Oregon's Coordinated Care Organizations:Oregon's Coordinated Care Organizations:
First Year Expenditure and UtilizationFirst Year Expenditure and Utilization
Authors: Neal Wallace, PhD, Peter Geissert, MPH1, and K. John McConnell, Ph.D.2Authors: Neal Wallace, PhD, Peter Geissert, MPH1, and K. John McConnell, Ph.D.2
1. Portland State University 2. Oregon Health & Science University1. Portland State University 2. Oregon Health & Science University
As a part of its continuing health system transformationactivities, the state of Oregon has implemented CoordinatedCare Organizations (CCOs) to provide care for Oregon’sMedicaid beneficiaries. Like Accountable Care Organizations(ACOs), CCOs are community-based networks of providers,community members, and insurers who bear financial risk fora portion of the Medicaid population. Each CCO will receive aglobal budget and will be responsible for coordinatingphysical, behavioral and dental health care for its memberswhile being held accountable for maintaining or improvingpopulation health. Specific characteristics of Oregon’s CCOswill vary, since they are intended to evolve from individualcommunities who best know their own needs. CCOimplementation began in July 2012. There are currently 16CCOs covering all geographic regions of the state providingcare to over 90% of Oregon’s Medicaid enrollees.
Estimate changes in expenditures and utilization related toimplementation of Oregon’s Medicaid Coordinated CareOrganizations overall and by CCO type.
CCO effects were estimated as the difference-in-difference ofcontinuously enrolled adult OHP members and propensityscore matched commercially insured Oregonians. Subjectmatching was based on presence during the study period of adiagnosis for eight chronic conditions (asthma, COPD,diabetes, CHF, schizophrenia/bipolar disorder, dementia,hypertension, hyperlipidemia) along with age, gender andgeographic location. Study data were derived from the OregonAll Payers All Claims database (APAC), reflecting one yearpre- and post- CCO implementation (July 2011 - June 2012 &October 2012 -September 2013). CCO “Level” reflectscommunity advisory committee and CCO board engagement,as well as span of representation of CCO organizationalmembers, Level 1 reflects highest engagement andrepresentation. A two-part model with propensity scoreweighting and adjustments for temporal price changes wasemployed to generate estimates of the rate of change inprobability of use, cost per user and cost per subject in totaland for salient service categories.
Background
Research Objective
Study Design
Study Population
•Primary care expenses increased while specialty care decreased
•No other changes in $/person were statistically significant
•Pharmacy use down, $/user up, but no net effect on expenses
•Some reductions in overall probability of service use
•Level 1 &2 CCOs appear to have similar effects
•Level 3 CCOs appear to be targeting service use more
•Enhanced primary care services and reduced specialty careappear to be consistent with expectations of the programand with findings for concurrent implementation of PatientCentered Primary Care Homes (PCPCH)
•Other expected changes, such as reduced ED and IP, maybe emerging but are not yet evident through the first year
•CCOs with organizational features most aligned withprogram intent appeared to effect the most change overall
•Different strategic approaches may be occurring acrossCCO types
Principal Findings
Policy Implications
•CCOs appear to be effective in shifting patterns of treatmentat least in respect to use of ambulatory care
•CCOs with organizational features most aligned withprogram intent appear to be having the most impact onoverall expenses
•Individual CCO impacts may vary appreciably
Conclusions
Table 1: Study SampleCharacteristics
Table 2: Pre-Post CCO Utilization andExpenditure Change
A random sample of 4,241 continuously enrolled adult OHP members and 67,511 propensity scorematched commercially insured Oregonians. Sample reflects individuals sampled and surveyed inan additional branch of this research. CCO personnel and organizational members wereinterviewed to develop assessment of CCO organizational characteristics.
Results
Limitations
•Results reflect only adults and thus do not capture effectsfor children or true overall impact of CCOs
•Results reflect short- term (one year) impacts of CCOs only
•Commercially insured comparison group may differ onunobserved characteristics that could bias results
•Study may not have sufficient power to capture allindividual service level effects
•Level 3 CCO subjects underrepresented
Contact Information
Neal Wallace, Ph.D., Professor of Public Administration
Mark O. Hatfield School of Government, Portland State University
CCO
Control
(%)
(%)
N =4241
N =67511
Age
18-25
5.2
5.2
26-35
19
19
36-45
20.2
20.2
46-55
33.7
33.7
56-64
21.6
21.6
64+
< 1
< 1
Female
58.4
58.4
Asthma
11.7
11.7
Bipolar/Schizophrenia
7.2
7.2
Cerebrovascular disease
4.6
4.6
Congestive Heart Failure
1.8
1.8
COPD
11.7
11.7
Dementia
< 1
< 1
Diabetes
18.1
18.1
Chronic Kidney disease
1.3
1.3
$ per Person
All
Level 1
Level 2
Level 3
(% Rate of Change)
CCOs
CCOs
CCOs
CCOs
Service Category
N=4,241
N=1,603
N=1,895
N=565
Total
-0.043
-0.059
-0.055
0.058
Primary care services
0.073
*
0.112
*
0.083
*
-0.145
Specialty care services
-0.188
*
-0.22
*
-0.221
*
0.083
MH services
0.100
0.042
0.133
0.088
Pharmacy
0.029
0.074
0.017
-0.014
ED
-0.092
-0.197
-0.062
-0.089
Inpatient
-0.161
0.116
-0.203
-0.219
$ per User (% Rate of Change)
Total
-0.026
-0.032
-0.042
0.051
Primary care services
0.063
*
0.108
*
0.028
-0.031
Specialty care services
-0.043
-0.061
-0.077
0.198
MH services
0.046
0.113
-0.021
0.269
Pharmacy
0.099
*
0.164
0.079
0.018
ED
-0.029
-0.212
0.005
0.129
Inpatient
-0.232
-0.162
-0.002
-0.336
Rate of Change in Probability of Use
Total
-0.014
*
-0.022
*
-0.011
0.005
Primary care services
0.010
0.004
0.049
*
-0.104
*
Specialty care services
-0.131
*
-0.143
*
-0.13
*
-0.104
*
MH services
0.053
-0.07
0.15
-0.18
Pharmacy
-0.063
*
-0.08
*
-0.056
*
-0.029
ED
-0.064
0.012
-0.067
-0.213
*
Inpatient
0.071
0.274
-0.198
0.116
* = p<.05