Is Oregon's New Health Care System a Model for the Nation?

Known as the "Health System Transformation Bill," Oregon House Bill 3650 passed last year during the 2011 legislative session, creating a new health-care delivery system for Medicaid and Medicare patients. Recently passed Senate Bill 1580 is a continuation and further refinement of that system. Governor John Kitzhaber, MD, staying true to his word, supported complementary and alternative medical providers, inserting our nondiscrimination language within his Health System Transformation Bill, Senate Bill 1580. Here is that language, representing two years of diligence;

"SECTION 4. (1) A fully capitated health plan, physician care organization or coordinated care organization may not discriminate with respect to participation in the plan or organization or coverage against any health care provider who is acting within the scope of the provider's license or certification under applicable state law. This section does not require that a plan or organization contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or organization. This section does not prevent a plan or organization from establishing varying reimbursement rates based on quality or performance measures.

"(2) A plan or organization may establish an internal review process for a provider aggrieved under this section, including an alternative dispute resolution or peer review process. An aggrieved provider may appeal the determination of the internal review to the Oregon Health Authority.

"(3) The authority shall adopt by rule a process for resolving claims of discrimination under this section and, in making a determination of whether there has been discrimination, must consider the plan's or organization's: (a) Network adequacy; (b) Provider types and qualifications; (C) Provider disciplines; and (d) Provider reimbursement rates.

"(4) A prevailing party in an appeal under this section shall be awarded the costs of the appeal."

We strategically formed a coalition of non-MD health-care providers to network and lobby for nondiscrimination within our new health care system. Our coalition consists of chiropractic and naturopathic physicians, nurse practitioners, nurse anesthetists, optometrists, licensed acupuncturists, and licensed massage therapists. Our starting template was Section 2706 of the Patient Protection and Affordable Care Act, a section the American Chiropractic Association and its federal coalition of non-MD providers successfully hammered through Congress. What we accomplished in Oregon could never have been if it were not for the foundational, if not heroic work of the ACA.

Coordinated Care Organizations (CCOs), Oregon's version of Accountable Care Organizations (ACOs) found in the Patient Protection and Affordable Care Act (PPACA), are central to our new health-care delivery system. CCOs will be local health entities that deliver care to a defined population of covered individuals and will be accountable for health outcomes of the population they serve.

Via federal waivers, Oregon will move from a fee-for-service model to a global budget that grows at a fixed rate for mental, physical, and ultimately dental care for Medicaid and Medicare patients. The patient-centered medical home model is principal to the delivery of care within the CCO as an integrated team approach and will offer flexibility within the budget to deliver defined outcomes. CCOs will be governed by a partnership among health care providers, community members, and stakeholders in the health systems that take financial responsibility and risk.

In summary, Oregon's new health-care delivery system presents a unique opportunity for the chiropractic profession in regards to the treatment of Medicaid and Medicare patients; and if the model works, it will also be applied to state employees and school districts. We are moving away from fee for service to a global budget administered by the coming CCOs, which may not discriminate against chiropractic physicians' participation or reimbursement.

For example value-based services under Oregon's essential benefit package will require no out-of-pocket cost to the consumer and will likely include two diagnostic visits per year, well-person visits, and basic office diagnostics, all of which fall within our scope of practice here in Oregon. As a consequence, when providing services to the Medicaid and Medicare populations, chiropractors will be paid for their consultations, X-rays, physical examinations and basic bloodwork.

With the new plan underway, we remain hopeful and excited. What we have created will go a long way in achieving a level playing field for our chiropractic colleagues and may serve as a model for the entire nation when it comes to equality in health care.