Does Skin in the Game Matter if You Aren't Playing? Examining Participation in Oregon's Public Employee Health Engagement Model.

PURPOSE: Employers are increasingly exploring health benefits that incentivize lifestyle change for employees. We used early data from an ongoing study of one such model-the Health Engagement Model (HEM), which Oregon implemented for all public employees in 2012-to analyze variation in employee participation and engagement. DESIGN: A survey was designed to assess program engagement, opinions of the program, and self-reported lifestyle changes. SETTING: Data were collected in 2012, about 9 months after HEM launched. SUBJECTS: A representative random sample of 4500 state employees served as the study subjects. MEASURES: Primary measures included whether employees signed up for the program, completed its required activities, and reported making lifestyle changes. ANALYSIS: Logistic regression was used to analyze survey results. RESULTS: Most employees (86%) chose to participate, but there were important socioeconomic differences: some key target populations, including smokers and obese employees, were the least likely to sign up; less educated employees were also less likely to complete program activities. Despite mostly negative opinions of the program, almost half of participants reported making lifestyle changes. CONCLUSION: Oregon's HEM launch was largely unpopular with employees, but many reported making the desired lifestyle changes. However, some of those the program is most interested in enrolling were the least likely to engage. People involved with implementing similar programs will need to think carefully about how to cultivate broad interest among employees.

Funding Accountable Care in Oregon: Financial Models in Two Coordinated Care Organizations.

EXECUTIVE SUMMARY: Oregon's coordinated care organizations (CCOs) are an integral part of a massive statewide reform that brings accountable care to Medicaid. CCOs are regional collaboratives among health plans, providers, county public health, and communitybased organizations that administer a single global budget covering physical, mental, and dental healthcare for low-income Oregonians. CCOs have been given freedom within the global budget to implement reforms that might capture efficiencies in cost and quality. For this study-fielded between 2012 and 2015-we traced the path of the global budget through the interior structures of two of Oregon's most promising CCOs. Using document review and in-depth qualitative interviews, we synthesized and summarized descriptive narrative data to produce case studies of the financial models in each CCO. We found that the CCOs feature substantially different market contexts, governance models, organizational structures, and financial systems.

Building the foundation for health system transformation: Oregon's Patient-Centered Primary Care Home program.

OBJECTIVE: Health system reform is largely dependent upon the transformation of primary care in addition to the alignment of incentives that mediate the allocation of resources. The Patient-Centered Medical Home (PCMH) is a model of enhanced primary care that encourages coordination, patient-centered care, integration of public health services, and innovative methods for improving population health-all critical elements of health system reform. Because it changes the way primary care is organized and delivered, the PCMH model has been adopted as a foundational component of Oregon's health system transformation. This article presents insights drawn from an evaluation of the implementation of Oregon's Patient-Centered Primary Care Home (PCPCH) program and the adoption of the model by primary care providers. DESIGN: We used a mixed-methods approach consisting of 2 surveys of recognized PCPCH practices, qualitative document analysis, and key informant interviews. Evaluation research findings were triangulated with findings from PCPCH clinic site visits conducted as part of a regulatory verification process. RESULTS: Survey results describe a broad range of strategies and practices adopted by recognized PCPCH clinics within 6 defined core attributes: (1) access to care; (2) accountability; (3) comprehensive whole-person care; (4) continuity; (5) coordination and integration; and (6) person- and family-centered care. We also identify 4 key factors that influenced the conceptualization, development, and implementation of the PCPCH program: (1) support and motivations; (2) administrative barriers and resource constraints; (3) alignment of short- and long-term financial incentives; and (4) leadership and interpersonal relationships. CONCLUSIONS: This evaluation provides insights into the factors that influence implementation of a primary care home program as public policy; the strategies and challenges associated with implementation of the model; and the implications of both for other states that are engaged in-or considering-similar system reform efforts.

Health insurance status, medical debt, and their impact on access to care in Arizona.

OBJECTIVES: We examined the impact of health insurance status on medical debt among Arizona residents and the impact of both of these factors on access to care. METHODS: We estimated logistic regression models for medical debt (problems paying and currently paying medical bills) and access to care (medical care and medications delayed or missed because of cost or lack of insurance). RESULTS: Insured status did not predict medical debt after control for health status, income, age, and household characteristics. Insured status (adjusted odds ratio [AOR] = 0.32), problems paying medical bills (AOR = 4.96), and currently paying off medical bills (AOR = 3.04) were all independent predictors of delayed medical care, but only problems paying (AOR = 6.16) and currently paying (AOR = 3.68) medical bills predicted delayed medications. Inconsistent coverage, however, was a strong predictor of problems paying bills, and both of these factors led to delays in medical care and medications. CONCLUSIONS: At least in Arizona, health insurance does not protect individuals from medical debt, and medical debt and lack of insurance coverage both predict reduced access to care. These results may represent a troubling message for US health care in general.