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They said partnerships and creativity are going to be key. A panel of Salem lobbyists later that morning highlighted political uncertainties around the gubernatorial and legislative elections. The House Health Care Committee will be dominated by new faces, with seats possibly changing hands in its Senate counterpart.

We're one of the first states to go in to recession and the last to come out. He expects the rosy state budget outlook that prevailed in September to change soon. Courtni Dresser, vice president of government relations for the Oregon Medical Association, said workforce shortages will be the major issue of the session.

She said the state needs short and a long term strategies to retain employees and cultivate new ones. How do we get people excited about the healthcare industry?

Christine Goodwin of Roseburg, and Rep. Raquel Moore-Green of Salem, spoke about their interests as the next session nears. As we have talked about this meeting, it is very critical that we continue to allow access to services in our smaller rural communities everywhere. They already to me are like a huge freightliner that's just loaded with cargo, and they just can hardly move.

And we just keep adding to them. And I'm wondering at what point this just sinks. I mean, this is obviously a system that has to be evaluated. She said discussion in legislative leadership to do away with the House Behavioral Health Committee is misguided.

I believe that we have a system that everybody has acknowledged needs help and needs design; it needs leadership. During a lunch keynote, Oregon Health Authority Director Patrick Allen cited some of the agency's successes in recent years but framed the state's challenges starkly as well. Too many people in Oregon still lack health coverage. The cost of health care is rising faster than inflation.

The toxic impact of disinformation and polarization has led to threats against health care and public health workers. And underlying all these issues is the stark and unacceptable reality of health inequity.

In the afternoon, three Democratic legislative leaders one who is leaving the Legislature echoed others in saying health care workforce challenges and hospital capacity will be major issues at the Legislature this year. They reported on a number of initiatives under way, including the recent federal approval of Oregon Health Plan program changes and the Bridge Health Plan task force that's crafting a new coverage program for people who earn too much to qualify for OHP.

Guidelines also have a role in the provision of services that fall below the cut off point for funding where it has been recognised that more severely ill patients would benefit from earlier intervention rather than waiting for treatment of complications arising from the original diagnosis. Such services include treatment of uncomplicated hernias in adults, treatment of severe rhinitis, tonsillectomies, and adenoidectomies.

The adoption of guidelines for these services demonstrates the difficulty of ruling out whole categories of care or treatment from funding. The experience in Oregon suggests that strict adherence to a defined set of core services is likely to be problematic. This observation is reinforced by the fact that doctors in managed care plans have the freedom to decide whether treatments not listed in the basic package should be provided.

For the bulk of patients covered by Medicaid, this means that the list of funded services acts mainly as a cost containment instrument. Managed care plans carry the risk and expense of providing services that fall below the cut off for funding when doctors nevertheless determine that such treatments are needed; the plans are responsible for making their own arrangements for monitoring whether this happens.

The changes to the basic package and the adoption of guidelines have increased the scope of the services that are funded. In part, this has resulted from developments in healthcare technology and the availability of evidence which challenges earlier decisions to exclude treatments. It has also been driven by the experience of implementing the original list of services and the need to make adjustments based on advice received from clinicians.

This advice has been instrumental in developing guidelines that give doctors greater discretion in offering services that initially fell below the funding threshold. Taken together, these factors mean that in Oregon explicit priority setting has expanded the range of services provided. The addition of treatments to the list has created problems for the funding of Medicaid, especially since the number of people enrolled has increased, in line with the intentions of the politicians in Oregon.

In , during the early phase of implementation, the helpline set up to provide residents with information on the plan received calls each day; only calls each week had been expected. The backlog of need that was revealed in areas such as dental care, reminiscent of what happened when the NHS was set up in , made accurate budgeting difficult. This option was not implemented, but other changes were.

Changes in the economy and the labour market, which have taken people out of poverty, have reduced the number of people dependent on Medicaid. On one level, this reflects the strong performance of the Oregon economy and the additional jobs that have been created. At another, it has resulted from action by the state government to move people out of welfare and into work. Paradoxically, these developments have in turn created problems; those above the poverty level and in work do not always have private health insurance.

These groups have challenged claims made by the state government about the extent to which the proportion of the population without insurance has fallen, arguing that official figures do not reflect the true numbers. An unintended and unanticipated effect of the implementation of the plan has been to bring into question the funding of safety net providers who deliver services to patients with special needs such as people with HIV or AIDS and migrant workers who do not speak English.

These services were fully funded in the past and enabled providers to deliver appropriate care. The capitation payments available under the plan are less generous, and this has made it difficult to sustain these services at their previous level. Providers of safety net services in Oregon have responded by forming their own managed care plan, CareOregon, which is lobbying for capitation payments to be adjusted for risk to allow for the higher cost of treating those clients who need these services.

Beyond its effects on those covered by Medicaid, the plan has had a number of other effects. Progress has been made in enabling patients in high risk groups and those who are employed in small businesses to obtain insurance coverage, thereby reducing the number of people who are uninsured.

However, the employer mandate lapsed in when a waiver of federal laws could not be obtained. The failure to proceed with the mandate means that people who are working and yet are still uninsured continue to pose a challenge to those seeking to ensure universal coverage. More positively, the revenue from a new tobacco tax 30 cents 18 pence on a packet of cigarettes has been earmarked for the maintenance and expansion of the plan. Other options for expanding coverage will be considered during by the Oregon health council, a group of citizens appointed by Governor John Kitzhaber to advise on reforms.

The deliberations of the council will be informed by the results of a new programme of community consultations on fairness and financing in health care that are being undertaken by Oregon Health Decisions, a non-profit making organisation which organised the community meetings in and which helped to clarify the values the public believed should guide priority setting for the basic package.

