Transformation in the State of Oregon: A Collaborative Plan to Weather the Storm

1. Transformation in the State of Oregon:A Collaborative Plan to Weather the Storm Erin Fair, MPH, JD CareOregon Sr. Manager of State & Federal Regulatory Policy

2. About • Medicaid & Medicare Managed Care Org. • More than 155,000 OHP and Medicare Advantage members • Most MA members are enrolled in SNP • 76% of members live in the Portland metro area • 54% of members are female • 59% are 19 & younger; 19% are 4 & younger • 26% do not speak English as their first language • 46% self identify as non-Caucasian

3. Key Data – Portland Metro Area • Total Population – 1.6 Million • Medicaid + Dually Eligible – 216,400 • Uninsured ~232,000 • Annual Portland Medicaid Budget ~ $1.2 Billion (state & federal funding combined) • 11% cut to OHP budget in 2011 • Another 19% cut has been proposed in 2012 • High Medicare Advantage penetration, overall 28% of Portland pop.

4. Portland Context • Resource withdrawal • 11% payment reduction in late 2011 • Anticipate another 19% cut in mid-2012 • In Portland that is -$230M annually, permanently • ~$115M the Inpatient and Outpatient Services; ~$115M from MD, Ancillary, Mental Health, etc. • Portland/Oregon is traditionally an efficient market • Major ‘low hanging fruit’ is picked • New innovations and tight integration & coordination necessary • Systems must be embedded in our Communities • ‘Creative Disruption and Innovation’ are core actions • No longer ‘Every Person for Themselves’ • Re-envisioning community health resources as Health Commons with local rules, governance and disciplines with equitable distribution among and for all stakeholders

5. Oregon Poverty Rate 8.9% in 2000 12.2% in 2010 NYT, November 17, 2011

6. 2012 State Budget Reduction Estimates 1. YEARLY REDUCTION = • $1,064 • per member • per year • reduction 216,000 Tri-County Enrollees -$230M Portland 2. MONTHLY REDUCTION • $89 average • reductions • per member • per month • required • $1,064 • per member • per year • reduction = 12 months

7. Challenge + Urgency = Opportunity Challenge • State Budget • Siloed System • History of Competition Urgency • State Budget • Shrinking Reserves • Economic “Reset” • CMMI Grant • Medicaid Expansion • Opportunity • CMMI Grant • Shared sense of urgency is compelling unusual behavior

8. Redefining our Larger Family of Responsibilities & Relationships We’re searching for a new way to relate to a whole community’s need together – one that serves the needs of our very poor & uninsured; has hope to evolve into a healthier tomorrow; while not becoming overwhelmed or deteriorating our key organizations in the process; and actually, emotionally and morally renews our foundational American Dream of justice and opportunity for All.

9. Guiding Principles “If you want to go fast, go alone; if you want to go far, go together.” -African Proverb Transformation that is Bottom-up, Top-Enabled Invest FORWARD

10. Healthy Community Triple Aim: Key Portfolio of Changes for Impact & Success Population Health POPULATION SEGMENTS (By Outcome Drivers) STRATEGIC INITIATIVES Quicker ROI Care Cost High • Hi Needs Customized Care: • ED / Hosp. Hi-Utilizer Care Teams • Complex Case Mgmt • ED Diversion / Navigation • Rx Opioid Abuse Reduction • Supportive Service Assessment Hot Spots Hi Medical Hi MH / AD Hi Social Burning Smoldering • Delivery System Redesign: • Primary Care Home • Behav / Oral / Med Integration • Care Transitions • Aligned Specialty / E-referral • Healthy Birth Midwifery • LEAN Hospital • Community Standards Mod - Hi Medical Mod - Hi MH / AD Lower Social Health Care System • Resource Integration: • Service partnerships • Community Schools • Asset Support • Public health alignment Lo Medical Lo MH / AD Hi Social Community Health System Care Cost Low Slower ROI Quality Life Experience Social Resource Use

11. Immediate Strategic Co-Initiatives

12. Medium Term Strategic Co-Initiatives

13. Longer Term Strategic Co-Initiatives • Healthy Birth / Midwifery Program • Housing Services Assessment / Strategy • Public Health Alignment • Social Service Alignment • LEAN Institute

