Coordinated Care Organizations Research Articles

Wildfire Response and Recovery: The Importance of Coordinated Care and Social Support

Summary A decade ago, the Oregon legislature created coordinated care organizations (CCOs) through a Medicaid 1115 Demonstration waiver as a way of integrating physical, behavioral, and oral health in a single funding stream. The intent of the legislation was to facilitate the development of regional organizations that would coordinate comprehensive care for their Medicaid populations. AllCare Health, through AllCare CCO, serves approximately 61,000 members in the Southern Oregon region by partnering with providers and community organizations and stakeholders. As a participant in this community network beginning in the mid-1990s, prior to CCO legislation — and having developed the infrastructure to support community development and the trust to reinforce relationship management — AllCare Health was able to help facilitate the local response to the destructive wildfires affecting Southern Oregon in the fall of 2020. Using geographic information systems technology, AllCare Health identified members at risk in the fire zones and coordinated evacuation, health care services, and social needs in the immediate crisis. AllCare Health’s experience with integrating social determinants of health (SDOH) and preexisting relationships developed over many years allowed the organization to be a catalyst in the community response to the wildfires, which, given the changing climate, have become more frequent. Further, the CCO model supports care delivery that recognizes SDOH and supports the Triple Aim of improved patient experience of care, improved health of populations, and reduced per capita cost of care.

Improving screening, treatment, and intervention for unhealthy alcohol use in primary care through clinic, practice-based research network, and health plan partnerships: Protocol of the ANTECEDENT study.

BackgroundUnhealthy alcohol use (UAU) is a leading cause of morbidity and mortality in the United States, contributing to 95,000 deaths annually. When offered in primary care, screening, brief intervention, referral to treatment (SBIRT), and medication-assisted treatment for alcohol use disorder (MAUD) can effectively address UAU. However, these interventions are not yet routine in primary care clinics. Therefore, our study evaluates tailored implementation support to increase SBIRT and MAUD in primary care.MethodsANTECEDENT is a pragmatic implementation study designed to support 150 primary care clinics in Oregon adopting and optimizing SBIRT and MAUD workflows to address UAU. The study is a partnership between the Oregon Health Authority Transformation Center—state leaders in Medicaid health system transformation—SBIRT Oregon and the Oregon Rural Practice-based Research Network. We recruited clinics providing primary care in Oregon and prioritized reaching clinics that were small to medium in size (<10 providers). All participating clinics receive foundational support (i.e., a baseline assessment, exit assessment, and access to the online SBIRT Oregon materials) and may opt to receive tailored implementation support delivered by a practice facilitator over 12 months. Tailored implementation support is designed to address identified needs and may include health information technology support, peer-to-peer learning, workflow mapping, or expert consultation via academic detailing. The study aims are to 1) engage, recruit, and conduct needs assessments with 150 primary care clinics and their regional Medicaid health plans called Coordinated Care Organizations within the state of Oregon, 2) implement and evaluate the impact of foundational and supplemental implementation support on clinic change in SBIRT and MAUD, and 3) describe how practice facilitators tailor implementation support based on context and personal expertise. Our convergent parallel mixed-methods analysis uses RE-AIM (reach, effectiveness, adoption, implementation, maintenance). It is informed by a hybrid of the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) and the Dynamic Sustainability Framework.DiscussionThis study will explore how primary care clinics implement SBIRT and MAUD in routine practice and how practice facilitators vary implementation support across diverse clinic settings. Findings will inform how to effectively align implementation support to context, advance our understanding of practice facilitator skill development over time, and ultimately improve detection and treatment of UAU across diverse primary care clinics.

Expanding Inpatient Addiction Consult Services Through Accountable Care Organizations for Medicaid Enrollees: A Modeling Study.