As in federal policy, the aim is to gradually extend health coverage in recognition of the difficulty of achieving more fundamental change. One other aspect of the implementation process merits comment.

An explicit objective of the plan was to reimburse health insurers at a level sufficient to make it attractive for them to treat clients with Medicaid. This objective appears to have been met with the exception of safety net services.

They also argue that shortages of doctors, dentists, and other staff in some parts of the state have frustrated the attempt to translate health insurance coverage into the effective delivery of service. From this perspective, the main weakness of the plan is not healthcare rationing, since most services are now funded in the basic package, but managed care.

These developments in Oregon mirror those occurring across the United States as the drive towards managed care gathers pace. The emphasis on delivering Medicaid through a system of managed care has led to changes in the organisation of state government.

The Office of Medical Assistance Programmes, the agency charged with putting the basic package into operation, has had to shift its role from paying for Medicaid services to actively purchasing them. This new role includes monitoring the performance of the 15 health plans with which it has contracts and ensuring that they are meeting the needs of Medicaid patients. The office does this by carrying out client satisfaction surveys.

It is also arranging to assess standards of clinical care by commissioning an external agency to sample and review the medical records of patients with conditions such as diabetes to ensure that they are receiving appropriate care.

The office also aims to develop a scorecard for monitoring performance in order to address some of the criticisms that have been levelled at managed care.

Just as in the United Kingdom, establishing strong purchasing bodies that are able to negotiate on equal terms with providers has not been easy. As a consequence, the needs of clients are still not well articulated.

Although this problem has been recognised, it will take time until it has been rectified to the satisfaction of those lobbying on behalf of citizens. Judged on its own terms, the Oregon health plan has achieved success in some areas but has failed in others. While some of the improvement is a result of a reduction in unemployment, the contribution of the plan, including the protection offered to people in high risk groups and people employed in small businesses, is estimated to have been responsible for around two thirds of the increase in insurance coverage D Coffman, personal communication.

Not only that, but the basic package has been expanded and encompasses a great deal more than a narrow set of services. The work that has been done on clinical guidelines has begun to define more precisely the way treatments on the list should be provided and has blurred the distinction between services that are or are not funded. The difficulties encountered by safety net services also show that the part of the population covered by Medicaid may have been put at a disadvantage by the implementation of the plan even though others may have benefited.

The failure to implement the employer mandate means that many people who work and whose incomes are above the federal poverty level still lack coverage in the event of illness. Furthermore, defining a list of services to be funded has to go together with work on clinical guidelines to ensure that treatments both above and below the threshold for funding are provided in a way that is consistent with evidence on the effective and appropriate provision of care. Because of the rapid changes in the availability of healthcare technologies and in the evidence of their effectiveness, priority lists must be continuously reviewed.

In the process, those who are charged with making decisions are dependent on the advice of experts but they must also take account of the views and values of the community. Additionally, clinical discretion remains important in the implementation of the basic package, at least in managed care plans where doctors are able to decide whether treatments beyond those included in the package should be provided in practice.

Whether the outcome looks like a glass half full or a glass half empty depends on your perspective. The award to the state of the prestigious Innovations in American Government prize by the Ford Foundation brought national recognition to Oregon and testifies to the progress made by the state.

It also indicates that in a country where government sponsored change in health care is notoriously difficult to achieve, Oregon has done better than most in terms of increasing access among the most vulnerable residents. However, the extent of unfinished business is daunting and illuminates the obstacles that have to be overcome even when the political commitment to change is strong.

For the future, much hinges on the strength of the economy. The Oregon health plan has been implemented in favourable economic circumstances; a downturn in the economic cycle would probably increase the number of families in poverty and at the same time put pressure on tax revenues. At that point, the balance that has been struck between the comprehensiveness of the basic package and eligibility for Medicaid would have to be reviewed. In a context in which the Health Care Financing Administration has been resistant to reductions in the list of funded services, there may be little choice but to further tighten eligibility criteria, especially if Oregon remains a fiscally conservative state.

I would like to thank all those who provided the information on which this article is based. Funding: This article is based on a research programme supported by the Gatsby Charitable Foundation.

Chris Ham , professor of health policy and management. Author information Article notes Copyright and License information Disclaimer. Accepted May Summary points The basic healthcare package available to those eligible for Medicaid coverage under the Oregon health plan has been expanded.

The delivery of services through managed care plans may put those who receive Medicaid at a disadvantage. The employer mandate to provide health insurance lapsed in and the problem of providing health insurance to people who are working and yet are still uninsured remains.

Explicit priority setting tends to result in inflation of the basic healthcare package. Defining a list of services to be covered must go together with the development of clinical guidelines. Genesis During its development, the Oregon health plan attracted a range of commentary.

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Amerigroup benefits fl This article is for premium subscribers. An unintended and unanticipated effect of the implementation of the plan has been to bring into question the funding heaalthcare safety net providers who deliver services to patients with special needs such as people with HIV or AIDS and migrant workers who do not speak English. Note : "Gross expenditures include employer and employee premium contributions. For instance, the American Recovery and Reinvestment Act of required most health providers to adopt electronic health recetn by In certain cases, these guidelines are meant to ensure that the cost of providing services is kept within the available budget. Follow Us In Real Time twitter facebook linkedin. In the afternoon, three Democratic legislative leaders one who is yealthcare the Legislature echoed others in thought carefirst dental plan maryland final health care workforce challenges and hospital capacity will be major issues at the Legislature this year.
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