14. Strategies for Innovation:SampleInvesting Forward Portfolio • Primary Care Renewal (PC3) • Releasing Time to Care Focused Lean Improvements • Child and Adult Discharge Engagements • Mental Health and Clinical Integration • ED Navigation • Community Care Teams Resource Use Improvements Changing Site of Care • Specialty E-Referral • Local Telemedicine • Commons Health Record • Public Health Invigoration Technology Infrastructures • SUN as Community Center Environment Attitudes Behaviors ProcessesValue Chains Structures New Formations Methods of Change

15. CMMI Health Innovation Challenge Grant – The Spark • $1M - $30M • 3-year cooperative agreement • Focuses on high cost/high risk groups • Significant workforce development/deployment • Rapid deployment (“shovel ready”) • LOI – 12/19 • Application Deadline – 1/27/12

16. Accelerated Timeline for Building Collaborations • CCO Governance • Design • Legal Structure • Finance & Operations CCO Community Workgroups Macro M e d i c a i d E x p a n s i o n New Partnerships? Oregon Health Leadership Council ROW Demon-strated Outcomes ROW Demon-strated Outcomes Mezzo Speed-dating & Collaboration Collaborative Oversight, Shared Learning, CCO? Hotspotting CMMI Grant Proposal ER Diver-sion Pain Mgmt Micro PCPCH Mid-wifery In-patient Admits C-Section 7/1 1/1 11/6 Feb-March 7/1 8/1 11/1 1/1 7/1 1/1 2/1 2011 2012 2013 2014 Timeline ‘13-’15 Budget Begins 2012 DMAP Contract Year 2 of ‘11-’13 Biennium ‘13-’15 Budget Begins Election Day CCO Global Budget Begins? Full oral & mental health integration 2012 Legislative Session 2013 Legislative Session

17. Evaluation & Measurement Funding/ Financing Health IT Partnership/Alliance/ Collaborative Shared Learning & Change Mgmt. Pharmacy Acute Care Inpatient & ED Outpatient/ Behavioral Health/ High Risk Pop. CMMI Grant – Draft Workgroup & Oversight Structure

18. TriCounty Health Collaborative Draft Risk/Delivery/Governance Structure System Transparent Feedback & Learning Metrics Whole System Outcomes Community Community/Member Advisory Board(s) Provider Network 1 Provider Network 2 Provider Network 3 Provider Network 4 Secondary Risk: Clinical, Value, Performance- Based Risk Mental Health Mental Health Mental Health Council: Clinical Integrated Care Delivery Partners (Physical/Mental/Dental/Social Service/Addictions/Etc.) Delivery Technical and Learning Supports (Coordinated & Shared Services) Primary Risk: Insurance Risk Payer 1 Payer 2 Payer 3 Payer 4 Community Health Alliance Board of Directors Alliance: Joint Performance & Accountability, CCO? State Integrated Funding Draft Drawing for Discussion Only

19. Design Principles for Governing the Commons:Commons as metaphor for Collaborative • Individuals know the boundaries and limits • Of the resource (“Common Pool Resource”) • Of the community of users (“Appropriators”) • Rules are locally made and adapted to context • Decisions are made together • Active measurement and monitoring • Effective sanctions • Mechanisms for conflict resolution • Latitude from higher authorities to act locally • Nested Commons Source: Ostrom quote by Don Berwick in 2009 IHI Forum Plenary

20. HMA Revenue EnhancementEstimates

21. Triple Aim Policy Scorecard Population Health (PH) PH PH PH Examples: Instructions Give the policy a score 1-5 for each of the three Triple Aim goals in the table below; Plot the score on the Triangle Connect the dots (5 = Achieves best possible outcome; 1= does NOT achieve at all) Good Policy: achieves all three goals of the Triple Aim 5 EC EC EC 4 CC CC CC 3 Mediocre Policy: A policy that achieves only one or two goals of the Triple Aim 2 1 Bad Policy: one that does not achieve the goals Triple Aim 1 1 2 3 2 3 4 4 Experience of Care (EC) Cost Containment (CC) 5 5