Building Healthier Lives by Addressing Social Determinants

During the COVID-19 public health emergency, COHO CCOs have continued to invest in their communities to improve access to health care services. One such investment serving thousands of Oregon Health Plan (OHP) members is the Trillium Resource Exchange, or T-REX for short.

This investment, made by Trillium Community Health Plan helps connect OHP members to nearby resources they need, like local food banks, housing and utility resources, and more. It’s translated into over 100 languages to help ensure language is not a barrier to accessing care.

This investment is not only available for OHP members. Traditional health care workers, providers, and others who work regularly with OHP members can access this database in order to provide extra support.

T-REX is a user-friendly program that allows health care providers, care teams, and non-profit services providers to send and receive referrals and update the status of referrals easily and efficiently. T-REX also connects to electronic health records so providers are able to seamlessly manage their patients’ care.

Why are investments like these important to Oregon’s health care system?

Investments like these address Social Determinants of Health and Equity (SDoH-E). Other examples of SDoH-E investments include funding food banks, shelters, interpreters, and more. These evidence-based investments help decrease health inequities and keep OHP members healthier.

Our CCOs have shown evidence-based SDoH-E play a significant role in a person’s health, in turn reducing the cost of health care for Oregon. We know that when individuals have food and housing security, they are more likely to be healthy. This focus on preventive services results in fewer ER visits and other more expensive health services – saving the state money. For these reasons, CCOs spend millions of dollars each year investing in specific supports that their individual communities need. Programs like T-REX make sure this network of resources is readily available to our most vulnerable communities.

Nurturing Investment

If our goal is to ensure Oregonians remain healthy, we need to create stable funding streams for initiatives that fit each of their communities’ unique needs. We are doing a disservice to Oregonians working to rise out of generational poverty, trauma, and poor health if the programs they rely on only exist in sporadic timelines.

We are working to identify sustained funding streams for programs with proven long-term health outcomes. Investing in overall health is long game, and our CCOs are intent on keeping these programs in place.

About COHO

COHO is a coalition of six locally-based coordinated care organizations charged by the legislature to deliver care to Oregon Health Plan (OHP) members. COHO CCOs serve just over 184,000 OHP members or approximately 16% of the statewide membership.

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.

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.

Trillium Community Health Plan investments to address housing and food security concerns for OHP Members

Affordable housing advocates have been working with legislators for years to craft state policies to meaningfully address housing affordability and access to affordable housing. Without attempting to grade past performance in this area, it is safe to say there is still work to be done in this policy area.

In this fourth installment in our COHO Health Equity series, we spotlight COHO member Trillium Community Health Plan investments to address housing and food security concerns for Oregon Health Plan (OHP) Members that they serve. Trillium Community Health Plan serves the Lane County and Springfield areas, which holds Eugene, a city ranked in the list of Top 10 cities with the biggest housing crunch, but many rural communities Trillium serves are also experiencing the same problem.

Lack of housing availability tends to be thought of as the problem of large metropolitan cities, but the reality is that average rent costs exceed average/median income levels throughout the state, and the inequality is often most pronounced in Oregon rural communities. People also tend to think of COVID-19 in terms of its infection rate, hospital capacity, and availability of personal protective equipment, but it exacerbated many social determinants of health in significant ways.

Massive layoffs combined with the Employment Department’s failure to provide unemployment relief in a timely manner have resulted in loss of income for hundreds of thousands of Oregonians, both widening the disparity between income coming in and rent going out, and amplifying the prevalence of food insecurity for low income families and the working poor.

We know that the COVID-19 pandemic has had disproportionate impacts on African American communities, Asian and Pacific Islander communities, Native American communities, and Latino, Latina, and Latinx communities. These are communities that  already face increased barriers to basic tenets of livelihood and may not have access to some of the resources provided through this pandemic, like the Federal stimulus check of $1,200.

Trillium has long been dedicated to breaking down barriers that cause health inequities by focusing programmatic investments on the social determinants of health, like housing and food security. Because of their experience with addressing social determinants of health, during the COVID-19 pandemic, Trillium was able to quickly identify areas of need in their community and take action to address those needs.

Food Security: 

In response to food security needs, Trillium donated nearly $2,000 worth of Walmart gift cards to a nonprofit organization called Centro Latino that offers a variety of services to families ranging from crisis intervention to job search assistance, and include connecting members with rent assistance. David Saez, Executive Director of Centro Latino said, “Thanks to this donation, we will be able to help children and families who are struggling to get their basic needs met during this difficult time.” 10 other organizations that work with unhoused youth and many others also received a large donation of Wal-Mart gift cards to ensure Oregonians have access to basic necessities.

