Medicaid patients denied treatment, adding to Oregon’s mental health crisis
A state system that often blocks treatment, with contractors trained by YouTube videos assessing patients, is under review after a whistleblower complained.
The Oregon Health Authority is facing mounting questions from agency staff and disability advocates about its system that determines whether vulnerable Oregonians receive the mental health care they need.
Earlier this year, the authority launched an internal audit after an agency staffer grew concerned about possible financial mismanagement, unprofessional behavior and poor decisions about how much care Oregonians in residential facilities should receive, the Capital Chronicle discovered through public records. The whistleblower, whose name is redacted in documents, contacted the Oregon Secretary of State’s hotline in March, sparking the audit, which is due for completion as soon as mid-September.
The system directly impacts the plight of hundreds of Oregonians who need behavioral health services, often intensive care in residential facilities, by determining what treatment and services Medicaid insurers will pay for as well. The system is part of the reason Oregon has a mental health crisis, advocates say.
Many patients don’t get the care they need – partly because assessors are ill trained, often through YouTube videos, advocates found.
Oregon Health Authority spokesman Tim Heider did not answer questions from the Capital Chronicle about the issue, including what improvements, if any, it has made in response to the concerns of disability advocates. Instead, he sent a four-sentence statement saying the agency acknowledges concerns and recognizes that people need community support.
“Oregon Health Authority is undertaking a comprehensive audit of the program and is working with Comagine Health and listening to our community partners to resolve the outstanding issues and adopt any corrective measures,” Heider said.
To qualify for treatment, Oregonians in the Medicaid-funded Oregon Health Plan must undergo assessments that determine how much care they should receive. Usually, the assessments are annual. The health authority has a $35 million contract with Comagine Health, a national Seattle-based nonprofit with more than 400 employees, a presence in more than 20 states, including Oregon, and a 50-year history. Its contract with the Oregon Health Authority started in 2020, and it has nearly 100 employees in the state. For its work, the contractor is paid an hourly rate of $118 to $181.
Providers who know the clients don’t assess the patients – Comagine specialists do through in-person or video interviews, often working with them and a guardian to set goals.
Their findings don’t always align with the more intensive – and more expensive – care that providers say they need. Instead, assessments can assign patients to a diminished level of care – or make them ineligible for services that could help them work through crises, become more independent and stay healthy.
Mental health organizations have pushed the Oregon Health Authority for years to tackle the problem.
In 2022, Disability Rights Oregon, a Portland-based federally sanctioned watchdog organization, asked the agency and Comagine Health to address the issue after investigating multiple instances of people losing their behavioral health services while in residential care.
Disability Rights Oregon said faulty assessments were not unusual: They were the norm. And they remain the norm, records show.
Evan Stults, chief of staff for Comagine Health, said in an email that its goal is to ensure Oregonians receive the right care and services in the right setting. He said the organization is committed to doing better.
“This is a challenging journey for all involved, and we continue to work closely with the OHA and provider community to make improvements and address issues as they arise,” he said.
He said staff are credentialed and properly trained in accordance with the health authority’s requirements.
Although this contract is three years old, the company has worked on other contracts with the authority and Oregon Department of Human Services for more than 20 years, he said.
At the Oregon Health Authority, records show officials are fretting about the Comagine assessments. After two staffers in charge of the contract resigned or transferred elsewhere within the agency within a short period of time, the agency’s main ombudsperson, Ellen Pinney, told another employee in a March email she was deeply worried about the effect of Coimagine’s assessments on patients. The authority’s Ombuds Program advocates for people on Medicaid.
I fear the worst for our clients.– Ellen Pinney, Oregon Health Authority main ombudsperson
That same month, the Ombuds Program released its 2022 report and detailed concerns about the assessment system forcing months of delays for the care, called “1915i services” that includes home-based and supportive services for people who need mental health care.
“A golden (or squandered) opportunity to get the contract back on track and no one to pick up the ball,” Pinney emailed the whistleblower on March 14.
