A Coordinated Care Organization (CCO) is a locally governed managed care entity primarily associated with the Oregon Health Plan (OHP), the state’s Medicaid program. The central purpose of a CCO is to take full accountability for the physical, behavioral, and dental health outcomes of its enrolled population. This model represents a significant shift from traditional health care, focusing on coordinated efforts across various provider types to manage wellness rather than simply treating sickness.
Defining the Coordinated Care Model
The core philosophy of a Coordinated Care Organization is driven by the “Triple Aim,” a framework focused on simultaneously improving the patient experience, improving population health, and reducing the per capita cost of health care. CCOs apply this philosophy by managing the health of their entire community of members, moving beyond the reactive, fee-for-service model of individual episodic care. This approach emphasizes population health management, which involves identifying health trends and risks across the whole group of enrollees. CCOs also work to address underlying social determinants of health, such as access to housing, food security, and transportation. This coordinated structure requires diverse local partners, including hospitals, community groups, and health care providers, to collaborate effectively.
Integrating Physical, Behavioral, and Dental Health
A defining characteristic of the CCO model is the mandated integration of physical, behavioral (mental health and substance use disorder treatment), and dental health services for all members. This structural change recognizes that these three areas of health are interconnected, and treating them separately leads to fragmented, less effective care. For example, a patient with Type 2 diabetes may also struggle with depression, making it difficult to adhere to a complex treatment plan. In a CCO, the patient’s primary care provider, mental health specialist, and a community health worker can communicate directly and coordinate treatment goals.
Integration is achieved through methods like the co-location of services, where a dental clinic might exist within a community health center that also offers primary care and counseling. Another method involves creating integrated care teams, where providers from different disciplines share electronic health records and participate in joint treatment planning. For example, a dental provider might apply fluoride varnish in a primary care setting, or a medical team might screen for and refer a patient for substance use treatment. This whole-person approach is designed to ensure that a patient’s overall well-being is addressed, leading to better management of chronic conditions and improved health outcomes.
Financial Structure and Accountability
The financial engine of the Coordinated Care Organization is the global budget, a fixed, prospective payment the CCO receives from the state for each member for an entire year. This system replaces the traditional fee-for-service model, which incentivizes volume by paying providers for every service delivered. The global budget structure motivates CCOs to manage costs by preventing illness and keeping their population healthy. If the CCO delivers high-quality care efficiently and spends less than the budget, it can share in the savings.
Accountability is enforced through a robust system of quality metrics that CCOs are financially responsible for meeting. A portion of the global budget, historically ranging from 2% to 4.25%, is tied to a Quality Incentive Pool, which CCOs earn back based on their performance on specific measures. These metrics cover public health goals, such as increasing childhood vaccination rates, improving timely access to care, and ensuring adequate management of chronic diseases. This pay-for-performance model ensures CCOs focus on delivering measurable improvements in patient outcomes and population health.
Eligibility and Patient Experience
CCOs primarily serve individuals enrolled in the Oregon Health Plan (OHP), the state’s Medicaid program for low-income residents. When a person is approved for OHP coverage, they are assigned to a CCO based on their geographic location or existing provider relationships. The CCO is then responsible for managing the member’s comprehensive health care benefits, including all medical, behavioral, and dental services.
The patient experience emphasizes coordinated support. Members are assigned a medical home and benefit from care coordination services that help them navigate the system and connect with social services. Community Health Workers are frequently utilized by CCOs to bridge the gap between clinical care and the social needs of the patient. Furthermore, CCOs are governed by local community boards that include health care providers, community members, and OHP members, ensuring that organizational decisions reflect the specific health needs and priorities of the local population.