Our Health Plan

Community Governed Healthcare That Works

Jim Rickards

• Publisher: Morgan James Publishing
• Year: 2017
• ISBN:
  9781683503002
• Topic: Ciencias sociales
• Subtopic: Sociología rural

Just when you thought there was no cure for an ailing healthcare system, Our Health Plan will change your mind entirely. Chronicling the journey of a single community through the labyrinth of local healthcare in its efforts to effect change, proponents focus on the most economically disadvantaged and vulnerable-the Medicaid population, as well as reaching out to the commercially insured, creating a revolutionary Coordinated Care Organization, or CCO, in the process. Harnessing the power of its doctors, hospitals, dentists, psychologists, addiction counselors, paramedics, educators, and other integral healthcare forces, the medical community learns to work as a cohesive unit. Results include vastly improved care, reduced costs, favorable relationships and communication among providers, and patients with a decisive voice in a totally reimagined healthcare system.

CHAPTER 1:

HEALTHCARE:

THERE IS A BETTER WAY

The issues we face in Yamhill County, Oregon, plus or minus, are the issues that all communities across the country face every day. Healthcare spending is on the rise. Patients and healthcare providers alike are frustrated because they aren’t getting great results. Insurance companies are increasing their sway. There is a lack of communication within healthcare provider networks. And, thanks to Obamacare, there is a burgeoning caseload of newly insured patients. We all want and need a better system.

Oregon has decided to address these issues with a new care model for the most economically disadvantaged: the Medicaid population. The approach is the Coordinated Care Model and it is delivered through organizations called coordinated care organizations or CCOs. This is the story of how one community, Yamhill County, took healthcare into its own hands and started a CCO. Thus, Yamhill has been able to improve care, lower costs, develop relationships among providers, and give patients a true voice in their healthcare system.

Healthcare, much like politics, is local. What we’re doing in Yamhill County and in Oregon in general would require some adaptation if it were to be configured to the specific needs for other communities. At the same time, what we’re doing here could work just about anywhere. A man slips on the stairs, falls, and breaks his wrist. Regardless of where in the United States this happens, the key issue is the same: Do you only treat the wrist, or do you look at the big picture? Our approach allows us to look at the big picture. It allows us to consider why the man broke his wrist in the first place, instead of just treating it. Maybe he lived in a dilapidated house with the electricity cut off and it was cold and dark. Maybe he had PTSD or depression. Taking care of him is a lot more than just setting the wrist. It’s about recognizing and treating patients from a big-picture perspective. Since these problems exist everywhere, I believe this solution can exist everywhere.

Urban areas have unique challenges, given the larger number of people that are packed into a smaller geographic area. And yet, Oregon has urban CCOs that are doing similar work to what we’ve seen in Yamhill County. In larger cities like Chicago, one idea is that each ward could be its own CCO. It just depends on how one defined community and whether one can put the right people into leadership positions. Can it work anywhere? It can certainly improve things anywhere—that’s for sure.

If you’re concerned that the CCO concept might not work in your community because a meaningful percentage of your patients are of cultural or ethnic diversity, note that in Yamhill County, nearly 16 percent of our population is Hispanic. Hence, we consciously work to make our services bilingual and inclusive. Things don’t have to be a one-size-fits-all variety. That’s the good news.

So how does one begin? Go to the community providers—the doctors, the nurses, the social workers, the dentists, and so on. Tell them you want them to be involved in this process and take part in its leadership. They probably haven’t had that choice or opportunity in the past. Trust the community to self-organize. All you must do is give them the basic structure, and then they can decide how exactly the whole thing will work. Reach out to hospitals, government officials, Head Start folks, and so on. The greater the outreach at the beginning of the process, the more likely you’ll get buy-ins from the people you need on board.

Keep in mind that you cannot force doctors to do what’s best for them any more easily than you can force patients to comply with prescriptions and recommendations. The process is not about telling people they must be a part of it; it is about asking people to join with others in the community. In Yamhill, providers saw the value of the process and platform, came together, and got the job done.

Another challenge in many communities is that the hospital systems are the biggest organizations in town. Sometimes, they are even bigger than local government, because they are often the largest employer in an area; they have the biggest budgets, the most revenue, the highest expenses, and the greatest number of suppliers. They may not be politically involved in a traditional sense, like serving on a county board or helping to set legislative policies. Yet, in a model like a CCO, hospitals run the risk of being the eight-hundred-pound gorilla in the room.

In Yamhill, we have been fortunate to have two hospital systems that essentially balance one another. One is a large, independent hospital that is owned by an out-of-state medical corporation. The smaller is part of a larger regional system.