What about those that do not have access to a Walmart? Trillium recognized that many of their more remote OHP members living in rural areas may not be able to utilize these gift cards. Instead, they distributed about $5,000 worth of Amazon gift cards between six rural, community-based organizations in Oakridge, Cottage Grove, Florence, Reedsport, McKenzie Bridge, and Harrisburg that help to address the needs of those living in rural poverty. Now, Oregonians with access to these gift cards will have the ability to order cleaning supplies, safety gear like masks, and many other necessities while remaining safe in their homes.

Housing Concerns: 

To address housing concerns, Trillium donated $5,000 to Safe Place Family Justice Center, a nonprofit in Clackamas County, Oregon that focuses on providing housing and housing supports for women and families. Because instances of domestic violence are increasing across the nation during COVID-19, and many are in unsafe housing, Trillium also donated $5,000 each to The Relief Nursery & Womenspace, two organizations that aid people in domestic violence situations.

Trillium knows that health is not just seeing your doctor when you are feeling under the weather. The food you eat, the air you breathe, your access to stable housing and food, access to transportation, and whether or not you face discrimination (among many other things) are all factors that significantly contribute to health. By considering these different areas as health care issues, and investing in them, we can increase positive health outcomes for Oregonians and spend less money on health care.

COHO CCOs have strong, aligned policy priorities that seek to decrease barriers and discrimination in health care that help guide our programmatic investments. While our CCOs put policy priorities like breaking down language barriers and increasing housing security into place on the ground, our government affairs team is working hard to pass even more legislation to address health inequities. Our priorities, like promoting social determinant of health spending and instituting protection of those investments, increasing value-based payments to providers, fighting OHP provider reimbursement cuts, and many more, are all part of COHO’s plan to make Oregon’s public health care system a model that people across the nation will look to for guidance.

Join us in ensuring Oregonians have the access to the equitable health care that they deserve.

Thank you Trillium, for leading the way in dismantling health equity barriers in our state.

COHO Member Announces Significant Investment

We are incredibly excited to share the third feature of our health equity series! Last Month, Cascade Health Alliance announced a significant investment in Klamath & Lake Community Action Services (KLCAS), a nonprofit that assists individuals who have been financially impacted by the pandemic. KLCAS’ services to Oregonians include assistance with rental payments, utility payments, parenting supports, and more.

Cascade Health Alliance has long been dedicated to breaking down barriers that cause health inequities by focusing programmatic investments on the social determinants of health. These determinants, like stable housing, food security, access to transportation, connection to support systems and community, fit a new idea of what “health” is. This idea of health truly encompasses the full systemic view of a person’s life, and how other factors affect their health.

We know that across Oregon, hundreds of thousands of people have been laid off or furloughed without pay, and therefore have lost their health insurance. Additionally, they may have medical bills from contracting COVID-19, which leaves little to no room to continue to pay rent, buy groceries, and afford basic necessities. Even worse, our unemployment system is falling behind due to the staggering number of claims, leaving many without unemployment insurance for months. In a message from Director Pat Allen of the Oregon Health Authority, he shared that the COVID-19 pandemic has had disproportionate impacts on Black and African American communities, Asian and Pacific Islander communities, Native American communities, and Latino, Latina, and Latinx people in Oregon. When our communities are hurting, it is our job to ensure that they are cared for.

Because Cascade Health Alliance knows that health is more than just ensuring you see your doctor at regular intervals, they made the decision to invest $50,000 in KLCAS so they could continue to provide basic necessities to Oregonians who may not be able to afford them right now. The donation provided by Cascade Health Alliance was used as matching funds by KLCAS to secure an additional $198,738 for rent relief funding through COVID-19 CARES Act funding.

Tayo Akins, Cascade Health Alliance CEO, stated, “There is a tremendous need for organizations like Klamath & Lake Community Action Services right now. With more of our neighbors losing their jobs and uncertain about their futures, now is the time to step up and support agencies that extend a firm hand of relief. KLCAS had been one of them for a long time, and we appreciate their hard work to help those most in need.”

This dedication to dismantling health inequities before, during, and after COVID-19 does not just benefit Oregonians receiving rental assistance, utility assistance, childcare assistance, as well as stellar health care coverage. When we provide the support that Oregonians need to keep them safe and healthy, we save the state and all Oregonians money, because fewer people end up in the Emergency Department.

Have you been wondering how COHO CCOs are able to make quick decisions on dynamic investments in key areas across the State, while still focusing on the needs of their community? COHO CCOs all have strong, aligned, policy priorities that include their dedication to decreasing barriers and discrimination in health care. These policy priorities guide not only our government affairs teams in working with legislators and other public officials on passing legislation that protects Oregonians on the Oregon Health Plan (OHP), but also guides our CCOs in making programmatic investments. We look forward to continuing our health equity series, in which we share the stories of our CCOs working together across the state, to ensure that OHP members are getting the care that they need on the ground, and the advocates they need at the Legislature.

