Oregon Health Authority Director Pat Allen came on the job seven months ago amid a furor over the treatment of one of the state’s largest Medicaid plans, the last in a string of problems that doomed his successor.
The state had failed to redetermine Medicaid eligibility on time, leaving people enrolled in the system who may not have been otherwise eligible. Those who did get renewed saw their coverage lapse, and they may have been dropped from their coordinated care organization and siloed in a health plan outside their regular medical network.
And then, after years of litigation with OHA, FamilyCare, the smaller of two Portland CCOs, closed its doors on short notice, forcing the Oregon Health Authority to negotiate an arrangement that kept the company open for one more month as all its members were transferred to other Medicaid providers, primarily Health Share of Oregon.
Allen spoke with The Lund Report last week in a wide-ranging interview about the challenges at the Oregon Health Authority, one of the state’s largest bureaucracies.
“That transition went fairly smoothly,” he said of the FamilyCare closure. “I didn’t hear from a single legislator during the session about a constituent problem that they had related to that. And I absolutely expected to hear a healthy volume of concerns that were getting to legislators and there weren’t any at all.”
One reason: former FamilyCare members are still in a grace period where Health Share and other CCOs are working with all of their medical providers. That could change come May, when the three-month carryover ends for physical health providers. An extension for all behavioral health providers was given through July. “We could potentially have some friction. … I don’t actually expect much of that.”
The director pushed back on the depiction of a “secret plan” by former OHA Director Lynne Saxton to tarnish FamilyCare and he said, if anything, his big surprise was how ready the remaining staff at OHA were to be transparent.
“I don’t know if I want to buy into the characterization of a secret plan around FamilyCare. I think when you’re in litigation, you approach litigation in a mindset where you think about the tools and levers you have to defend yourself. And an advantage I have from a long record in public service is that I have radar on what are some of the tools that other people can use that we can’t?,” he said.
“I came into this job worried that the agency had a cultural problem around transparency and what I came to believe was far from it, people are really hungry to provide good information to people, whether that’s legislators or the press or the public or customers.”
FamilyCare may have shut its Medicaid program at the end of January, but the litigation between the former CCO and the state continues.
Spring Brings Stability
However, Allen said the agency has finally turned a corner. Just as a good winter of snow and rain help Oregon’s forests recover from a bad wildfire season, by February he found that the agency’s metaphorical fires had died out and OHA could refocus on its mission for the first time since he took office.
“The first four or five months were really about responding to and managing crises -- putting out fires and those kinds of things,” he said. “Somewhere a couple months ago that really died down quite a bit. And when you’re managing a crisis, the energy you put into managing a crisis comes at the expense of focusing on your mission. As the crises have died down, I’ve spent time thinking mostly about healthcare and behavioral health and the core stuff that we actually do, our transformational mission. It’s been a welcome shift in how I’ve been spending my time.”
“We’re doing the renewals on time and using the ONE system by and large. It’s been successful, and you can see that in the percentage data. The number of people who get redetermined as ineligible and then retroactively reinstated and that number that’s occurring is going down. We’re doing it right the first time.”
Allen said he didn’t expect any big changes to the state’s coordinated care networks through 2019, but once the new contract takes effect in January 2020, Oregon could see a very different landscape for its Medicaid market.
“It’s possible there may be more CCOs, could be there are fewer, could be there are consolidations or mergers,” Allen said. “Some CCOs may decide to change the geography they serve. I’ve been asked questions about all those kinds of permutations. The only thing I’d say is that the geography will change but I can’t say what that will look like.”
For the new contract, Brown has charged him with managing costs, encouraging prospective CCOs to put in place more alternative payment models that move away from paying for the volume of services, reducing the inequities caused by the social determinants of health, and integrating behavioral health.
He said the FamilyCare dissolution could actually prepare them for this shift, particularly if some Medicaid members are handed off from the current organization to another.
“People on the Oregon Health Plan have a lot of challenges in their life and we don’t need to add a lot of unnecessary challenges or any badly managed dislocation of their healthcare. Our job is to manage that transition as to minimize that dislocation.”
Less Worried about DC in 2018
He was less worried about drastic changes coming down from Washington, D.C., to the Medicaid system than he was last year, when he, other top state officials and Gov. Kate Brown warned federal action could leave hundreds of thousands of Oregonians without health insurance.
“I think having a waiver in place that we don’t need to touch, and in absence of Congress able to achieve critical mass about making changes, what we’re left with are [the Centers for Medicare and Medicaid Services] making regulatory changes that are at the margins, but have an impact. But that’s still a bigger risk in the individual market than the Medicaid market. I’m less concerned about those changes than I was a year ago.”
Much of the big changes to Medicaid have been to force work requirements, copayments and premiums on low-income households that receive benefits, and he said neither he nor Brown were interested in those ideas, which are being allowed on a state-by-state basis.
“They’re really interested in having you impose work requirements on Medicaid, which we’re not at all interested in. We don’t want to have a conversation about work requirements.”
Allen said earlier that one of his key goals is reducing the problems of “churn” -- where people bounce back and forth between health insurance systems from Medicaid to the exchange and employer health insurance, which can force them to switch doctors and hospitals each time.
Forcing poor people who are otherwise eligible for Medicaid to jump through more hoops would only increase the problem of churn and impede the ability of the CCOs to manage population health.
“Indiana does [premiums] and the cost of managing [premiums] far outstrips the revenue that comes from it. The churn from people missing a small monthly premium and being kicked off the system and not having access to healthcare is a significant problem,” Allen said. “We really continue to be oriented to ensuring as many people as possible have access to healthcare, and things that you do to create barriers to that are not in Oregonians’ interest.”
Allen didn’t mention it, but placing those barriers on Oregon Health Plan members would also reduce the federal money flowing into the state that has bolstered the healthcare system, stabilized rural hospitals and allowed the state to employ so many more healthcare workers.
Mental Health Concerns
Coming from the Department of Consumer & Business Services, which regulates private health insurance, Allen said he was the least knowledgeable about behavioral healthcare and the details of the system’s shortcomings. He said the Behavioral Health Collaborative that Saxton had been working on provided a good foundation to fix the breakdowns in the system.
He said there were huge breakdowns in treating children, especially those with high psychiatric needs. “Where you are and who you’re insured by has more to do with the kind of mental health services you’re able to get access to than what help you need.”
At the state hospital, his agency’s other big responsibility, he said some counties, including Marion and Multnomah, have curtailed overuse of the mental hospital to house people with mental illness who are arrested for petty crimes, but the Oregon State Hospital in Salem once again exceeded its capacity for these patients this winter, eliminating space for people in need of a civil commitment.
He said work continues getting the state’s other counties to act more like Marion and Multnomah to triage the needs of people in mental health crises and hook them up with a better care situation than institutionalizing them -- at a huge cost to the state.
“I think it’s taking learning like that [in the successful counties] and driving it to other counties across the state,” he said.
Reach Chris Gray at [email protected].