Addiction consult services (ACS) care for hospitalized patients with substance use disorder, including opioid use disorder (OUD). Medicaid Accountable Care Organizations (ACOs) could enhance access to ACS. This study extends data from Oregon's only ACS to Oregon's 15 regional Medicaid Coordinated Care Organizations (CCOs) to illustrate the potential value of enhanced in- and out-patient care for hospitalized patients with OUD. The study objectives were to estimate the effects of (1) expanding ACS care through CCOs in Oregon, and (2) increasing community treatment access within CCOs, on post-discharge OUD treatment engagement. We used a validated Markov model, populated with Oregon Medicaid data from April 2015 to December 2017, to estimate study objectives. Oregon Medicaid patients hospitalized with OUD with care billed to a CCO (n = 5878) included 1298 (22.1%) patients engaged in post-discharge OUD treatment. Simulation of referral to an ACS increased post-discharge OUD treatment engagement to 47.0% (95% confidence interval [CI] 45.7%, 48.3%), or 2684 patients (95% CI 2610, 2758). Ten of fifteen (66.7%) CCOs had fewer than 20% of patients engage in post-discharge OUD care. Without ACS, increasing outpatient treatment such that 20% of patients engage increased the patients engaging in post-discharge OUD care from 12.9% or 296 patients in care at baseline to 20% (95% CI 18.1%, 21.4%) or 453 (95% CI 416, 491). ACOs can improve care for patients hospitalized with OUD. Implementing ACS in ACO networks can potentially improve post-discharge OUD treatment engagement, but community treatment systems must be prepared to accept more patients as inpatient addiction care improves.

Evaluation of a Medicaid performance improvement project to reduce high-dose opioid prescriptions

BackgroundIn 2015, Oregon’s Medicaid program implemented a performance improvement project to reduce high-dose opioid prescribing across its 16 coordinated care organizations (CCOs). The objective of this study was to evaluate the effect of that program on prescription opioid use and outcomes.MethodsUsing Medicaid claims data from 2014 to 2017, we conducted interrupted time-series analyses to examine changes in the prescription opioid use and overdose rates before (July 2014 to June 2015) and after (January 2016 to December 2017) implementation of Oregon’s high-dose policy initiative (July 2015 to December 2015). Prescribing outcomes were: 1) total opioid prescriptions 2) high-dose [> 90 morphine milligram equivalents per day] opioid prescriptions, and 3) proportion of opioid prescriptions that were high-dose. Opioid overdose outcomes included emergency department visits or hospitalizations that involved an opioid-related poisoning (total, heroin-involved, non-heroin involved). Analyses were performed at the state and CCO level.ResultsThere was an immediate reduction in high dose opioid prescriptions after the program was implemented (− 1.55 prescription per 1000 enrollee; 95% CI − 2.26 to − 0.84; p < 0.01). Program implementation was also associated with an immediate drop (− 1.29 percentage points; 95% CI − 1.94 to − 0.64 percentage points; p < 0.01) and trend reduction (− 0.23 percentage point per month; 95% CI − 0.33 to − 0.14 percentage points; p < 0.01) in the monthly proportion of high-dose opioid prescriptions. The trend in total, heroin-involved, and non-heroin overdose rates increased significantly following implementation of the program.ConclusionsAlthough Oregon’s high-dose opioid performance improvement project was associated with declines in high-dose opioid prescriptions, rates of opioid overdose did not decrease. Policy efforts to reduce opioid prescribing risks may not be sufficient to address the growing opioid crisis.

Effect of relaxing hepatitis C treatment restrictions on direct-acting antiviral use in a Medicaid program: an interrupted time series analysis.

