In the past five years, the way health care is provided in Douglas County, especially to its lower-income residents, has dramatically changed. Privatization has been a key element in these changes. Another has been the passage of Obamacare.
Today, we have two stories, one that takes a look at the Umpqua Health Alliance, the coordinated care organization that now manages care for most Douglas County residents on the Oregon Health Plan, and another that looks at a movement to reform UHA and other organizations like it. On Tuesday and Wednesday, we’ll look at the dismantling of the Douglas County Mental Health Department and what has replaced it, and the privatization of the county’s Public Health Department.
Thirty percent of Douglas County residents are on the Oregon Health Plan, the state’s Medicaid insurance program for low-income people, according to Oregon’s Health System Transformation Quarterly Legislative Report, published in January.
Most of them — about 26,000 people — are enrolled in a Roseburg-based company called the Umpqua Health Alliance. That’s a pretty big chunk of a county whose overall population is about 110,000. So the way their care is managed has a big effect, not only on their quality of life, but on the county as a whole.
The Umpqua Health Alliance is a for-profit company, owned by another company, until recently known as Architrave. Architrave, or as it’s now known, Umpqua Health, has two owners — Mercy Medical Center and DCIPA, a local physicians’ organization.
At its simplest, the Umpqua Health Alliance is a company that manages care for local OHP patients, who it refers to as members. In 2015, for example, the company received $145 million in taxpayer dollars. The amount was based on the number of its members, and the company decided how best to spend the money.
Its directive from the state was to simultaneously improve care and lower costs. The key to that seemingly contradictory task is to increase preventative care, thus reducing the number of people who wind up in the hospital because their health problems weren’t addressed before they became emergencies.
It’s no small feat. UHA has so far been successful at reducing unnecessary hospital visits, according to Umpqua Health CEO Brent Eichman. Eichman said improving access to health care remains one of the company’s biggest challenges for the future. Another is the potential Obamacare repeal. Many of UHA’s members are eligible for OHP only because of the Medicaid expansion that was included in the act.
HOW WE GOT HERE:
Six or seven years ago, a group of health care reformers began meeting to discuss the future of care for Medicaid patients on the Oregon Health Plan. They wanted that care to be managed by local, community organizations. They wanted to see the traditional, separate silos of care like dental, physical and mental health care broken down so that different types of providers could work together to improve the overall health of their patients. And they wanted to emphasize preventative care — shelling out a bit more up front in order to save money down the line. All too often, lower-income patients weren’t getting the routine care they needed for diabetes, or asthma, or other chronic conditions, so their health declined until they wound up in the hospital with an emergency that could have been prevented. Those emergency visits were very expensive, many times the cost of the preventative care those patients could have received.
So Oregon came up with a novel plan. It would allow the formation of locally-run coordinated care organizations (CCOs). These companies would receive per capita payments for every Oregon Health Plan patient they enrolled, and would have the authority to decide how that money would be spent. The state would oversee their performance on measures like increased primary care visits and reduced hospitalizations and award bonus dollars for their successes.
Roseburg pediatrician Bob Dannenhoffer was one of the key architects of the CCO model. He said the system is unique to the state and he has yet to see a better model for providing care to Medicaid patients. The CCOs are locally run, they’re solvent and they’re providing good quality care, he said.
Dannenhoffer was the CEO of DCIPA at the time CCOs were first proposed. DCIPA formed one of the state’s first CCOs in 2012, and named it the Umpqua Health Alliance.
In 2013, DCIPA and Mercy Medical Center joined forces to create another company, called Architrave. In the deal, Architrave took ownership of many of DCIPA’s subsidiary companies, including the Umpqua Health Alliance. Dannenhoffer became the CEO of Architrave. He and the company he founded had a rather spectacular falling out in 2015, and Architrave fired him. In 2016, he sued the company, claiming he was fired as a whistleblower for reporting $10 million in fraudulent Medicare claims he alleged were made by doctors connected with Architrave. The claim was settled out of court.
After a couple of short-term hires, Architrave selected Eichman, DCIPA’s former chief financial officer, to head Architrave. This year, it rebranded itself as Umpqua Health. It’s a name that matches the Umpqua Health Alliance, and the company has also included the words “Umpqua Health” in the names of its other subsidiaries, like the two health care clinics it operates at Harvard Medical Park.
SUCCESSES AND CHALLENGES
If the goals of the CCO program are to improve patient care and spend less money doing it, there’s evidence they’re succeeding. The Oregon Health Authority is happy with the results so far, saying the CCOs have saved the state $1.4 billion so far while improving patient health.
Locally, Umpqua Health has decreased its per member cost of health care by 10 percent, Eichman said. Preventative care is the primary reason. Since 2013, well-care visits with primary care providers have increased by 50 percent. That’s a cost, but the savings comes on the other end.
Between 2013 and 2016, the number of annual unnecessary emergency room visits decreased by 30 percent.
“There’s a correlation between the uptick in well-care visits and reduced (Emergency Department) visits and hospitalizations, which means chronic disease management and regular checkups with (primary care providers) are keeping our members healthier and out of the hospital,” Eichman said.
Umpqua Health’s biggest challenge remains recruiting and retaining doctors and other health care providers, Eichman said, and the needs are particularly acute for primary and mental health care.
“We are always recruiting full throttle,” Eichman said.
Over the past year, it’s added 20 new mental health providers, bringing the total number in its network to 52. Two of those are psychiatrists and three are psychologists. Those numbers don’t include the providers at Adapt, which contracts with Umpqua Health to provide additional mental health services.
The company’s also building. Umpqua Health has opened two outpatient clinics at Harvard Medical Park. And it has acquired a piece of property at the corner of Newton Creek and Stephens streets in Roseburg where it plans to build a new 14,000-square-foot primary care and dental clinic, slated to open in late 2018.
Another focus has been improving care for children in crisis. In the past 18 months, UHA has given financial assistance to Douglas C.A.R.E.S. for its work assessing child abuse victims and to the New Day program, which helps opiate-addicted pregnant women get therapy.
OBAMACARE AND THE UHA
More than a third of UHA’s members only became eligible for the Oregon Health Plan after the Medicaid expansion was passed as part of Obamacare. So while House Republicans debated a possible replacement for Obamacare two weeks ago, called the American Health Care Act, Eichman and his staff were reviewing the ongoing changes to the bill on “an hourly if not a minute-by-minute basis.” While the ACHA was defeated after Republicans on the right refused to vote for it, calling it Obamacare Lite or Obamacare 2.0, conservatives have continued their push to repeal Obamacare.
If the Medicaid expansion is cut as a part of whatever package is ultimately approved, that will put UHA members at risk. It will also be a significant hit to the local economy. In 2015, Umpqua Health contributed about $38.3 million to that economy, according to an independent analysis by the consulting firm of ECONorthwest.
“Just at a structural level, if you take 10,000 or 12,000 individuals and take away their health insurance, what that results in is more charity care within our hospital system, and within our physician network, and it has a very destabilizing impact in terms of our local health care delivery system,” Eichman said.
“People put the brakes on hiring, people put the brakes on physician recruitment, and it really introduces a lot of uncertainty into our system,” he said. “My view is the Medicaid expansion, at least for Oregon, has been very, very successfully administered by the state.”
Oregon’s been successful, he said, because it chose to put those dollars in the hands of the CCOs. It was a social experiment, but one that’s showed good results so far, he said.
“In whole, there is mounting evidence that CCOs are delivering on the promise of health care transformation, but we are early in the experiment,” Eichman said.