“I fear the worst for our clients who would otherwise qualify for 1915i services but for (a) leadership vacuum,”she wrote. “Without action, getting this right will be a very, very long time coming.”
Secretary of State receives report
The same day, the whistleblower notified the Oregon Secretary of State’s hotline. By then, that staffer had become worried about what they had heard from other health authority employees.
Reported concerns by the whistleblower and other authority staff are detailed in hundreds of pages of health authority records obtained by the Capital Chronicle. They include:
- A lack of transparency at the authority about Comagine’s contract’s management and a “very odd protocol” that made it difficult for authority staff to communicate with the contractor. The process created barriers to care for some people and slowed down the work of the Ombuds Program, which receives complaints from people on Medicaid and advocates for them.
- A potential “misuse of authority” by a former agency staffer who did not hold the contractor responsible and rushed to renew the contract in December.
- Inappropriate comments from that former staffer about an individual’s required hours of care, including food needs. One statement: “It doesn’t take two hours to make a smoothie.”
Ann Chakwin, who suspected the misuse of authority after she took over the contract’s management in January, began logging issues on a spreadsheet, records show. The whistleblower reported that Chakwin told colleagues she was so frustrated by the situation she decided to leave and transfer to a different role within the agency.
Meanwhile, the whistleblower began gathering contracts, records, emails and Comagine reports and sending records to the Secretary of State’s office.
Health Authority officials decided to start an internal audit, records show. Those details remain under wraps because the audit is ongoing and authority records for audits are considered confidential until an audit is finished, the authority said in its response to a public records request.
The company reports, contracts, memorandum and emails reviewed by the Capital Chronicle detail some of the festering problems.
Disability Rights Oregon steps in
Tom Stenson, deputy legal director for Disability Rights Oregon, said the organization started to work on the problem because it affected people who were in residential programs and doing well after long periods of struggle, including in the justice system.
Stenson told the Capital Chronicle that the outcomes of assessments made no sense.
“Comagine would say they weren’t even eligible for services at all,” he said. “It was bizarre to see an assessment of people who have well-documented, longstanding mental health needs go from very intensive service levels to being told that they weren’t even eligible for services in the first place.”
Disability Rights Oregon, he said, started a “very protracted effort” to get to the bottom of the situation and faced difficulties in getting records.
“We spent just months wrangling with them and Comagine and OHA and saying, ‘Look, we really need to get these records so that we understand what’s going on,’” Stenson said.
After months of getting stonewalled, Disability Rights Oregon received the records, he said. They found that Comagine staffers who do the assessments were inadequately trained, Stenson said.
What we ultimately found was that Comagine was doing pretty perfunctory work. They didn't have much of a training system. They were getting a lot of their education by watching a handful of YouTube videos. And this was qualifying them to review complex behavioral cases.– Tom Stenson, deputy legal director, Disability Rights Oregon
“What we ultimately found was that Comagine was doing pretty perfunctory work,” he said. “They didn’t have much of a training system. They were getting a lot of their education by watching a handful of YouTube videos. And this was qualifying them to review complex behavioral cases.”
At a certain point, providers had to choose between essentially housing people for free because they weren’t getting reimbursed based on inadequate reviews – or sending them onto the street, Stenson said.
“It was so frustrating to see (providers) doing their best to help people out and the state just suddenly slam the door shut and say, ‘Well, we don’t have any funding for this. We’ve decided that somebody who has these really well-documented issues just doesn’t deserve this level of care that they’ve needed for a very long time,’” he said.
Stenson said the organization met several times to discuss concerns with the authority and Comagine. He declined to provide a number of cases, but stressed their concerns stemmed from “repeated incidents.”
After meeting with Comagine and health authority officials, Stenson said, Disability Rights Oregon never got a satisfactory answer about why they were managing vital care through inadequate assessments. “It’s just really disheartening to see people really poorly treated this way,” he said.
Stenson said the cases his organization handled – after receiving reports from different sources – were primarily in the Portland region but reflect a statewide problem.