BACKGROUND: Although direct-acting antivirals (DAA) have revolutionized the treatment of chronic hepatitis C virus (HCV), many state Medicaid programs have limited coverage because of their expense. In 2015, the Centers for Medicare & Medicaid Services (CMS) notified states about the legality of Medicaid coverage limitations, particularly within managed care programs. OBJECTIVES: To (1) examine how relaxation and alignment of hepatitis C policies within the Oregon Medicaid program affected DAA utilization and (2) describe changes in DAA coverage policies and patient characteristics of treated individuals over time. METHODS: We manually collected DAA Medicaid drug policies in the state of Oregon before and after the CMS notification was released. After categorizing DAA policies into 2 groups based on baseline prior authorization criteria (restrictive and permissive), we evaluated how changes in these DAA policies affected utilization over 3 time periods (pre-CMS period, post-CMS period, and fibrosis policy alignment). Immediate and gradual changes in trend were assessed using an interrupted time series regression model. Finally, we examined patient characteristics and liver disease complications over time as policy restrictions were removed and aligned with one another. RESULTS: From 2014 to 2018, Oregon's coordinated care organizations and fee-for-service drug policies relaxed liver fibrosis and substance abstinence coverage criteria leading to immediate increases in DAA use in 2016 (0.62 prescriptions per 10,000 enrollees per month; 95% CI = 0.17 to 1.08) and 2018 (1.07 prescriptions per 10,000 enrollees per month; 95% CI = 0.63 to 1.51) among more restrictive coordinated care organizations at baseline. This was followed by a decrease in trend after the 2016 and 2018 impact (-0.05; 95% CI = -0.11 to -0.001 and -0.07; 95% CI = -0.13 to -0.02, respectively). Over the 3 periods, there was a decrease in treated individuals with liver-related complications (P < 0.0001) and an increase in those with a substance use diagnosis (P = 0.0013). CONCLUSIONS: Reducing coverage limitations resulted in treatment of patients with fewer liver-related complications and more substance use disorders. Expanding access to treatment did not result in sustained increases in utilization, and additional interventions may be necessary to meet HCV elimination goals. DISCLOSURES: This study was funded in part by AbbVie Pharmaceuticals, which did not have any role in the study design, collection, analysis and interpretation of data, writing the report, or the decision to submit the report for publication. Hartung received support for his work on this study via a grant from AbbVie Pharmaceuticals. The other authors did not receive any financial support for their contributions to this study. The authors have no other financial disclosures to report. This study was presented at the Academy Health Annual Research Meeting in Washington, DC, on June 3, 2019.

Increased Use of Complementary and Alternative Therapies for Back Pain Following Statewide Medicaid Coverage Changes in Oregon.

In 2016, Oregon introduced a policy to improve back pain treatment among Medicaid enrollees by expanding benefits for evidence-based complementary and alternative medical (CAM) services and establishing opioid prescribing restrictions. To examine changes in CAM utilization following the policy and variations in utilization across patient populations. A retrospective study of Oregon Medicaid claims data, examining CAM therapy utilization by back pain patients pre- vs post-policy. We used an interrupted time series analysis to evaluate changes in CAM use and examined the association between patient characteristics and CAM use post-policy using linear regression models. Adult Medicaid patients with back pain. The Oregon Medicaid back pain policy, administered through Coordinated Care Organizations (CCOs). Use of CAM services. Use of any CAM service increased from 7.9% (95% CI 7.6-8.2%) prior to the policy to 30.9% (95% CI 30.4-31.3%) after the policy. Acupuncture increased from 0.3 to 5.6%, chiropractic from 0.3 to 11.1%, massage from 1.6 to 14.8%, PT/OT from 6.0 to 17.7%, and osteopathic from 1.4 to 1.9%. Interrupted time series showed an overall increase in proportion of back pain patients who used CAM service following the policy. Among those who accessed CAM, the policy did not appear to increase the number of services used. In the post period, CAM services were accessed more often by female and older enrollees and urban populations. Black, American Indian/Alaska Native, and Hispanic enrollees were less likely to access CAM services; for Black enrollees, this was true for all types of services. CAM service utilization increased among back pain patients following implementation of Oregon's policy. There was significant heterogeneity in uptake across service types, CCOs, and patient subgroups. Policymakers should consider implementation factors that might limit impact and perpetuate health disparities.

Coordinated Care: Capacity Allocation to Improve Itinerary Completion in Queueing Networks

Coordinated care is a burgeoning paradigm where patients receive diagnosis and treatment planning involving collaboration between two or more medical specialties to facilitate rapid and effective solutions to complex conditions. A key service metric for coordinated care organizations is how quickly they can move patients through their sequence of appointments at multiple clinical services in the network. Each patient's care path is uncertain when the appointment capacities are being planned, because information about the patient's condition evolves over the course of the patient's care process. Hence, the planning of root (first) appointments is the primary operational lever, as the other appointments evolve stochastically. In this work, we develop a discrete-time queueing network to optimize this root appointment allocation over a cyclic time horizon to maximize the proportion of patients that can complete their care by a class-dependent deadline. The model accounts for several salient features of coordinated care networks, including parallel appointment requests, stochastic paths, and time-varying features. We provide an {exact} characterization of the sojourn time in the network with a doubly-stochastic phase-type distribution and leverage a mean-field model with convergence guarantees to address intractability. We then develop a policy improvement framework that approximates the original stochastic optimization by a sequence of linear programs (LP), where the sojourn time model is parameterized in the policy evaluation step. The LPs are computationally efficient, and our algorithm can solve large-scale stochastic optimization for networks of realistic sizes (e.g., 26 service stations). In a case study of the Mayo Clinic, our solution improves on-time completion to more than 93\%, from 60\% under the current plan. We demonstrate that this is a multifaceted problem, and that ignoring any those facets can lead to poor performance. Simultaneously accounting for all these complexities makes manual template design challenging and highlights the practical significance of our optimization algorithm.

