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Friday, February 22, 2013

Eyes On Oregon’s $1.9 Billion Medicaid Experiment

Oregon Gov. John Kitzhaber speaks during a press conference in Portland, Ore. on May 4, 2012, after securing key federal financial backing for the revamp of the Oregon Health Plan that was approved by the state Legislature earlier in the year. (Don Ryan/AP)

Oregon Gov. John Kitzhaber speaks during a press conference in Portland, Ore. on May 4, 2012, after securing key federal financial backing for the revamp of the Oregon Health Plan that was approved by the state Legislature earlier in the year. (Don Ryan/AP)

Facing a $2 billion hole in the state Medicaid budget, Oregon’s Democratic Governor John Kitzhaber - a former emergency room doctor – struck a deal with the White House in May 2012.

The Obama administration agreed to give Oregon $1.9 billion over five years, but the state has to make sure its Medicaid budget growth is two percent slower than the rest of the country.

It’s part of Kitzhaber’s health care reform plan that divides the state into 15 regions called coordinated care organizations.

The idea is to keep people from relying on emergency rooms for care.

“We created a model that focuses on prevention and wellness and the community-based management of chronic conditions, which drives the bulk of medical costs,” Kitzhaber told Here & Now’s Robin Young.

Now, eyes are on Oregon as a possible model for health care reform.

Guest:

  • John Kitzhaber, the Governor of Oregon and a former emergency room physician.

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  • Manuel Yvellez

    At one point in the show, the hostess reviews a new program and explains that the participants were about 144 people from the hospital and “only about 66″ of these took advantage of the new program.  Then she goes on to say something like, “But out of those [66], they were able to reduce future health care costs by 49%.”  Some of my figures here may be a little off.

    I wish that the hostess would be more informed on how to interpret such studies.  Because the selection was not random, the study is compromised and one cannot assume that if all had participated that there would be an overall savings of 49%.  It may well be that the 66 who selected the additional help were the ones more likely to take care of themselves with the recommended post hospital care.  In other words, that particular group may have done 49% better even without the program.  Those that declined the new program could easily be more likely to include patients who would not take care of themselves.  It MIGHT be that this monitor program would help these patients.  But the study itself, at least with the limitation described in the radio program, would have to be viewed skeptically, especially the implication that 49% percent could be saved.  Instead the hostess seems to gasp at how powerful the study is to show such a large savings.  Such lack of examination is disappointing.

    • Jen

      Manuel, while I and any other experienced researchers would certainly agree that the self-selection bias which you are describing can absolutely pose a threat to the validity of any study,  I am afraid you have misquoted Ms. Young (the hostess) and may have reached your concern a bit too prematurely.  

      Ms. Young actually says, “Only 62 agreed to work with this community worker that planned their care.  But of those, the emergency department visits fell by 49%, and the program saved $3,000 per patient.”  Ms. Young does not generalize thse specific savings, at least not in this statement.  Governor Kitzhaber does make some generalizing statements related to potential cost savings, but these statements seem to be made based on forecasting methods, not solely on the results of the specific pilot study in this quote.  

      In regards to the possible selection bias at hand, there are methods for ruling out selection bias.  Your primary concern is that those patients who selected to enter themselves into the program are likely more motivated in general to make a change in their life, in this case a change towards better health.   Based on the correct quote above, it sounds like emergency department visits fell by 49% for the 62 patients.  When the same group so subjects is used for both the control and comparison group, selection bias is often considered greatly reduced, if not eliminated.  In this case, it sounds like the 62 patients’ current emergency department visits were compared to their previous emergency department visits (e.g. # of their ER visits for the year 2011 compared to 2010), making self-selection bias not too much of a concern, as their own ER rates did change. 

      It is unfortunate that all NPR and Here and Now reports cannot always go into full details regarding such research design issues.  However, in this case, the pilot study constituted only a portion of what the whole report was about.   With a 12 minute time slot, my expectation must be much lower than yours regarding detailed analysis of study design in media reporting.

