -8.2% -11.0% -7.2% 88
FFS Reimbursement Rate Comparisons continued… Behavioral Health Willamette/ Central/ South Tri-County All Regions North Coast Eastern west -45.0% -25.5% -2.4% -15.1% -28.1% FFS vs CCO -17.6% -19.6% -12.9% -9.1% -15.0% FFS vs Medicare Dental Services Willamette/ Central/ South Tri-County All Regions North Coast Eastern west -35.2% -32.7% -26.9% -37.1% -32.4% FFS vs CCO -65.2% -64.7% -62.5% -62.6% -63.3% FFS vs ADA Home Health Services • For Home Health services, OHA reimburses providers based on revenue codes • Due to the relative size of data, regional comparisons are not available for Home Health Revenue Code Revenue Code Description Average Actual Reimbursement Rate Average CCO Reimbursement Rate % Difference 421Physical therapy visit $145.14 $137.44 5.60% 424Physical therapy evaluation or reevaluation $146.95 $128.74 14.20% 431Occupational therapy visit $154.45 $147.80 4.50% 434Occupational therapy evaluation or reevaluation $153.95 $133.41 15.40% 441Speech-language pathology visit $182.49 $169.44 7.70% 444Speech-language pathology evaluation or reevaluation $173.97 $171.71 1.30% 551Skilled nursing visit $184.39 $148.68 24.00% 559Skilled nursing evaluation $152.26 $135.21 12.60% 571Home Health Aide visit $54.19 $32.46 66.90% $149.75 $133.88 16.91% 89
Access to Care Beneficiary Complaint Trends January 2015 – May 2016 Urban Regions Access Complaint Trend 140 # of Access Complaints 120 100 Tri-Counties 80 60 Willamette Valley 40 20 Linear (Tri-Counties) 0 Linear (Willamette Valley) Month of Complaint Rural Regions Access Complaint Trend 60 # of Access Complaints 50 Central Oregon 40 North Coast 30 Southwest 20 Linear (Central Oregon) 10 0 Linear (North Coast) Linear (Southwest) Month of Complaint 90
Access to Care Beneficiary Complaint Trends cont … January 2015 – May 2016 Frontier/Rural Regions Access Complaint Trend 25 # of Access Complaints 20 15 Columbia Gorge 10 Eastern Oregon 5 Linear (Columbia Gorge) Linear (Eastern Oregon) 0 Month of Complaint 91
Access Measures: Utilization Calendar Year 2015 Measure CCO results Open Card results Adolescent Well-Care 35.7% 13.8% Child/Adolescent Access to Primary Care All ages 89.5% 72.9% 12 to 24 months 94.8% 79.3% 25 months to 6 years 86.7% 66.7% 7 to 11 years 90.1% 73.9% 12 to 19 years 90.6% 75.7% Well-child Visits (first 15 62.8% 29.2% months of life) Follow-up after MH 87.7% 66.0% hospitalization Follow-up ADHD meds Initiation phase 61.0% 42.3% Continuation and 68.9% 45.1% maintenance phase Initiation and Engagement for SUD Treatment Initiation phase 37.7% 35.4% Engagement phase 18.8% 15.8% Use of dental sealants in 6- 17.2% 2.8% 14 year olds with mental illness 92
Access Measures: CAHPS Survey Results Consumer Assessment of Healthcare Providers and Systems (CAHPS) Measure Medicaid Total FFS Source Adult Child Adult Child Access to CAHPS Health Plan Survey 84% 92% 89% 94% emergency and urgent care Access to 77% 84% 80% 88% CAHPS Health Plan Survey Routine Care CAHPS Health Plan Survey Access to 75% 88% 82% 89% Specialist CAHPS Health Plan Survey Access to 80% 88% 79% 92% Personal Doctor CAHPS Health Plan Survey Access to 44% 52% 41% 52% urgent Dental Care Access to a 57% 79% 57% 79% CAHPS Health Plan Survey Regular Dentist Access to Mental Health Services Survey, 2015 74% 82% 78% 79% timely MH services 93
Access Measures: Physician Workforce Survey 2015 Physician Workforce Survey - No FFS break-out. Provider availability measures specifically pertaining to FFS population will be introduced in 2016 Physician Workforce Survey. Measure Population Source Providers accepting new Medicaid patients 88% (Adult + Child) Physician Workforce Survey, 2015 Provider currently with Medicaid patients under their care 90% (Adult + Child) Physician Workforce Survey, 2015 Reasons providers are not accepting new Medicaid patients Reimbursement rate 83% Balancing payers 77% Administrative requirements 77% Patient load 74% Liability insurance 23% Complex needs of patients 64% Non compliance of patients 69% Ease of referral for Medicaid patients by providers* Specialist 64% Ancillary services 45% Non-emergency hospital services 59% Diagnostic imaging 77% Inpatient mental health services 27% Outpatient mental health services 31% Inpatient substance use disorder services 18% Outpatient substance use disorder services 24% *Providers responding “Usually” or “Always” to survey question 94