Oregon’s approach to leveraging system-level data to guide a social determinants of health-informed approach to children’s healthcare

BackgroundChildren’s health and healthcare use are impacted by both medical conditions and social factors, such as their home and community environment. As healthcare systems manage a pediatric population, information about...

Oregon Experiment with Medicaid Accountable Care and Pediatric Preventive Care Utilization Among Infants

Research ObjectiveIn August 2012, Oregon began enrolling Medicaid beneficiaries in coordinated care organizations (CCOs), a unique mandatory‐enrollment accountable care organization (ACO) model with payment methods strongly tied to preventive care and care coordination through patient‐centered medical homes. No study has examined the impact of CCOs on preventive care utilization among infants. The main goal of this study was to examine the impact of this new delivery model on the utilization of preventive care services among infants enrolled in Medicaid during 2 years after birth. We also investigated heterogeneous impacts of the CCO model for preterm and full‐term infants as well as over time.Study DesignWe linked Oregon 2008‐14 birth certificates to Medicaid eligibility and claims data, and created the pre‐ and post‐CCO cohorts of Medicaid infants. Medicaid infants were defined as being enrolled in Medicaid for at least 80% of the two years after birth. Pediatric preventive care outcomes included indicators of preventive care adequacy as recommended by American Academy of Pediatrics: six well‐child visits by the first birthday, nine well‐child visits by the second birthday, and annual developmental screening. We estimated logistic regression models and linear probability models, adjusting for time trends of outcomes and a comprehensive set of maternal and infant characteristics. We utilized a difference‐in‐differences approach to examine heterogeneous effects of CCOs for preterm and full‐term infants. Spline regression was used to test the effect of CCOs on the outcomes for every six months from the start of the CCO implementation. We conducted a range of sensitivity analyses, such as different thresholds of Medicaid enrollment for the definition of Medicaid infants and excluding infants of mothers in the Medicaid expansion group.Population Studied36 546 pre‐CCO infants born between August 2008 and July 2010 and 47 973 post‐CCO infants born between August 2012 and December 2014Principal FindingsDuring the 2 years after birth, infants enrolled in Medicaid CCOs had higher probability of well‐child visit adequacy: 10% points (95%CI: 8.2; 11.8) by the first birthday and 5.7% point (95%CI: 4.3; 7.1) by the second birthday. Annual probability of developmental screening increased by 23.1% points (95%CI: 21.6; 24.6) after the CCO implementation. No difference in the CCOs’ impact was found between preterm infants and full‐term infants. Increase in preventive care was found to start in the second year of the CCO implementation.ConclusionsThe CCO model was associated with an increase in preventive care utilization among infants enrolled in Medicaid during the first 2 years of birth.Implications for Policy or PracticeIncrease in preventive services among low‐income infants after CCO implementation implies that the Oregon Medicaid ACO model could improve quality of care for infants in their early years. A growing number of states have been adopting accountable care models for their Medicaid enrollees. Our findings suggest that other states benefit from studying the Oregon approach to accountable care for Medicaid enrollees that integrates financing and delivery of care, and implements a payment methodology with clear performance targets for pediatric preventive services.Primary Funding SourceCenters for Disease Control and Prevention.

Rapid Deployment of a Statewide COVID-19 ECHO Program for Frontline Clinicians: Early Results and Lessons Learned.

Rapid Deployment of a Statewide COVID-19 ECHO Program for Frontline Clinicians: Early Results and Lessons Learned.

Early Lessons and Strategies from Statewide Efforts to Integrate Community Health Workers into Medicaid.