  • Rlupodimare

    All is not a panacea in he State of Oregon. This is one of the most regressive states in the union for seniors when the retire trying to pay their state income tax. If one takes from his retirement fund he or she is taxed 20%. At year end his or her pension which is taxed at around 20% too monthly, is combined once for for with a third grand federal tax at years end. This combined sum is used by the state of Oregon for the basis of one’s state tax! In short, one may need to or wish to withdraw from his retirement fund, but if he cannot pay for his state tax he or she may lose their home. The bottom line for all of these great retirement plans including medical plans is that they are designed for the wealthy, especially those earning more than $250,000 (now $400,000) a year who can afford them because of their wealth. There are many wealthy people in Bend, and in other parts of Oregon whom receive Medicare along with social security who do not need them, yet many of theses same people are parked at Bend Memorial Hospital  almost on a daily basis trying to extend life forever at the expense of Big Government whom they lambast daily. In short the tax and medical system is a rigged system that benefits the wealthy and must be changed. I voted for change not for the same old good old boys system for the wealthy in America. Last but never least, I am paying more federal and state income tax than Mitt Romney! 

  • gbrinoregon

    Proud to be an Oregonian – even as this system gets worked out over time (and EVERY system is going to have some issues that need to be improved), at least we’re doing something different instead of beating the same old drum.  Thanks to Gov. Kitzhaber for  his ongoing work to improve health care in our state!

  • Rlupodimare

    Edited:

    All is not a panacea in he State of Oregon. This
    is one of the most regressive states in the union for seniors when they retire
    trying to pay their state income tax. If one takes from his retirement fund he
    or she is taxed 20%. At years end his or her pension which is taxed at around
    20% too monthly, is combined with his or her withdrawn funds for  with a third grand federal tax at years
    end which places him or her an a much higher taxable bracket. This combined sum
    is used by the state of Oregon for the basis of one’s state tax! In short, one
    may need or wish to withdraw from his retirement fund, but if he cannot pay for
    his state tax he or she may lose their home. The bottom line for all of these
    great retirement plans including medical plans is that they are designed for
    the wealthy, especially those earning more than $250,000 (now $400,000) a year
    who can afford them because of their wealth and are able to pay a federal tax
    or state rate below 15%. There are many wealthy people in Bend, and in other
    parts of Oregon whom receive Medicare along with Social Security who do not
    need them, yet many of theses same people are parked at Bend Memorial Hospital,
    almost on a daily basis, trying to extend life forever at the expense of Big
    Government whom they lambast daily. In short the tax and medical system is a
    rigged system that benefits the wealthy and must be changed. I voted for change
    not for the same old good old boys system for the wealthy in America. Last but
    never least, I am paying more federal and state income tax than Mitt
    Romney! 

  • MyongDong

    Kitzhaber is still riding on what he did in the eighties. It is a wonder he is getting away with it. He drains the people of Portland, the Port of Portland anything with a brain and gives it to You gene, Salem and some bench or side walk that needs to get built in Bend, Oregon. How can you tell everyone? We are going to be the model for the Presidents health care plan. Take billions of dollars to do so. However, no one can get such health care. That is how you can demonstrate you can save money!! You can ensure no one can get on the healthcare plan. Kitzhaber and Bruce Goldberg are pointing around saying they have no earthly idea why this didn’t happen. Gbrinoregon must be white. It is hard to get healthcare even IF YOU HAVE INSURANCE. The wait to see a doctor is LONG!! why because no one wants to pay doctors. They want you to decide you think you like enough to perform career suicide BECAUSE PORTLAND IS SUCH A PRETTY PLACE TO LIVE.. a MD makes less than what I make. the head of family MEDICINE AT OHSU was listed at 120,000.
    Neil McFarlane ole KITZY friend who was appointed to TRIMET makes more than that.,

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