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Audit flags ‘system failures’ in ensuring mental health patients receive care

The Oregon Health Authority’s system that determines whether vulnerable Oregonians receive mental health care has widespread “failures” that hurt the people who need care, an internal audit found.

Agency officials started its work on the audit after a whistleblower within the agency contacted the Oregon Secretary of State’s hotline for reporting waste and fraud in government in March. That employee, whose name is redacted, reported concerns about possible financial mismanagement and poor decisions about how much care Oregonians should receive, the Capital Chronicle reported

The health authority authority on Monday released a copy of the audit to the Capital Chronicle in response to a public records request. Auditors found a “fragmented, poorly monitored” system that determines how much care people in the behavioral health system should receive – and who is eligible. 

The outcome: Some people had their care arbitrarily reduced, while others bunked in secure residential facilities they did not medically qualify for, despite the state’s shortage of behavioral health services. As a result, some Oregonians unnecessarily stayed in the state’s most advanced behavioral health facilities, even as others languished while waiting for care. And other Oregonians experienced reductions in the hours of personal care they receive in their home to keep them on their medication and healthy. 

“System failures at this juncture have real consequences for consumer well-being and continuity of care, as well as on the behavioral health system,” auditors wrote.

In an interview with the Capital Chronicle, interim Oregon Health Authority director David Baden said the audit shows how “the cracks in the behavioral health system are still way too damn apparent.”

Baden said the agency agrees with the audit and needs to ensure that people receive care they need and don’t  end up in a more restrictive setting than necessary.

“That’s not acceptable,” he said. “We’ve got to do better.”

Before the audit began, authority employees had concerns. The agency’s main ombudsperson, Ellen Pinney, told another employee – the eventual whistleblower – in a March email she feared the worst for clients who qualify for services but don’t get help.

And in 2022, Disability Rights Oregon, a Portland-based federally sanctioned watchdog organization, asked the agency to make changes after it uncovered cases of people who arbitrarily lost their behavioral health services and an inadequate training system that relied upon YouTube videos for staffers employed by Comagine Health, the authority’s contractor that assesses patients.

The system directly impacts the plight of thousands of Oregonians who need behavioral health services, often intensive care in residential facilities, by determining what treatment patients can receive.

To qualify for treatment, members of the Medicaid-funded Oregon Health Plan must undergo assessments that determine how much care they should receive. Comagine Health, a national Seattle-based nonprofit with nearly 100 employees in Oregon, handles the assessments. The contractor is paid an hourly rate of $118 to $181 and has a four-year $70 million contract. This year, Comagine will assess an estimated 2,500 Oregonians.

Delayed care

Auditors found an assessment system that keeps some Oregonians in secure residential facilities when they don’t need it. But elsewhere, behavioral health providers are frustrated because the assessments give patients a lower level of care than they need.

The end result leaves the state hampered in giving people the care they need, shortchanges providers of the money they need to care for patients and frustrates advocates who try to navigate the red tape and help their clients.

For example, auditors found people stayed in secure residential treatment facilities, even after assessments denied further care. Those facilities, among the most secure in Oregon, are in high demand. Agency officials automatically approved requests for secure residential treatment and Medicaid money was “sometimes improperly used” to pay for those services. Auditors noted this “delays other patients’ access to care.”

At the same time, providers don’t have a clear path to appeal assessments that fail to match patients’ needs. This forces providers to make tough choices about patients and their finances, knowing that a financial decision also may add to Oregon’s homelessness crisis.

“OHA potentially faces mistrust and strained provider relations without transparent appeal processes,” auditors wrote.

Auditors also found a sloppy system and a lack of necessary documentation – even when assessors made life-changing decisions. For example, when an assessor decided to reduce a person’s care and services, auditors couldn’t find any records to back up the rationale. 

Not all the programs are residential. The state’s personal care program helps people in their homes. But auditors found the state has failed to adequately inform patients about that Medicaid-funded service. That program is necessary to reach people who struggle to access mental health services and reduce the pressure on the overall system, the audit said.

Other problems 

Behavioral health providers have told the Capital Chronicle that the assessments pose problems. Essentially, if an assessment approves a less intensive care for a person than they need, a provider must determine if they want to treat the person but not be paid – or release them. 

Those assessments, auditors found, are not compliant with state rules. For example, the assessors are not using a standardized questionnaire to determine and document the patient’s skill, abilities and level of assistance in a “consistent and objective manner,” auditors wrote.

Auditors also found residential providers are required to ask the same assessor to reconsider their determinations if they want to contest it, and that they need an independent review.

For the program that serves people in their homes, auditors found there was no objective criteria used to determine how many hours of care people get. Assessments can approve housekeeping and meal help for people as well as reminders to take medication.

“This increases the perception of arbitrary decision-making,” auditors wrote about the lack of criteria, adding there is a “lack of sufficient oversight.”

Authority plans fixes

Baden, with the health authority, said the agency is taking steps to address the issues in the audit. In the short-term, the agency is adding two more staffers to manage the contract, making the total three, Baden said.

“We’ve recognized that we need more oversight, especially because this contract has a lot of responsibilities for the contractor and a lot of responsibilities for OHA,” he said.  “Frankly, we just did not have enough staff and time to do that.”

In November, the health authority will start a new assessment system for new clients who need personal care services, Baden said. It’s intended to ensure they get the care they need.

In 2024, the health authority will start a pilot program to handle cases for people in residential care settings.

“These are human beings, we’re talking about –  human beings with extraordinarily complex behavioral health concerns,” Baden said. “What this audit pointed out is that we need something better.”

Baden said the complexity of the project makes it necessary to test a pilot before being adopting a new system..

Baden said the state has no plans to cancel its contract with Comagine.

“At this stage, I think we’re really focused on making sure that our house is in order so that we can do better oversight, generally,” he said. “Frankly, I think Comagine will do a better job when we’re in better shape.”


Auditors recommended changes to the state’s system across the board that include:

  • Developing consistent questionnaires to use when patients are assessed.
  • Monitoring to ensure patients who stay in secure residential treatment facilities are properly documented and medically appropriate.
  • Establishing an independent review process so providers can appeal cases.

A spokesperson for Comagine didn’t immediately respond to a request for comment about the audit. A spokesperson for the company has previously said Comagine would cooperate with the audit and work with the authority to make improvements.

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