The 2010 Affordable Care Act provided new impetus and funding opportunities for state Medicaid agencies to integrate community health workers (CHWs) into their health systems. Community health workers are trusted community members who participate in training so they can promote health in their own communities. This qualitative study shares lessons and strategies from Oregon's early efforts to integrate CHWs into Medicaid with concomitant financing, policy, and infrastructure issues. Key informant interviews were conducted with 16 Coordinated care organizations (CCO) and analyzed using an iterative, immersion-crystallization approach. Coordinated care organizations found CHW integration a supportive factor for Medicaid-enrolled members navigating health and social services, educating members about disease conditions, and facilitating member engagement in primary care. Barriers to CHW integration included a lack of understanding about CHW roles and their benefits to health systems, as well as a need for more intensive guidance and support on financing and integrating CHW services.

Coordinated Care Organizations and mortality among low-income infants in Oregon.

To examine the impact of Oregon's Coordinated Care Organizations (CCOs), an accountable care model for Oregon Medicaid enrollees implemented in 2012, on neonatal and infant mortality. Oregon birth certificates linked with death certificates, and Medicaid/CCO enrollment files for years 2008-2016. The sample consisted of the pre-CCO birth cohort of 135753 infants (August 2008-July 2011) and the post-CCO birth cohort of 148650 infants (August 2012-December 2015). We used a difference-in-differences probit model to estimate the difference in mortality between infants enrolled in Medicaid and infants who were not enrolled. We examined heterogeneous effects of CCOs for preterm and full-term infants and the impact of CCOs over the implementation timeline. All models were adjusted for maternal and infant characteristics and secular time trends. The CCO model was associated with a 56 percent reduction in infant mortality compared to the pre-CCO level (-0.20 percentage points [95% CI: -0.35; -0.05]), and also with a greater reduction in infant mortality among preterm infants compared to full-term infants. The impact on mortality grew in magnitude over the postimplementation timeline. The CCO model contributed to a reduction in mortality within the first year of birth among infants enrolled in Medicaid.

Inappropriate Opioid Prescribing in Oregon's Coordinated Care Organizations.

The objective of this study is to identify demographic and clinical characteristics of patients with a pain diagnosis who fill potentially inappropriate opioid prescriptions within the Oregon Medicaid population. Using de-identified Oregon Medicaid claims data (2010-2014), a series of logistic regression models was estimated to identify factors associated with receipt of potential inappropriate opioid prescriptions among patients with acute or chronic pain. Analyses included a total of 204,364 records, representing 118,671 unique patients. The percentage of patients with a pain diagnosis filling at least 1 inappropriate opioid prescription decreased over the study period, falling from 32.5% in 2010 to 22.3% in 2014. Multivariate logistic regression results indicated that white and older enrollees were more likely to fill an inappropriate prescription over the study period. The odds of filling an inappropriate opioid prescription were also greater for patients with chronic health conditions, psychiatric disorders, and substance use disorder. Results were similar for patients diagnosed with either acute or chronic pain, chronic pain only, or acute pain only. Inappropriate opioid prescribing for patients with pain diagnoses decreased over the study period, which stands in stark contrast to other state Medicaid programs. However, in 2014, almost 23% of patients in the Oregon Medicaid program filled at least 1 inappropriate opioid prescription, suggesting additional strategies are needed to further reduce potential inappropriate prescribing. Medicaid programs may consider adopting enhanced prescription drug monitoring program features, enacting pain clinic legislation, and implementing additional prior authorization policies to reduce inappropriate prescribing of opioids.

The Evolution of State-Based Dental Sealant Programs in Oregon Within the Context of the State Health Care Transformation Process.