If you are mulling the creation of a CCO, I cannot stress strongly enough how important it is for the hospitals and other frontline providers to be involved. These are the folks who actually see the problems, deal with the patients, and take home the headaches and the heartaches at the end of the day. These are the hospitals, the individual family-practice doctors, and other primary-care providers. In some cases, a provider might be the doctor, perhaps a nurse in his office, and his daughter working the front desk. In a CCO, the doctor’s voice might carry more weight than, perhaps, the CEO of a multimillion-dollar hospital, because that doctor is out there seeing people and recognizing the issues. He’s also the one who must meet the challenges of implementing decisions and find a way to get paid at the end of the day.

Don’t be intimidated by the fact that large stakeholders may attempt to dissuade you from trying to start something like this. Do, however, involve them from the start, because their voices matter. Furthermore, and more importantly, in this model, patients—“members,” as we call them—have input through a unique part of the governance structure called the Community Advisory Council.

If you want to create your own CCO, first see if there is some existing structure within which you could work. This may be a risk based contract arrangement between an insurance company and an existing Independent Practice Association of physicians or a county run clinic system. As I’ve described throughout the book, we had a legislative mandate from the state of Oregon to create this kind of change. Thus, we had rules and requirements about what was needed to create a CCO. In our case, the legislation specified a board of directors that would include at least one physician in active practice, at least one representative from local county government, and at least one behavioral health provider, among others. That set of rules gave us a basic framework with which to start.

Perhaps there is an existing set of rules in your community, or a stakeholder who wants to find a new way to deliver care. Perhaps it’s an insurance company that wants to form an ACO or develop a new way to deliver care that is more coordinated in a community. If there’s a simple framework out there already, consider using it.

If there is no such framework, that’s fine too. You can still come together and use some of the elements that we have used, as they may be appropriate for your community. Just make sure that you are engaging a diverse group of stakeholders from across the community, including those who are actively involved in changing the “determinants of health.”

These determinants of health include housing, employment, behavior, and education. These are the areas of life and the sectors of society in which we live and that affect our health during the 99 percent of time we spend outside a hospital or clinic office. In other words, you want not just medical-care and behavioral healthcare folks, but also individuals who represent the socioeconomic interests in your community, such as the head of a local Head Start program or people involved in transportation, housing, or job skills training. Perhaps you can involve someone from the local Department of Public Health. The broader the representation of community stakeholders, the more likely it is that you are going to succeed.

I was a big proponent of including leaders from the various sectors of the community that addressed the so-called “social determinants of health.” As a result, I was given the nickname “Dr. Determinants” for my willingness to embrace those providing “health care” but not in the traditional sense of being a physician or hospital.

In our model, the board of directors acts as the voice of the payer, because these people make decisions regarding rates and what kinds of programs get funded. You need to make sure you have a balanced board of stakeholders. The board needs to be informed by the care-providers. We do this by having a Clinical Advisory Panel (CAP) composed of different providers from around the community. They help set clinical policies and develop transformation programs to deliver healthcare in new and different ways. We also have our Community Advisory Council (CAC), where the members (the patients) or their family members can give input. It is really a three-legged stool: the providers (CAP), the payers (the board), and the patients (CAC). When all three are represented, the whole system balances.

To get there, you build an organization the way you would any other. We started first by developing relationships, understanding who the various stakeholders were, and inviting them to the table. Next, we generated excitement, showing stakeholders that a model of paying for and delivering care in a different and better way was possible. We then formulated our mission, vision, and guiding principles. This was largely accomplished by the CAC and the community members the organization serves. We then focused on metrics: How will we be measured for the sorts of care we want to provide? How will we meet those metrics and stay within our budget while living within the spirit of our mission, vision, and guiding principles?

Once we had worked out the basics for these issues, we had to provide to the state of Oregon, in clear detail, the exact nature of our plan for transforming healthcare. We addressed eight elements in our formally titled “Transformation Plan.” Here are some of the key ones:

• Improving health information technology in our community

• Increasing the number of our members enrolled in patient-centered, primary-care homes or so-called “super clinics”

• Paying for value of healthcare delivery and not just volume

• How to address diversity: What were our plans for ensuring cultural competence, language training, and sensitivity to issues affecting different ethnicities?

It is an extremely valuable and necessary exercise to create a plan like this, because by doing so, you end up with a blueprint that everyone can accept.

We had to align our eight-point transformation plan with our metrics to make sure that our efforts would produce legitimate outcomes tracked by external parties and against which payments could be made.

Once you have these elements in place, you have the essential framework for a high-functioning, community-governed healthcare plan ready to bear risk for financial and clinical outcomes with a network of all kinds of providers ready to do the work.