Thank you, Cascade Health Alliance, for continuing to lead the effort in building and maintaining healthy communities! To read Cascade Health Alliance’s press release on the topic, click here.

COHO Members Testify to Senate Health Care Committee

This Monday, two members of the Coalition for a Healthy Oregon testified to the Senate Health Care Committee on their provider support strategies during the COVID-19 pandemic. Dr. Jeanne Savage, Chief Medical Officer of Trillium Community Health Plan, and Will Brake, the Chief Operating Officer of AllCare Health represented our association to the Senate Health Care committee, sharing succinctly the many different innovative solutions our CCOs have dreamt up to help keep provider doors open through this crisis.

Dr. Savage testified on her perspective as a physician herself, sharing that her role as a provider helped her see the needs in the community, because she saw them in her own practice. She detailed some of the many investments Trillium has made in their community to ensure that providers were able to maintain staffing capacity and see OHP members. Will Brake followed Dr. Savage, detailing the interpreter services delivered by AllCare, and putting an incredible fine point on the fact that AllCare (like many CCOs) also pay providers a monthly rate instead of per-member reimbursement for services.

A few days before the committee hearing, Brian Neuubert, the Legislative Policy and Research Office (LPRO) Analyst for the Senate Health Care Committee reached out to request COHO’s help in finding members of our CCOs to testify on CCO provider supports.

COHO got to work brainstorming a representation that would share both an urban and rural perspective, so legislators could have a clear understanding of what is happening on the ground. Trillium Community Health Plan was excited to share the many ways they have been aiding providers, and identified Dr. Jeanne Savage, both the CMO and a provider that serves Trillium as the perfect person to deliver our message.

AllCare Health was equally excited to join in on the conversation, and helped us determine that Will Brake, the COO and member of the Metrics and Scoring Committee run by OHA, would be another amazing messenger.

Thank you for your willingness to participate, and your wonderful representation of both rural and urban CCOs.

To read more about investments made by Trillium Community Health, click here. To read more about investments made by AllCare Health, click here.

Trillium

AllCare

Deferred Elective Procedures Expected to Surge

At the outset of Oregon’s coronavirus outbreak, Gov. Kate Brown issued sweeping executive orders to help “flatten the curve” and preserve health system capacity. One of these orders was a ban on non-urgent medical procedures, which has since been lifted.

Gov. Brown and her medical experts have encouraged people to seek the health care they need. Nevertheless, the volume of activity has not returned to normal (this could be for a variety of reasons, such as folks worrying about contracting COVID-19 or spreading it to others). While necessary in the early weeks of the pandemic, the ongoing slowdown has meant a major decline in revenue for many providers. Most importantly, there are concerns that deferred care could lead to worsening of certain health conditions.

In the months ahead, health care professionals expect a surge in demand for preventive care, dental care, elective surgeries, and other services. This begs the question: what effect will this have on our Medicaid system?

Throughout the pandemic, CCOs have been helping providers, clinics, and other health care providers keep their doors open and maintain capacity by delivering financial support. However, CCOs’ global budgets do not necessarily take into consideration the multi-month global pandemic we are currently going through.

Many of the providers who serve Medicaid patients are reimbursed through sub-capitated payments (per member per month). These payment arrangements could help level off the peaks and valleys of utilization, as well a potential future surge in demand. Nevertheless, there is little reason to believe the decline in utilization during the second quarter will lead to any real “savings” by the CCOs. This is especially true when considering the potential spike in activity and the progression of certain conditions due to the interruption in care.

In order to responsibly plan for the medical surge that may lie ahead, CCOs are focused on coordinating care for members and keeping their partners, the provider community, in business. It remains to be seen how the system will be impacted in the long run, but CCOs are well positioned to handle these irregularities while providing excellent health care to Oregon Health Plan members.

CCO Highlight: Yamhill CCO

All our member CCOs are doing a fantastic job ensuring that their members get the care that they need during this crisis, and this week we decided to highlight the work of a CCO that is not currently in our membership. Yamhill CCO is constantly innovating for the Oregonians living in their service area, and we wanted to share a heart-warming story of how our friend, Yamhill CCO, is aiding its community.

As the first waves of COVID-19 hit our state, Yamhill CCO was working to keep their members connected to the services they needed. As Yamhill’s team brainstormed, they realized that their Non-Emergent Medical Transport (NEMT) contracted service, which had taken a downturn, could be utilized to take members important places that are not traditionally covered under this service.

Yamhill gave their NEMT contractor the go-ahead to take their OHP members to health-related services: meaning that members could now utilize NEMT to travel to food pantries, grocery stores, the employment office, the bank.

Yamhill’s innovation will allow OHP members to safely travel from their home or shelter to essential services that they may otherwise not have had access to. These safe, clean, and free rides are incredibly helpful for vulnerable Oregonians as well, as members using the services will only have contact with only a single person during their ride, decreasing their risk of exposure.

