By Amanda Waldroupe
A patient’s housing and sociological condition can have a direct effect on his or her health care, but a bill in Salem to incorporate those providers into the new health care reform failed to make the books.
As a result, the legislature has left unanswered a critical question in the state’s new health care structure: Will health providers serving Oregon Health Plan patients work with social-service providers to address a patient’s sociological and psychological barriers to health care.
Senate Bill 1522 would have required coordinated care organizations, which are currently developing to provide care to Oregon Health Plan patients by July, to incorporate and pay for addressing a patient’s sociological and psychological barriers to getting quality health care and becoming healthy.
Coordinated care organizations (CCOs) are the backbone of the reforms the Legislature has made to the Oregon Health Plan’s delivery system (see, “Just What the Legislature Ordered,” Street Roots, Oct. 14). CCOs are foreseen as locally driven organizations made up of patient teams — including doctors, nurses, behavioral health providers, community health workers, etc.
Those providers will coordinate and integrate the physical, mental and dental health care of Oregon Health Plan patients, who receive health care through Medicaid. The hope is that better coordinated care will keep people out of the emergency room, lower costs, and provide better healthcare.
But the Oregon Primary Care Association (OPCA), which represents the state’s safety net clinics, sponsored Senate Bill 1522 out of the concern that addressing those barriers would get lost in the shuffle of making sure that CCOs are able to adequately provide care by July.
“A great majority of patients that our clinics serve have behavioral and socio-economic barriers to health,” says Jennifer Pratt, the OPCA’s deputy director of policy. “It’s a critical issue.”
Behavioral, socio-economic and sociological barriers to health include homelessness, issues related to substance abuse, access to transportation, socio-economic status, rural isolation, race, ethnicity, and other factors that are often called the “social determinants” of health.
“They are part of a person’s health situation,” Pratt says. “They are intrinsic, not an add on.”
“This is where the rubber meets the road,” Doug Riggs, the OPCA’s lobbyist told the committee. “These are the most vulnerable patients.”
Pratt uses the example of people who are homeless and diabetic. People with diabetes have to manage their weight, diet, and also take daily medications that have to be refrigerated. All of those things become extremely difficult, if not impossible, if someone does not have a home.
In general, caring for those patients is more time intensive and costly because of the variety and complexity of the issues they face. They also tend to be unhealthier, Pratt and others say, which leads to a disparity in health among populations simply because they have more barriers to accessing healthcare than other populations.
The OPCA was joined by almost 30 organizations calling for Senate Bill 1522’s passage. But it died in the Senate’s Healthcare, Human Services and Rural Policy committee after two hearings. Legislators worried that the bill was unnecessary.
“The goal of CCOs is to take care of these people,” said Sen. Alan Bates (D-Medford). “I don’t think we need to call it out any more than we are.”
Without the bill, some worry that a segment of Oregon Health Plan patients will continue to be unhealthier than other populations. And without a legislative mandate, it will be up to each individual CCO whether it chooses to address barriers to health, or works with social service providers to better address those concerns.
The OPCA is planning to convene a workgroup to talk about the organization’s next steps and influence the development of CCOs when the Oregon Health Authority begins drafting and writing the administrative rules and regulations for CCOs this summer.
Bob Joondeph, the executive director of Disability Rights Oregon, says it’s going to be absolutely necessary to address a patient’s social and psychological needs, in addition to their medical ones.
“It’s going to be a really primary piece of what these CCOs are going to do,” he says. “Frankly, that’s where the state sees the opportunity to improve health and save money.”
Although Senate Bill 1522 did not pass, he thinks there is ample opportunity for people to influence the development of CCOs. Each CCO will have a “community advisory committee” made up of stakeholders from the community who are not involved in a CCO as providers. That, he says, provides an opportunity to pressure CCOs to take a certain course of action when it comes to determinants of health.
“Many, many more details are going to be worked out at the local level,” Joondeph says. “There’s a lot of opportunity for people to be engaged and to steer the course of how any particular CCO goes.”
He thinks it is highly likely that CCOs will begin forming strong partnerships with social service agencies to the effect of “social service-izing the medical world.”
“It goes beyond patching a person up,” he says.
Ed Blackburn, the executive director of Central City Concern, agrees. “The social interventions are going to be critical,” he says.
Central City Concern’s programs are built on the assumption that providing all the social services one might need — whether it’s housing, medical care, substance abuse treatment, detox services, drug free housing, etc. — can make providing health care to those people more effective.
“We know we can reduce incidents of hospitalization … and reduce conditions that are exacerbated by those (psychological and social) conditions,” Blackburn says. “Someday, we’ll not see (health care and social services) as separate.”