The complexity of issues in health care in the United States--specifically insurance coverage, access, affordability, quality of care, and financing--requires effective new models for governing, in which governmental and non-governmental organizations seek to solve problems collaboratively rather than independently. This research explores collaborative governance as a model to form new partnerships among for-profit, nonprofit, and public organizations in an effort to create community-based, locally governed health care entities in Oregon through coordinated care organizations (CCOs). A key question is whether collaboration, through CCOs, brings together government and non-governmental organizations to solve "intractable problems" by establishing new public-private partnerships in Medicaid. The research focuses on the formation of CCOs, including the influence of local, political, institutional, and historical contexts, planning processes, and governance structures. The hypothesis is that conditions, norms, governance structures and processes, and the presence or absence of a combination of these factors, facilitate or impede participation and decision-making, and over time, successful system integration by these new complex organizations. This study developed insights into similarities and differences among CCO governance structures by investigating three CCOs. Findings from the case study suggest that the following key factors influence the collaborative governance process among government and non-governmental organizations within CCOs: prior history of conflict or cooperation; open, transparent, and inclusive processes for stakeholders; face-to-face dialogue, trust building, and shared understanding; and high-functioning governing boards. Results also indicate that maintaining stakeholder participation can be challenging due to time and cost, power imbalances and competing interests among stakeholders, and mistrust and lack of facilitative leadership. The results suggest that collaborative governance is a strategic approach for the allocation of limited resources across public, private, and nonprofit organizations to deliver services to Oregon's Medicaid population. The significance of this study is that it identified starting conditions that facilitate and hinder the ability of CCOs to effectively solve problems through governance mechanisms. Oregon's CCOs offer an example of multiple layers of governing institutions--federal, state, and county--using formal authority to influence a specified set of outcomes, the Triple Aim, in a specific policy domain: provision of health care services for underserved Oregonians. Results of the study can help inform a larger, more fundamental question in public administration about contemporary governance: whether government through collaborative governance can create the "conditions for rule and collective action" through public-private partnerships to achieve policy goals (Stoker, 1998). Further research is needed to better understand whether local community-based organizations such as CCOs offer a sustainable model to address policy issues in other arenas by which there is "more government action and less government involvement" (Agranoff & McGuire, 2003). This study contributes to the theory of collaborative governance and may inform future policy decisions about CCOs in Oregon and, more broadly, ongoing national health care reform efforts.

The prevalence of untreated and undertreated mental health concerns and the comorbidity of chronic conditions and mental illness has led to greater calls for the integration of primary care and mental health. In 2012, the Oregon Health Authority authorized 16 Coordinated Care Organizations (CCO) to partner with their local communities to better coordinate physical, behavioral, and dental health care for Medicaid recipients. One part of this larger effort to increase coordination is the integration of primary care and mental health services in both primary care and community mental health settings. The underlying assumption of CCOs is that organizations have the capacity to fundamentally change how health care is organized, delivered, and financed in ways that lead to improved access, quality of care, and health outcomes. Using the Rainbow Model of Integrated Care (RMIC), this study examined the factors that impact organizational efforts to facilitate the integration of primary care and mental health through interviews with executive and senior staff from three CCOs. The RMIC focuses attention on the different levels at which integration processes may occur as well as acknowledges the role that both functional and normative enablers of integration can play in facilitating integration processes within as well as across levels. The following research question was explored: What key factors in Oregon's health care system impede or facilitate the ability of Coordinated Care Organizations to encourage the integration of primary care and mental health? Using a case study approach, this study drew upon qualitative methods to examine and identify the factors throughout the system, organizational, professional, and clinic levels that support CCO efforts to facilitate the integration of primary care and mental health. Fourteen primary interviews were conducted with executive and senior staff. In addition, eleven secondary interviews from a NIDA funded project as well as twenty-four key CCO documents from three CCOs were also included in this study. The RMIC was successful in differentiating extent of CCO integration of primary care and mental health. Findings demonstrate that normative and functional enablers of integration were most prevalent at the system and organization level for integrating mental health into primary care for these three CCOs. However, there was variation in CCO involvement in the development of functional and normative enablers of integration at the professional and clinic levels. Normative and functional enablers of integration were limited at all of the RMIC levels for integrating primary care into community mental health settings across all three CCOs. The Patient-Centered Primary Care Home model provided CCOs with an opportunity to develop functional and normative enablers of integration for integrating mental health in primary care settings. The lack of a fully developed model for integrating primary care services in community mental health settings serves as a barrier for reverse integration. An additional barrier is the instability of community mental health as compared to primary care; contributing factors include historically low wages and increased administrative burden. System wide conversations about where people are best served (i.e., primary care or community mental health) has yet to occur; yet these conversations may be critical for facilitating cross-collaboration and referral processes. Finally, work is needed to create and validate measures of integration for both primary care and community mental health settings. Overall findings confirm that integrating primary care and mental health is complex but that organizations can play an important role by ensuring the development of normative and functional enablers of integration at all levels of the system.

This study collects the views of 38 health policy leaders, answering one open-ended question in a 1-hour interview: What state-level reforms do you believe are necessary to implement a feasible model of universal health insurance in Oregon? Interviewees represented seven groups: state officials, insurers, purchasers, hospitals, physicians, public interest, and experts. About 370 coded arguments in the interview transcripts were condensed into 95 categorical topics. A code outline was constructed to present a dialogue among stakeholders in one comprehensive narrative. Topical sections include the cost imperative, politics, model systems, insurance, purchasing, delivery system, practice management, and finance. Summary results show the prevalence of group attention to each topic, group affinities, and proximity correlations of different arguments mentioned by individuals. The most common arguments related to problems of low-value care and delivery system reform. There was a generally felt imperative to control costs. Regarding universal health insurance, stakeholders were split between two main alternatives. One model, favored mostly by insurer and purchaser groups, supported the state-sponsored individual mandate. This plan, embodied in the current Oregon Action Plan to implement universal health insurance, involved managed competition for insurers and clinical governance over professional practice. A separate set of arguments, favored mostly by expert and physician groups, emphasized the need for a unified public system, or utility model, possibly with centralized funds and regional global budgets. The ability of the individual mandate plan to control costs or manage quality appears doubtful, which strengthens opposition. The utility model is more likely to work at cost control and governance, but it disrupts the status quo and its details are vague, which strengthens opposition. Neither model is endorsed by a majority of the stakeholders, and political success for either one alone is not promising. Possibly, a close analysis of the two models could find a way to combine them and generate unified support.