Goal alignment and unintended consequences of accountable care: How the structure of Oregon's Medicaid coordinated care model shapes health plan-clinic partnerships.

Introduction: Accountable care models for Medicaid reimbursement aim to improve care quality and reduce costs by linking payments to performance. Oregon's coordinated care organizations (CCOs) assume financial responsibility for their members and are incentivized to help clinics improve performance on specific quality metrics. This study explores how Oregon's CCO model influences partnerships between payers and primary care clinics, focusing on strategies used to enhance screening and treatment for unhealthy alcohol use (UAU). Methods: In this qualitative study, we conducted semi-structured interviews with informants from 12 of 13 Oregon CCOs active in 2019 and 2020. The interviews focused on payer-provider partnerships, specifically around UAU screening and treatment, which is a long-standing CCO metric. We used thematic analysis to identify key themes and causal-loop diagramming to uncover feedback dynamics and communicate key findings. Meadows' leverage point framework was applied to categorize findings based on their potential to drive change. Results: CCO strategies to support clinics included building relationships, reporting on metric progress, providing EHR technical assistance, offering training, and implementing alternative payment methods. CCOs prioritized clinics with more members and those highly motivated. Our analysis showed that while the CCO model aligned goals between payers and clinics, it may perpetuate rural disparities by prioritizing larger, better-resourced clinics. Conclusions: Oregon's CCO model fosters partnerships centered on quality metrics but may unintentionally reinforce rural disparities by incentivizing support for larger clinics. Applying the Meadows framework highlighted leverage points within these partnerships.