Talk Health Reform

Health Care Reform: Now, Soon, or Sometime Down the Road?

Last June, the Oregon Legislature directed the Oregon Health Fund Board to develop a comprehensive health reform plan for the state. The Board is currently discussing immediate, pragmatic steps, coupled with a longer term “staged approach” to reform. Critical aspects of the draft plan include:

Stage I (2009-2010)

• Create a streamlined public agency that will optimize value for purchasers of health care by: setting benchmarks and standards; measuring, analyzing and reporting information and performance; promoting public health; and acting as a convener for state investments in local collaborations.
• Preserve and expand the Oregon Health Plan by increasing eligibility for all children up to 200% of the federal poverty level and allowing open enrollment to adults below the poverty level. (Financing strategy to be determined). 

Stage II (2010-2011)

• Develop recommendations for enhanced state purchasing policies for contracts for state programs, public employees and others.

• Convene a payment reform council to recommend other necessary changes.

• Provide a detailed business plan for a Health Insurance Exchange with state premium contributions based on income, an essential benefit package and provisions for financial sustainability.

Both stages are part of a broad vision for increasing health and the value of health care through methods that can be achieved in Oregon's current political environment. Then again, one of the maxims of health care reform is that the more desirable a plan for change is on substantive grounds—the less politically feasible it is.

What do you think of the draft plan? Does it outline steps that occur too quickly or too slowly? Should we be trying to do more all at once, or ease into changes? How can the plan be improved?

Talk. Speak. Act.

And now for something a little more entertaining than our usual chatter: recording artist/poet Mike E on the perils of being uninsured and the reasons you'll want to tell the Presidential candidates what you think should be done about health reform. 

Here at TalkHealthReform.org, we think you should tell your state and federal legislators, too.  To find your state legislator, click here. You can find your Congressional Representative and Senator by clicking on the highlighted links.

Make it Cheaper, Make it Better

Recommendations from the OHFB Delivery Systems Committee:

After six months of hard work, the Delivery Systems Committee presented delivery system reform recommendations to the Health Fund Board in May. The Delivery Systems Committee had the hard task of developing recommendations to create high-performing health delivery systems in Oregon that provide high quality, timely, efficient, effective, and safe health care.

The Delivery Systems Committee recommendations fall into eight main topic areas:

• Primary Care and Chronic Disease Management - Encourage the use of primary care by offering Oregonians so-called "integrated health homes" that can manage and coordinate their care;
• Improving Quality and Transparency – Improve the availability of information about health care quality and costs and report it in a clear and easily accessible manner;
• Payment Reform Models – Support the development of new payment models that encourage providers to be more accountable for the quality and costs of the care they provide;
• Comparative Effectiveness and Medical Technology Assessment – A public-private collaborative effort to ensure that treatment and coverage decisions are based on the best available research and data;
• Shared Decision Making – Identify opportunities for patients to be more involved in decisions made about their care;
• Public Health Prevention and Wellness – Develop more unified, community-driven efforts to improve population health through prevention;
• Administrative Simplification and Standardization – Identify ways to decrease health care spending through more streamlined administrative processes;
• Reduced Pharmaceutical Spending – Encourage bulk purchasing to decrease spending on prescription drugs.

Throughout its recommendations, the Committee attempted to identify ways to contain costs across the delivery system. A final version of the Committee recommendations will be available on the Health Fund Board website by the middle of the June.

How do you think system savings should be achieved in Oregon? What are the best ways to reduce costs without compromising quality or access? Should cost be a driving factor in reform?

The Oregon Medical Marijuana Program: Support of alternative medicine or contradiction of federal law?

The Oregon Medical Marijuana Act was adopted by voters in the November 3, 1998 general election (Ballot Measure 67). The Act was amended by House bill 3052, passed during the 1999 legislative session. The Act was again amended by Senate bill 1085, passed during the 2005 legislative session.

The Act intends:

(1) To allow Oregonians with debilitating medical conditions who may benefit from the medical use of marijuana to receive the benefit of their doctor's professional advice regarding the possible risks and benefits of medical marijuana;

(2) To allow Oregonians suffering from debilitating medical conditions to use small amounts of marijuana without fear of civil or criminal penalties when their doctors advise that such use may provide a medical benefit to them; and

(3) To make only those changes to existing Oregon laws that are necessary to protect patients and their doctors from criminal and civil penalties, and are not intended to change current civil and criminal laws governing the use of marijuana for non-medical purposes.