A behavioral health provider the Capital Chronicle interviewed in rural Oregon reported similar problems with the Comagine assessments. The provider asked to remain anonymous because of concerns about damaging relationships with the health authority and contractor.
Stenson said the assessment system exacerbates Oregon’s behavioral health crisis because people are denied services and deteriorate.
“That’s part of why we’re in the trouble that we’re in, because if somebody doesn’t get the services they need, that’s when people end up homeless,” he said. “That’s how people end up charged with crimes. That’s how people end up filling up the Oregon State Hospital.”
Providers face years of roadblocks
The Oregon Council for Behavioral Health, which represents providers across the state, has tried for a long time to get the authority to address the problem, said Heather Jefferis, the council’s executive director.
The council has asked the authority for years to create a workgroup to tackle the issue and look for ways to improve the system, Jefferis said.
“If we don’t have enough of the right services at the right time, how do we help people?” Jefferis said. “It doesn’t help people. It makes the situation very difficult.”
Disability Rights Oregon – and Jefferis – note that the authority’s problems with managing behavioral health contracts predates Coimagine’s three-year history.
If we don't have enough of the right services at the right time, how do we help people? It doesn't help people. It makes the situation very difficult.– Heather Jefferis, executive director, Oregon Council for Behavioral Health
In 2019, the Oregon Health Authority failed vulnerable Oregonians through mismanagement of its contract with Kepro, a Pennsylvania-based company, The Oregonian/OregonLive reported.
That troubled history and past media coverage also surfaced in an Oregon Health Authority staff meeting in February to talk about Comagine, meeting notes show.
“Trying to get these contracts manageable has been interesting!” the notes say.
High volume of work
Advocates and providers are not alone in their concerns.
The Secretary of State’s Office contacted the whistleblower about two weeks after receiving the original report with word that Medicaid Director Dana Hittle ordered a “full audit” of the situation.
That was March 29, records show.
By then, the Secretary of State’s office had reviewed voluminous records that flagged problems. For example, one Oregon Health Authority staffer in February raised concerns about Comagine changing what an Oregon Health Plan member said in an assessment. The assessments should clearly reflect what the member requests, even if the agency does not approve the service, the staffer said in an email.
“This is highly concerning to me and I just want to make sure … Comagine/that assessor are clear that if something other than what the member is requesting is being granted that the assessment is clear,” the Jan. 25 email said.
That same month, another Oregon Health Authority employee passed along concerns to a colleague about a person on the Oregon Health Plan and a provider who “felt the assessment was rushed and the member was not given time to articulate his concerns/needs.”
The provider requested a new assessment after they tried to submit more information the next day and were told it was too late, the email said.
Several months later in June, the whistleblower contacted the Secretary of State’s office after meeting with auditors and getting an update.
“Some of their preliminary findings have mirrored some of the concerns that were shared,” the email said.
Without action, getting this right will be a very, very long time coming.– Ellen Pinney, main ombudsperson, Oregon Health Authority
Comagine, in its 2022 report to the health authority, reported that it has a high volume of work and continues to look for ways to provide people with access to high-quality programs and smooth transitions.
In 2022, the company completed nearly 2,800 plans of care for people. And on average, it makes 411 eligibility determinations for new cases every three months, the report said.
Its report gave examples of “success stories,” such as one anecdote about a patient with a sunny disposition who improved over time. He showed up for his annual assessment in a Zoom meeting dressed in a leather jacket and dark glasses, ready to play a guitar song for the case manager.
Still health authority staffers remain concerned about the big picture: getting an assessment system that works. It is “pivotal” to successful discharges for patients who exit Oregon State Hospital, the authority-run psychiatric hospital, said Pinney, with the Ombuds Program, in her email.
“This Comagine contract and how it is managed and understood is pivotal to equity for our clients whose disabilities are driven by behavioral health… and much, much more,” Pinney wrote. “I am hugely concerned.”
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