Should Addressing Low-Value Care be a Policy Priority?

Last week, the Oregon Health Authority and the Oregon Health Leadership Council released a study which seeks to identify ways to lower the cost of health care by eliminating “low-value” services – medical treatments, tests, and procedures that have been shown to provide little benefit in certain clinical scenarios.

In the battle to rein in ever-increasing costs of hospital services and pharmaceutical drugs, this study may be a small piece of the conversation in decreasing health care cost. It is by no means a silver bullet.

The study, Better Health for Oregonians: Opportunities to Reduce Low-Value Care, utilizes the Milliman Waste Calculator, a software tool that looks at 48 measures, treatments, and procedures to identify and quantify low-value health care services. The Oregon survey included commercial insurance, Medicare, and Medicaid. Of all three groups, Medicaid had the lowest occurrence of “low-value” services and spent the least on this type of care.
Background

Though our state leads most others in innovative and efficient Medicaid coverage, the conversation continues on how to reduce the cost while increasing the effectiveness of health care. Many pieces of legislation that have been introduced over the years, including capping pharmaceutical costs of specific drugs, importing less expensive drugs from other countries, and partnering with other states to increase our pharmaceutical purchasing power. None of these became law.

So in the 2019 regular session, the Oregon Legislature passed SB 889, which created a Health Care Cost Growth Benchmark program that controls the growth of health care expenditures in the state. This program is still in review by a governor-appointed committee to cap the cost growth of health care for commercial insurance and address other causes for the steady rise of health care costs.

We know that 50% of projected spending growth in our public health system is from increasing prices, meaning that the amount of money we spend on low-value care pales in comparison to what we could save if we had other cost-control checks in place.
Policy Concerns

There are also many factors that play into why decreasing the use of low-value care is complex and problematic. In November 2019, OHA Director Pat Allen gave a presentation about what the focus of the SB 889 cost-growth benchmark committee would be. An example of unnecessary services included a patient requesting an X-ray for a sprained ankle, even though their ankle was not broken. The assertion received bipartisan pushback as both Rep. Teresa Alonso Leon and Rep. Christine Drazan said women and people of color can be discriminated against in health care settings, which lead to negative health outcomes for those groups. Furthermore, if an OHP member does have a sprained ankle but wants an X-ray to be sure it is not broken, would it be medically ethical to refuse this service?
Preventive Care Decreases Cost

The Coalition for a Healthy Oregon (COHO) is dedicated to breaking down barriers like these by investing in the social determinants of health, like ensuring that Oregonians who do not speak English have access to certified interpreters, or hiring a graduation coach to ensure that children of color are graduating at the same rate as their white counterparts.

We’ve always known that preventative care, like an X-ray to ensure an ankle is not broken, a cancer screening, or educational attainment, saves us all money in the long run. With Medicaid having the fewest “low-value” services in this study, we hope the Health Care Cost Growth Benchmark committee utilizes this study as a small piece of the conversation instead of a catch-all response to solve the state’s rising health care costs.

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CCO Creation: Legislation (SB 1580)

In Oregon, about 23.8 percent of our population uses the Oregon Health Plan (OHP) for their health insurance. That means CCOs across the state are serving roughly 984,106 Oregonians by ensuring they have access to equitable, timely, and appropriate health services. This current organization that utilizes CCOs as a single point of contact for Medicaid health services is not always what OHP looked like.

In 2012, our state was at a breaking point. If we did not change the way we ran our Medicaid delivery service, we were looking at taking a 33 percent cut in reimbursement rates to providers. Because the Medicaid reimbursement rate is already much lower than other health insurance companies offer, this cut would have decimated the Oregon Health Plan. Health care providers across the state would have been unable to see Oregonians on OHP because the rate would not have covered the cost of the visit to the provider.

Not only were we looking down the barrel of a giant cut in reimbursement rates, the system that we had was not working for OHP members, either. Instead of OHP being a single over-arching health plan that included physical health, mental health, and dental health, it was broken into three different plans. These plans did not communicate among themselves, making it incredibly difficult for OHP members to understand how their Medicaid coverage worked, and how to effectively navigate the system.

Former Governor Kitzhaber, as well as several legislators, lobbyists, and other elected officials, stepped in to address not only the budgetary issue, but the concern that Oregonians were not receiving the care they needed due to systemic problems. To address the concern that Oregonians could not navigate the current Medicaid system, Governor Kitzhaber recommended the state create a single point of contact for physical, mental health, and dental services that works to organize not only OHP members, but providers as well. He thought that by coordinating the care that OHP members were receiving, we could increase our efficiency and decrease the cost.

Dr. Bruce Goldberg, the Director of the Oregon Health Authority at the time, was also at the forefront of the state’s push to re-organize our Medicaid system. Dr. Goldberg believed that we could make OHP easier to navigate, save the state dollars on health care, and push for incentives that create better health outcomes for Oregonians.

So, Governor Kitzhaber, Dr. Bruce Goldberg, Rep. Tina Kotek, Rep. Tim Freeman, and Sen. Alan Bates worked with lobbyists including Paul Phillips and Josh Balloch to create a new Medicaid program that would serve Oregonians, save our Medicaid program, push for better outcomes, and save the state money. Their ideas were groundbreaking and included concepts like utilizing a global budget for CCOs, creating incentive programs to increase positive health outcomes for Oregonians, and setting rate of growth allowances to lower than the national average.