Supporters say marijuana is an important option for pain relief when other drugs do not work.  As of April 1, 2008, 16,635 Oregonians have been issued medical marijuana cards that protect them from criminal prosecution under state laws. This protection does not extend to federal laws; under which marijuana is classified as a schedule I controlled substance.

Some advocates of the medical marijuana program would like Oregon to enact dispensary laws similar to those adopted in California, but some Oregonians express concern that this will also lead to the abuses seen in California. Recently the CBS program "60 Minutes" documented the ease with which many without a medical need could pay doctors to write prescriptions. Also weighing in are those who would like to substitute a THC pharmaceutical product for the program (as reported in the Willamette Week).

What would work in Oregon, and to what extent should the state enact laws that conflict with federal law?

How Low Can You Go?

The state of Florida recently passed a health reform bill that would reduce the number of uninsured in the state by offering a "no frills" state health insurance product for as low as $150 a month.  Insurers participating in the program would be required to provide coverage for annual physician visits, inpatient hospital stays, mammograms, prostate screenings, immunizations, emergency department visits, and prescription drugs. Specialist care and long-term hospitalizations would not have to be covered. The product would also be exempt from the mandatory benefits of other health insurance products sold in Florida. 

Oregon has experimented with the idea of limiting benefits in its Medicaid program, yet faced opposition from the federal government. The state currently has a Prioritized List of Health Services developed by a public commission for the Oregon Health Plan. Florida's plan is not administered through Medicaid; it does not get federal funding and does not require federal approval. 

The Oregon Health Fund Board Benefits Committee is currently considering recommendations to the Board to create an "Essential Benefits Package" that instead of covering all health services would prioritize evidence-based medicine that keeps people heathy.  Health services identified as higher priority would be provided at little or no cost to the patient, while lower priority services would have higher co-payments or not be covered.

Is limiting services the answer for expanding health coverage?  How can the maximum number of people be covered without breaking the state's bank?

Guest Post: Reforming Primary Health Care

This post was written by the Oregon Primary Care Association, a non-profit membership organization founded in 1984. OPCA represents Community Health Centers (also called Federally Qualified Health Centers or FQHCs).  The OPCA believes that every person has a right to accessible quality comprehensive health care.

The following post represents the views of the OPCA.

There is growing consensus among patients, providers, and policy makers that the delivery of primary health care is not working well in this country.  Providers are frustrated with the inability to prepare and review patient information before a visit and the financial pressures that limit their visit with each patient to 15 minutes or less.  Patients are dissatisfied with the relationships they have with their providers, and a majority of patients with chronic conditions report that they do not comply with treatment protocols in part because half of them did not understand their doctor’s advice (Bodenheimer, 2006).  Policy makers and health care purchasers are frustrated by a system that provides financial disincentives to support primary health care, despite strong evidence that investment in primary care will enhance outcomes and minimize expenditures over time.   

As Oregon looks to reform its health care system to enhance access, improve quality and reduce costs, how can we create a more efficient and higher quality delivery system for primary health care?

The Oregon Health Fund Board has been learning about national and local models to reform primary health care called the primary care medical home.  These models, supported nationally and locally by many health care organizations, aim to reform the delivery of primary health care by creating a patient-centered experience.  Important components/principles shared by these models include:

• The primary care visit is a Patient-Centered Experience, allowing adequate time for the visit, a sustained relationship with a culturally competent provider team, and patient-driven goals.
• Team Based Care is provided that is proactive, planned, and maximizes services during each visit.  Evidence-based medicine guides decision making, and team members each practice at the top of their ability/license.
• Behavioral health is fully integrated into primary health care.
• Provider Accessibility is enhanced through more timely visits, electronic (phone, email) contact with provider teams, and removal of transportation and cultural barriers.
• Care is coordinated and/or integrated throughout the entire health care process.  Community services are also coordinated, as needed, for the patient. 
• The Primary Care Medical Home is nested in a community structure that collaboratively leverages and maximizes resources.
• Payment Reform that provides appropriate compensation and incentives for these components is essential.

It is important to note that the Oregon Health Fund Board is also considering reform for the broader system termed the Integrated Health Home.  This discussion is focused on primary health care reform specifically – one of the key components of overall system reform.