Primary Care Access Review • Reimbursement Rates : 24% below CCOs; 30% below Medicare – Tri-County CCOs paying 35% more than FFS on average – Central/Eastern Oregon CCOs paying slightly more than FFS • Access Complaints : trending downward overall – Tri-county complaints spiked in Oct-2015 but reverted to baseline – Most regions experienced peak in complaints in Q1 2015 • Access Measurements – Utilization: FFS members utilizing primary care at much lower rate than CCO members; 33.6 percentage points below for Well-Child Visits – CAHPS: FFS members report experiencing slightly better access to primary care – Physician Workforce Survey: 88% of all physicians accepting new Medicaid patients in 2015 • Top reason for not accepting new Medicaid members is Reimbursement Rate , followed by Balancing Payers/Administrative Requirements • Only 45% report ease referring to Ancillary Services 95
Physician Specialist Access Review • Reimbursement Rates : 7% below CCOs; 12% below Medicare – FFS paying more than CCOs in Willamette/North Coast regions – Southwest and Tri-County reimbursing about 14-15% more than FFS • Access Complaints : trending downward overall – Tri-county complaints spiked in Oct-2015 but reverted to baseline – Most regions experienced peak in complaints in Q1 2015 • Access Measurements – No utilization measure currently – CAHPS: FFS members report experiencing slightly better access to specialists, and emergency services – Physician Workforce Survey: 88% of all physicians accepting new Medicaid patients in 2015 • Only 64% of primary care physicians report referring Medicaid patients to specialists is ‘usually’ or ‘always’ easy 96
Dental Services Access Review • Reimbursement Rates : FFS dental rates significantly below CCO and American Dental Association (ADA) fee schedule – FFS reimbursements 27% or more below CCOs in all regions – FFS reimbursements more than 60% below ADA fee schedule in all regions • Access Complaints : trending downward overall – Tri-county complaints spiked in Oct-2015 but reverted to baseline – Most regions experienced peak in complaints in Q1 2015 • Access Measurements – No utilization measure currently – CAHPS • Less than 50% of FFS members report adequate access to urgent dental services; however same as CCO members • Only 57% of adults report adequate access to regular dentist – Physician Workforce Survey: Only oral surgeons captured in 2015 • Plan to incorporate dentists in 2016 survey 97
Behavioral Health Access Review • Reimbursement Rates : Tri-County CCOs paying 45% more than FFS; CCOs average 28% more than FFS overall – Central/Eastern Oregon CCOs paying only 2.4% above FFS • Access Complaints : trending downward overall – Tri-county complaints spiked in Oct-2015 but reverted to baseline – Most regions experienced peak in complaints in Q1 2015 • Access Measurements – Utilization: CCO utilization much higher than FFS in most measures • F/u after MH hospitalization 22 percentage points higher for CCO members • F/u on ADHD medications also around 19-23 percentage pts higher • Similar utilization for Initiation and Engagement for SUD Treatment – CAHPS: FFS members report similar or better experience accessing timely MH services as CCO members – Physician Workforce Survey: Providers report the most difficulty referring Medicaid members to inpatient AND outpatient MH and SUD services 98
Obstetric Services Access Review • Reimbursement Rates : CCOs average reimbursement is 11.6% higher than FFS – Central/Eastern and Southwest average 5-6% higher – Tri-County and Willamette/North Coast average 14-15% higher • Access Complaints : trending downward overall – Tri-county complaints spiked in Oct-2015 but reverted to baseline – Most regions experienced peak in complaints in Q1 2015 • Access Measurements – No utilization measure currently – CAHPS: FFS members report similar or better experience accessing emergency and urgent care, routine care, and a personal doctor. – Physician Workforce Survey: Only 59% of providers report ease in referring Medicaid recipients to non-emergency hospital services 99
Home Health Services Access Review • Reimbursement Rates : Average actual FFS reimbursement is about 17% higher than CCO reimbursements • Access Complaints : trending downward overall – Tri-county complaints spiked in Oct-2015 but reverted to baseline – Most regions experienced peak in complaints in Q1 2015 • Access Measurements – No utilization measure currently – CAHPS: FFS members report similar or better experience accessing emergency and urgent care, routine care, and a personal doctor. – Physician Workforce Survey: Only 45% of providers report ease in referring Medicaid recipients to ancillary services 100
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