This will also provide income to local Oregonians who make their earnings through the NEMT service that Yamhill has contracted with.

This initiative was set up as a Community Benefit Health-Related Services expense in less than two weeks from conception to fruition, and Yamhill CCO invested about $50,000 to jumpstart the program.

Yamhill does not intend to shut this program down when our State reopens, though. They’re hoping that with the kickstart to this program already completed, that they will be able to continue funding this service for their OHP members. As Yamhill gains insight into how COVID-19 has affected their budget and if this is a service that OHP members will need after the pandemic, they can begin making plans to continue this program as permanent.

Thank you, Yamhill CCO for your amazing investments in our communities, and your dedication to serving Oregonians. We look forward to working with you again in the future!

OHP Budget Cuts & How to Protect Our Federal Match

Prior to the Revenue Forecast, which was released to the public this past Wednesday, Oregon Legislators and Governor Brown were staring down a budget shortfall of unknown proportions. In preparation for the Revenue Forecast, and to shore up potential budget holes before the end of the year, Governor Brown asked every agency to put together recommendations for large cuts across the board.

Now that the budget forecast has been released, we know that there is an estimated $2.698 billion shortfall for the 2019-2021 biennium, as shortfalls in the next two biennia that total $4.384 billion and $3.381 billion, respectively.

However, the Revenue Forecast was not all bad news. We know agencies have a positive ending fund balance that when added together totals about $1 billion. We also have about $1.586 billion held in the State’s “Rainy Day Fund.”

Even with the ending balance budget, and the large reserves that Oregon carries, we may still be short on shoring up the budget, meaning that agencies will most likely have to make cuts. Last week, the Oregon Health Authority (OHA) told Coordinated Care Organizations (CCOs) that in their worst case scenario, there could be up to a 2.38% cut to the Oregon Health Plan (OHP) funding.

While 2.38% certainly does not feel like a big number, it gets much larger when you begin considering the high federal match that Medicaid dollars bring in from the federal government. If we include the match dollars in that percentage, the cuts for OHP will look more like 6%. Last year, CCO budgets totaled $6 billion dollars. If this 2.38% cut is instituted, the Oregon Health Plan will lose $142.8 million dollars, and Oregonians will lose $360 million dollars in vital health and health related services.

While we recognize the difficult position our State Legislature and Governor are in with deciding how to balance the budget, we believe that continuing to preserve the federal match dollars we receive through our Medicaid program will enable our state to recover economically, while still allowing Oregonians access to vital programs.

At a time when we expect a surge of new enrollment due to job losses, the best way to support the health care safety net is by fully funding Oregon’s Medicaid program, the Oregon Health Plan.

CCO Highlight: Advanced Health

All our member CCOs are doing a wonderful job of ensuring that Oregon Health Plan (OHP) members are getting all their needs met during COVID-19, and this week, we decided to highlight an exciting new initiative by Advanced Health.

Out in Coos and Curry Counties, Advanced Health CCO is looking to increase access to telemedicine by creating what they call the “Telehealth Access Fund.” This fund is specifically geared toward providing funds to health care providers so they have the financial bandwidth to improve or install technology that allows them to visit patients virtually.

Essentially, any health care provider in Coos or Curry County can apply for dollars through Advanced Health CCO, sharing information on how much financial support they need, what they intend on purchasing, and a few other details. Then, Advanced Health runs these applications through its board and Clinical Advisory Panel (CAP). Once applications are approved, these dollars go straight to the provider to invest in telehealth.

While Advanced Health is accepting applications from all network providers across their service area, they are working to ensure that small, independent health care practitioners, especially those in behavioral health and substance use treatment, know about this program and have the information they need to apply for it.

Advanced Health has been interested in launching a program like this for quite some time. Because the service area they work in is incredibly rural, Oregonians often must drive long distances to get to an appointment. Increasing providers that utilize telehealth will be positive during COVID-19, so no one risks exposure, but the effects of this fund are much more long-lasting than that.

During the pandemic, health care providers utilizing telehealth can use a wider range of platforms than usual, including Zoom, FaceTime, Skype, etc. However, once COVID-19 is a thing of the past, providers will need to return to HIPPAA-compliant technology to deliver telehealth. By providing these dollars to local providers, Advanced Health is ensuring that those providers will be able to offer telehealth to everyone in their area, even after the COVID-19 pandemic has ended.

Advanced Health is not stopping there with their efforts to increase access to telehealth during this pandemic. On a case-by-case basis, they are working to get much-needed technology to those who may not have access to a computer or smart phone, so that they can continue their regular health care.

Thank you, Advanced Health, for your dedication to ensuring your community has the resources they need during the pandemic. These investments will reap positive outcomes for years to come. Your innovation is impressive!