Context:The 2007 Oregon Smile Survey of first, second, and third graders found that, since the first (2002) Smile Survey, all major measures of Oregon children's oral health had worsened. The Centers for Disease Control and Prevention recommends 2 interventions proven effective in preventing dental caries (cavities) in a population: community water fluoridation and school dental sealant programs. Repeated attempts at the state level to mandate water fluoridation had failed. State government therefore moved to increase the number of school dental sealant programs.Objectives:The objective of this article is to demonstrate how 2 interventions and subsequent statewide collaboration addressed the deterioration of children's oral health from 2002 to 2007.Design:An 11-year observational study to increase the number of schools in Oregon with dental sealant programs in the state of Oregon during health care transformation.Interventions:(1) Providing state general funds for a state school dental sealant program and (2) establishing an incentivized sealant metric for the Coordinated Care Organizations contracted to serve the Medicaid population.Results:In school year (SY) 2006-2007, only 26% (n = 92) of the state's eligible elementary schools had dental sealant programs. By SY 2013-2014, the use of state general funds increased the number of schools served to 78% (363 schools). By SY 2017-2018, with the establishment of the sealant metric, state and local programs served 92% (n = 473) of the eligible early elementary grades and 65% (n = 172) of the newly eligible middle school grades.Conclusion:Providing state general funds and establishing a sealant metric increased the number of schools served by school dental sealant programs and may have contributed to recent improvements in oral health.

Whole Systems Within Whole Systems: The Oregon Health Plan's Expansion of Services for Back and Neck Pain.

The authors employ a Whole Systems framework to explore implementation of new guidelines for back and neck pain in Oregon's Medicaid system. Whole Systems research is useful for understanding the relationship between complementary and integrative health care (CIH) and conventional health care systems in real-world clinical and practice settings. Preliminary results are from an observational study designed to evaluate state-wide implementation of CIH and other non-pharmacological treatments for neck and back pain among Oregon Medicaid patients. This natural experiment, even in early stages, provides insight into the challenges of integrating Whole Systems oriented therapies into Medicaid billing and treatment. Qualitative data are drawn from: (1) semi-structured interviews with representatives of each of the 16 coordinated care organizations (CCOs) responsible for administering the Oregon's Medicaid insurance through the Oregon Health Plan (OHP); and (2) open-ended survey responses from acupuncturists in all 16 CCO areas. Implementation of the new policy guidelines poses logistical and epistemological challenges. Differences in worldview, inadequate reimbursement, and simple lack of awareness of CIH among medical providers are some of the factors that pose barriers to merging CIH therapies into conventional frameworks. In this article, we explore the potential for a Whole Systems perspective to better explain the complexity of integrating CIH and other non-pharmacological services into a state financed health care system. Oregon's expansion of services for back and neck pain presents an opportunity to explore challenges and successes in melding multiple approaches to health and pain management into a managed system such as the OHP.

Does a transition to accountable care in Medicaid shift the modality of colorectal cancer testing?

BackgroundHealth care reform is changing preventive services delivery. This study explored trajectories in colorectal cancer (CRC) testing over a 5-year period that included implementation of 16 Medicaid Accountable Care Organizations (ACOs, 2012) and Medicaid expansion (2014) – two provisions of the Affordable Care Act (ACA) - within the state of Oregon, USA.MethodsRetrospective analysis of Oregon’s Medicaid claims for enrollee’s eligible for CRC screening (50–64 years) spanning January 2010 through December 2014. Our analysis was conducted and refined April 2016 through June 2018. The analysis assessed the annual probability of patients receiving CRC testing and the modality used (e.g., colonoscopy, fecal testing) relative to a baseline year (2010). We hypothesized that CRC testing would increase following Medicaid ACO formation – called Coordinated Care Organizations (CCOs).ResultsA total of 132,424 unique Medicaid enrollees (representing 255,192 person-years) met inclusion criteria over the 5-year study. Controlling for demographic and regional factors, the predicted probability of CRC testing was significantly higher in 2014 (+ 1.4 percentage points, p < 0.001) compared to the 2010 baseline but not in 2012 or 2013. Increased fecal testing using Fecal Occult Blood Tests (FOBT) or Fecal Immunochemical Tests (FIT) played a prominent role in 2014. The uptick in statewide fecal testing appears driven primarily by a subset of CCOs.ConclusionsObserved CRC testing did not immediately increase following the transition to CCOs in 2012. However increased testing in 2014, may reflect a delay in implementation of interventions to increase CRC screening and/or a strong desire by newly insured Medicaid CCO members to receive preventive care.

Oregon's Coordinated Care Organization Experiment: Are Members' Experiences of Care Actually Changing?