Questions: 

How can providers optimize communication with patients?  What is the most effective way to manage care (where does the care manager “live”)?  What financial incentives are necessary to support such an enhanced model of primary health care?  Is a primary care home necessary for everyone, or just patients with the most complex health and social needs?  What does it mean to provide culturally competent primary health care?  How does reforming the primary care system impact reform for the broader health care system? 

Your Oregon, Your Health (Your Meetings)

Starting on Thursday, May 1, a series of community meetings will be held across the state to discuss health reform.  The meetings, sponsored by Oregon Health Forum, the Northwest Health Foundation and Oregon Health Decisions, are being held on behalf of the Oregon Health Fund Board. 

The meetings are open to everyone.  Your participation in small and large group conversations will help shape the future of health care in our state. You can come to the meetings without preparing formal testimony.  Everyone’s voice matters, and the organizers want to hear from:

• people with or without health care
• employers
• seniors
• people with disabilities
• anyone else interested in helping Oregon tackle access, cost and service issues

Meetings will be  held in Gresham, Newport, Astoria, Klamath Falls, Medford, Washington County, La Grande, Ontario, Coos bay, Eugene, Bend, Portland and Salem.  Click here for the times and dates of each meeting.   

Interpreters and child care are available upon request. Please contact Oregon Health Forum by email or phone, 503-226-7870 or 800-501-4220, to arrange these services.

Oregon Health Plan in the News

When the prioritized list that is used for the Oregon Health Plan was first unveiled, Oregon’s health care system made world news. Now, with the announcement that the state will be using a “health care lottery” to determine who gets covered when OHP reopens, Oregon is again on the national - and international - radar. And not all of the press is positive.

A segment called "Pick Sicks" that recently aired on Comedy Central's Colbert Report lampooned the OHP lottery. Even though his description of the situation is delivered in a humorous, "tongue-in-cheek" manner, the topic is a serious one. 

Understanding that there are limited funds in the current system and that the federal government does not allow sicker or higher risk people to be moved to the front of the line, is a lottery the best way to get eligible people covered?  What do you think about Oregon being the first state to try using a lottery for health care? 

Guest Post: CareOregon

This Guest Post is from CareOregon, a Medicaid managed care plan serving over 95,000 Oregon Health Plan members in 16 counties across the state.

The Oregon Health Plan (OHP), as initially envisioned in 1987, was supposed to provide access to care for all Oregonians with all segments of society sharing in the cost. However, twenty years after the development of OHP, we do not have enough state general funds allocated to either cover the intended OHP population or maximize our federal match. That means that for every dollar the state is not spending on OHP, we give up $1.57 from the federal government. Not fully funding the OHP “Standard” population means there are more uninsured Oregonians. When the uninsured get care, providers, payors and health care consumers pay for this care.

In order to get the federal dollars we are entitled to, we need to allocate additional state general fund dollars to OHP. But let’s not just keep putting money into a system without thinking about whether the system is designed to give us what we want for our population. The primary care system is a good place to start since it will improve patient care and reduce costs. Another way to improve our “bang for the buck” is to think about how we deliver and pay for care.

We know that coordination of care at a primary care level can result in better health for people and save significant money in the whole system. Paying for nurses to provide some of these services, rather than doctors, would save dollars in the system and improve outcomes. If health plans and insurers had more flexibility in how clinicians are paid, the delivery system could be transformed to provide the care people need for less cost. In addition, information that compared outcomes across programs would allow us to see if the money we are spending is well used.

Hopefully, the Health Fund Board and its committees will look for as many opportunities as possible to provide that flexibility and to maximize the state’s federal matching dollars. It’s a shame to leave that money on the table.

New Feature: Guest Posts

As part of its effort to engage interested people and groups in discussions about health reform topics, the editors of Talk Health Reform have asked groups engaged in reform to participate in the blog through guest posts.  Guests are asked to write about topics of interest to their organizations, which may be as narrowly or broadly focused as they would like. 

Tomorrow we'll debut this feature with our first guest post, from CareOregon.  CareOregon is a Medicaid managed care plan serving 95,649 Oregon Health Plan members in 16 counties across the state. 

Over the coming weeks and months we will feature guest posts by other organizations around the state. If you work with an organization engaged in health reform work in Oregon and would like to write a guest post, please email the Talk Health Reform editors.