It might seem absurd or unworkable at first, but this approach really puts the control of governing healthcare resources into the hands of people who live in the community and who appreciate those services—the individuals who are invested in seeing those outcomes. These are the folks getting paid for doing the work or receiving the care. To put it simply, this works and it makes a whole lot of sense.

This model presents an opportunity to move beyond what typically happens when an outside third-party payer—one that just wants to contract with doctors and pay for their services on a one-off basis—is simply repeating the same old song and dance. The providers are trying to negotiate for higher rates every year, and the payers are trying to increase rates on their members. The members, of course, are unsatisfied with the diminishing scope of the services they receive and the rising costs. In our model, we could provide an alternative to that unsatisfying and unrewarding situation. We now have a platform that works for Medicaid members. Yamhill could now potentially go and work with commercial payers and offer its whole network of services to commercially insured members so that they could take advantage of all the great services we offer, like our Persistent-Pain Program or teledermatology service.

Unfortunately, those with commercial insurance in Yamhill County do not have access to all these great services; at least, they don’t right now. They do reap the benefits of these services because of a so-called “halo effect.” That is, the different ways care is improved though increased screening, development of medical homes, and a focus on prevention apply to all members of a community. But the commercial payers may not necessarily pay for all the same services, such as access to telemedicine to which the CCO members have access.

A potential next step would be to go to commercial insurers and contract with them to bear the risk for the lives they must cover, so that we could offer them the services we have developed for Medicaid. Then we can also address the question that many providers face: What percentage of their panel of patients should be Medicaid patients?

Classically, Medicaid pays only about half of what commercial insurance pays, so many providers will limit their percentage of Medicaid patients to about 10 to 20 percent. As a provider myself, this is difficult to handle. One of the guiding principles of modern medicine is justice. Limiting care does not align with this principle, but, unfortunately, it is an economic reality.

With our model, if we can get support from commercial insurers, we can offer one single rate to the providers who contract with us and pay them the same for all the patients they see, including both Medicaid patients and commercially insured patients. We are then able to tell providers, we’ll pay you the same amount for either Medicaid patients or commercially insured patients. We will measure your performance with both groups by the same set of metrics. You can then be paid based on meeting those metrics, so that you can develop programs, hire staff, and implement different resources to help you meet those performance criteria. These are resources that can then be applied across your whole patient population; you would not be offering these services only to Medicaid patients.

The result is a community where everyone has access to the same level of care—which is, quite frankly, how things should be. Again, as a provider, this is what I want for my patients and what my patients want for themselves.

Does this sound like a healthcare utopia? Not exactly. We still have our challenges, and we are still inventing and reinventing ourselves on the fly. The good news is that with each passing year, both our CCO here in Yamhill County and the CCO network across the state of Oregon are getting stronger, more efficient, and more effective. We are delivering better and better results to the people who need it most.

It is my fervent wish that you see something in our model that you can apply to your community. I would love to hear how things work out for you in that regard. And if you have any desire to come visit us in Oregon and see how we do things, our doors are always open.

There is not a soul alive in the United States who is unaware that we face a tremendous problem in terms of delivering and paying for healthcare. We spend the most of any industrial nation on our healthcare; one out of every five dollars of our GDP goes toward medical care. Yet when it comes to results or quality, we rank thirtieth in the world—and despite everything we’ve done, the situation only seems to get worse.

The approach I’m going to share with you comes from the state of Oregon, where we are perhaps more famous for fly-fishing or wine or our beautiful coastline than for innovations in healthcare! But I’m hoping that this book will change all that and bring to a national audience an approach that is proving itself in amazing ways in this beautiful state.

I’m a radiologist, which means that I’m a physician who interprets medical-imaging studies. I grew up in Valparaiso, Indiana, a small town close to Lake Michigan; I trained in Chicago; and somehow ended up in a town in Oregon called McMinnville, in Yamhill County.

As a radiologist in a relatively small community, I started to see the same patients coming back repeatedly. I would see a chest x-ray of an individual who had congestive heart failure, and that person would be in the hospital twice a month with the same problem. I would sit there and do the best job I could of interpreting his exam. I would make all the correct findings and I would tell my colleagues—internal-medicine doctors—what was going on. They would admit the patient, and the patient would get some great treatment in the hospital, and he’d be discharged to his home. And then, he would wind up back in the hospital two weeks later.

I saw this not just with congestive heart failure, but also with so many other conditions. A lot medical folks call these patients “frequent flyers.” It was just so frustrating to see these “frequent flyers” but be unable to do anything for them that could keep their problems from recurring, or could help resolve their chronic-pain issues.

When I started to investigate this conundrum, I learned that medical care affects only about 20 percent of our overall health. The other 80 percent is a function of things doctors and medical researchers call “the determinants of health.” These incl...