In 2012, Oregon embarked on an ambitious plan to redesign financing and care delivery for Medicaid. Oregon's Coordinated Care Organizations (CCOs) are the first statewide effort to use accountable care principles to pay for Medicaid benefits. We surveyed 8,864 Medicaid-eligible participants approximately 1 year before and 12 months after CCO implementation to assess the impact of CCOs on member-reported outcomes. We compared changes in outcomes over time between Medicaid CCO members, Medicaid fee-for-service (FFS) members, and those who were uninsured. After 1 year, Medicaid beneficiaries enrolled in CCOs reported better access to care, better quality care, and better connections to primary care than Medicaid FFS or uninsured persons. We did not find early evidence of improvements in preventive care and screenings or in ED utilization. Although these are early indicators, results suggest that Oregon's delivery system transformation is having a positive impact on patient experience outcomes.

A statewide effort to reduce high-dose opioid prescribing through coordinated care organizations

BackgroundOregon's Medicaid program is delivered through 16 Coordinated Care Organizations (CCOs) participating in a statewide performance improvement program to reduce high-dose opioid prescribing. CCOs were allowed flexibility to develop their own dose targets and any policies, trainings, guidelines, and/or materials to meet these targets. In this study, we characterize CCO strategies to reduce high-dose opioid prescribing across the 16 CCOs. MethodsWe reviewed relevant CCO documents and conducted semi-structured interviews with CCO administrators to acquire opioid-related policies, practices, timelines and contextual factors. We applied a systematic coding procedure to develop a comprehensive description of each CCO's strategy. We used administrative data from the state to summarize contextual utilization data for each CCO. ResultsMost CCOs selected a target daily morphine milligram equivalent (MME) dose of 90 mg. Sixteen issued quantity limits related to dose, eight restricted specific drug formulations (short-acting or long-acting), and 11 allowed for time-limited taper plan periods for patients over threshold. Many CCOs also employed provider trainings, feedback reports, and/or onsite technical assistance. Other innovations included incentive measures, electronic health record alerts, and toolkits with materials on local alternative therapy resources and strategies for patient communication. CCOs leveraging collaborations with regional partners appeared to mount a greater intensity of interventions than independently operating CCOs. ConclusionsCCOs developed a diversity of interventions to confront high-risk opioid prescribing within their organization. As healthcare systems mount interventions to reduce risky opioid prescribing, it is critical to carefully describe these activities and examine their impact on process and health outcomes.

Oregon's Emphasis On Equity Shows Signs Of Early Success For Black And American Indian Medicaid Enrollees.

In 2012 Oregon transformed its Medicaid program, providing coverage through sixteen coordinated care organizations (CCOs). The state identified the elimination of health disparities as a priority for the CCOs, implementing a multipronged approach that included strategic planning, community health workers, and Regional Health Equity Coalitions. We used claims-based measures of utilization, access, and quality to assess baseline disparities and test for changes over time. Prior to the CCO intervention there were significant white-black and white-American Indian/Alaska Native disparities in utilization measures and white-black disparities in quality measures. The CCOs' transformation and implementation of health equity policies was associated with reductions in disparities in primary care visits and white-black differences in access to care, but no change in emergency department use, with higher visit rates persisting among black and American Indian/Alaska Native enrollees, compared to whites. States that encourage payers and systems to prioritize health equity could reduce racial and ethnic disparities for some measures in their Medicaid populations.

Coordinated Care Organizations: Neonatal and Infant Outcomes in Oregon.

In 2012, Oregon's Medicaid program implemented a comprehensive accountable care model delivered through coordinated care organizations (CCOs). Because CCOs are expected to improve utilization of services and health outcomes, neonatal and infant outcomes may be important indicators of their impact. Estimating difference-in-differences models, we compared prepost CCO changes in outcomes (e.g., low birth weight, abnormal conditions, 5-minute Apgar score, congenital anomalies, and infant mortality) between Medicaid and non-Medicaid births among 99,924 infants born in Oregon during 2011 and 2013. We further examined differences in the impact of CCOs by ethnicity and rurality. Following CCO implementation the likelihood of low birth weight and abnormal conditions decreased by 0.95% and 1.08%, a reduction of 13.4% and 10.4% compared with the pre-CCO level for Medicaid enrollees, respectively. These reductions could be predictive of lifelong health benefits for infants and lower costs for acute care and are, therefore, important markers of success for the CCO model.