Every piece of this legislation was important. Global budgets ensure that the CCO, instead of the state, takes on the risk of paying out reimbursements for members. Incentives for CCOs to increase positive health outcomes push CCOs to continue transforming health care in new and creative ways, like including social determinants of health spending on food security, housing security, etc. Finally, setting the CCO’s rate of growth allowance 2% below the national average could save $2 billion dollars over four years.

Not everyone was a fan of the new plan for Medicaid. Powerful status quo providers were not interested in changing the way OHP was structured, and there were several other competing pieces of legislation. On top of that, the House was evenly split between 30 Republicans and 30 Democrats and headed by two co-speakers, making the job of these public officials and lobbyists even harder. Fortunately, this legislation passed off the Senate floor with 18 votes, and off the House floor with 53 votes. This was only possible because of the hard work of the many advocating for this change, and the bi-partisan understanding that Oregonians need access to quality health care.

The final step was securing federal funds to jump start the program. Gov. Kitzhaber and Director Goldberg flew to the White House to meet with President Obama. They shared our state’s revolutionary ideas for Medicaid delivery, and requested $1.9 billion dollars in Federal funds to start the program. They shared with the President that they planned to cap the CCOs at 2% below the national average rate of growth in health care so that they could save the Federal government $2 billion dollars within four years, effectively paying back the state-up money. President Obama approved the funding request whole-heartedly, and the Oregon Health Plan was reborn.

The legislation that they dreamt up in 2012 is still in effect today, ensuring that Oregonians get the care they need, the state saves money, and that we continue to push for health transformation that stays true to the original member-centered, locally-controlled CCO model.
Thank you, Governor Kitzhaber, Dr. Goldberg, Rep. Kotek, Commissioner Freeman, the late Sen. Bates, COHO lobbyists and members who helped conceive and pass this legislation, and the countless others who were involved in fighting for the Medicaid delivery system we have today!

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COHO Member Delivers Summer Fun

We have known for quite some time that our schools play a stabilizing role in many families’ lives, providing access to resources along with an education. Many schools were helping to ensure children were eating on a regular basis at reduced or waived rates, connecting children and parents to social services and community supports, and providing some mental health supports. During COVID-19, the question is: how do we now get these supports to children during a global crisis?

On top of that, children being out of school during the COVID-19 pandemic to halt infection rates has caused parents across the state headaches. As well, for parents who do not have the ability to work remotely, this pandemic has created much different obstacles including lack of income, which may lead to food and housing insecurity.

AllCare Health has long been dedicated to ensuring that children have access to resources that they need so they can succeed in school. For example, AllCare noticed that the children of color in a specific school were graduating at far lower rates then their white counterparts. To rectify this, AllCare invested in a Graduation Coach for the school, who was able to increase graduation rates in children of color from about 21% to 96% in the span of five years.

Now, during COVID-19, AllCare is not only ensuring that children are getting fed despite their lack of access to school meals, but they also just invested $10,000 in the Chetco Community Public Library to provide Grab & Go Summer Activity Kits for children across their service area! In June, 950 Summer Activity Kits were handed out, which contained activities that encourage children to stay engaged in learning during the summer. These activities included: sidewalk chalk, crayons, pencils, notebooks, birdhouse kits, paints, flower seeds with soil disks, flowerpots, literacy games, new high-interest hardcover books in English and Spanish, and inserts in the bag from local health and social services in English and Spanish, letting kids and families know where they can turn in emotional or financial distress. These bags are even color-coded to show the differences between preschool, school-age, and teen youth activity kits.

AllCare understands that many parents who have been laid off are trying to navigate life without an access to income, all while caring for their children and trying to facilitate distance learning. By providing these kits, AllCare is providing children with fun, engaging activities for the summer, information on much-needed resources and how to access them, and a sense of support and community. AllCare Health also knows how important education is and hopes that this program can continue to support at-risk children in their journey to becoming an independent learner.

These Grab & Go Activity Kits were so popular with families in their service area, AllCare expanded the program to give out 500 Activity Kits each Wednesday in July. At this rate, by the end of the month, more than 2,500 children will have access to activities that keep them engaged and learning while parents are hard at work. And, every single one of those families will have information on the community supports they may need if they are in emotional or financial duress.

Wondering how AllCare Health can fund initiative like this, even though their technical job is ensuring Oregon Health Plan (OHP) members get their needs met? The truth is that all the COHO CCOs are incredibly dedicated to shifting our definition of health to include the food you eat, the air you breath, access to education, access to stable housing and food, access to transportation, and whether you face discrimination as factors that all significantly contribute to your health. Because AllCare and COHO are all seeking a shift in how we talk and think about health, we have strong, aligned policy priorities that help guide investments like these.

Our recent policy priorities have included ensuring that Oregonians on unemployment have access to healthcare during the crisis, increasing access to mental health services for children in schools, and our continued support of the expansion of telehealth. All these pieces are part of a strategic, member-centered plan to help the state through crises, and continue to improve our CCO model.

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