There's nothing like a budget crisis to bring about full-blown change. At least, that's the thinking behind the efforts underway to re-shape the way low-income Oregonians receive health care.
The proposed overhaul is sweeping and fundamental, and supporters like Governor John Kitzhaber tout it as a way to save millions in health care costs. But skeptics say the savings won’t come as fast as the governor claims.
I'm going to start this story about complicated health care policy with a bit of make believe -- one that’s based on a common real-life example.
Let's say I wake up one morning with a real humdinger of a sore throat. It feels like I've swallowed a steak knife. Let’s say I can't afford to go see a doctor so I hustle off to the emergency room for some relief.
Back home the next day, my phone rings.
Rachael Postman: "Hey Chris, this is Rachael, a nurse at OHSU Richmond Clinic. I just wanted to see how you were doing after your recent emergency room visit."
Much better, I tell her. But Nurse Rachael isn't just calling to ask how I feel. She has a message about what I should do next time.
Rachael Postman: "I wanted to make sure that you knew that our clinic's actually open Monday through Saturday. And we do try to have urgent appointments available every single day that we're open so we can try to accommodate things."
This isn’t a marketing gimmick. Clinic visits are much cheaper than a trip to the ER. And if enough people -- especially those using public assistance -- choose the clinic over the ER, health care costs go down for everyone in the long run.
Now, I didn't really go to the ER for a sore throat, but Rachael Postman really is a nurse at Richmond Clinic in Portland. Managers there say they've been able to hold the line on medical costs by using non-traditional, proactive methods.
Clinic director Nick Gideonse says there are lots of ways to think outside the box. Here’s an example.
Sometimes when people walk in complaining of a physical ailment, Gideonse says it's soon clear that the source of the problem is really something like depression or domestic violence.
Nick Gideonse: "Rather than giving them a card for a counselor or a psychiatrist or a domestic violence shelter and wishing them well and hoping that they can access services, we actually bring a social worker into the room right during that conversation."
Gideonse says his clinic has found going through this effort makes it less likely the problems will escalate.
Another way to cut costs: calling people with chronic medical conditions to make sure they're taking their pills. But Gideonse says the problem is that all of these creative cost-saving measures don’t come with a Medicaid billing code.
Nick Gideonse: "We would prefer a payment system that would reward us for meeting a patient's needs whether it was based on an office visit or not."
In fact the proposal under consideration in Salem would do just that. It calls for restructuring how the state of Oregon pays providers to take care of low-income patients.
Instead of the state paying doctors per procedure, community-based non-profits would receive a pool of money. The idea is that clinics would be freed up to focus on patients' overall health and not just wait until they get sick.
Governor John Kitzhaber is counting on the strategy to work almost immediately. He's proposing deep cuts to Medicaid providers in the upcoming budget with the hope that some of those cuts will be offset by what he’s calling the health care transformation.
Mike Bonetto is the governor's health policy advisor.
Mike Bonetto: "We have an unsustainable system and this is kind of a ripe opportunity for change."
Bonetto expects this change to happen so quickly it will produce savings next year. But not everyone thinks savings will materialize that fast.
Martin Taylor is a lobbyist for CareOregon, a group of Medicaid providers.
Martin Taylor: "It is possible to offset some cuts by improving the system. At the same time, you won't be able to offset all of those cuts and there will be harm done to people."
Democratic Representative Mitch Greenlick agrees with that assessment. Greenlick has been tapped to help lead a special joint House-Senate committee that's crafting the health care transformation bill.
Mitch Greenlick: "I think it will produce savings downstream, but I don't think it will produce savings enough to absorb the deficit we have in the health budget. So people are going to have to be prepared out of the communities to eat a lot of that deficit."
But backers of the effort say that's even more reason to take action quickly. Bruce Goldberg heads the Oregon Health Authority.
Bruce Goldberg: "The faster we move to the new structure, the more ability we have to get better value and avoid some additional cuts."
Legislative leaders have bought into the urgency, giving the special committee just a few weeks to finalize details on the bill. But Republicans have already signaled that they want the effort to be paired with a separate measure to overhaul the state's medical liability laws.
GOP representative Jim Thompson says that might be necessary for the bill to win approval in the evenly divided Oregon House.
Representative Jim Thompson: "There are a number of individuals that that's going to be a big deal. And if we don't do it now when we're seriously talking about cost containment, when are we going to do it?"
Even if state lawmakers sign off on it, there’s another hurdle. For any transformation to happen, Oregon needs a Medicaid waiver from the Obama administration.
Oregon House Bill 3650: