This article has been updated with comment from Dave Baden, the Oregon Health Authority's interim director, and a spokesperson for Comagine Health.
An internal Oregon Health Authority audit has found the agency’s lax oversight of a key contractor resulted in wasted money and caused vulnerable Oregonians seeking mental health care to be placed in overly restrictive settings.
The audit concerns the health authority’s oversight of its $70 million, four-year contract with Comagine Health, a Seattle-based nonprofit hired to assess the needs of Oregonians with chronic mental illness who are eligible for services through the Medicaid-funded Oregon Health Plan.
Comagine is expected to provide services to about 2,500 people in 2023, including connecting them to care. The audit highlights a key point in the state’s behavioral health system and how Oregonians who need care are affected when it breaks down.
The health authority had “weaknesses in control activities and monitoring” over Comagine’s work, according to the audit, obtained by The Lund Report through Oregon Public Records Law. That meant state authorities didn’t catch Comagine’s spotty documentation, murky appeals process appeals processes that made it hard for providers to contest decisions or low payments.
The audit found the health authority did not do enough outreach for programs meant to care for patients at home and “reduce pressure on behavioral health residential capacity.” But the audit also found that patients who had voluntarily entered treatment had been placed in “locked and restricted settings without a medical or legal reason.”
“This unnecessary stay may not be conducive to the individual’s care, adds pressure on the overall behavioral health system capacity and delays other patients’ access to care,” the audit said.
The audit report is an almost-final draft that lacks a formal response from the agency. In an interview, interim health authority Director Dave Baden told The Lund Report that the agency is already working to address the problems identified by the audit. He said the health authority has dedicated two staff to overseeing the Comagine contract and is hiring a third. Additionally, he said the health authority is looking to improve processes and tools to put patients in the right setting.
“You don't want somebody in too restrictive of a care and you don’t want someone in not restrictive enough care,” he said. “This is really important work, and we’ve got to do it right. And I for sure am going to keep a close eye on the follow through of this to make sure that we are doing it right.”
Comagine spokesperson Meredith Mortensen told The Lund Report in an email that the company takes the audit’s results seriously. She said the health authority recently shared the audit results. Once the health authority provides data supporting the audit’s findings, Comagine will work to implement recommendations to improve the program, she said.
“As a nonprofit organization dedicated to improving health, Comagine Health is committed to working on complex health care challenges,” Comagine spokesperson Meredith Mortensen told The Lund Report in an email. “We care about the people we serve through this contract and are grateful for the feedback. We look forward to working with the state to address the recommendations included in the draft report.”
Audit faults fragmented OHA system
As part of its health authority contract, Comagine manages the state’s Medicaid-funded Home and Community Based Services that provide people with severe and ongoing mental illness in their homes or communities.
Previously, the Oregon Capital Chronicle reported extensively on the issues with Comagine’s work and patients’ access to needed care that led to the audit, noting it followed a hotline complaint from a state employee concerned by the mismanagement.
Now, the completed audit highlights what it describes as the health authority’s lax oversight of Comagine’s administration of the program, pointing to “a fragmented, poorly monitored structure for one of the most critical components of the behavioral health treatment system: eligibility and level of care.”
Other findings of the audit included that the use of Medicaid funds for restrictive treatments sometimes did not meet billing requirements. The assessments that were carried out in order to put patients in secure settings for treatment were a “significant waste” of Comagine’s staff time and health authority funds, the audit stated.
Additionally, the audit found the lack of oversight made it difficult to determine how decisions on care were made and whether they were accurate or consistent. Patients receiving services saw their level of care change without any documentation, the audit found. Comagine also did not use an objective method for determining to grant a personal care attendant to patients, the audit stated.
Care providers were also affected by Comagine’s failings, the audit found.
“Appeal processes for providers are not transparent or well-established and are not clearly communicated, making it difficult for providers to contest adverse agency decisions such as addressing assessment results that do not capture the full needs of an individual or disputing a lower payment rate for services,” reads the audit.
The audit took particular issue with the Comagine’s use of a rating system used to measure how much care a person needs in a residential setting and assess their ability to maintain personal hygiene, medications and other basic tasks.
The audit found repeated instances where a person’s rating changed without documentation. Additionally, it found Comagine had confusing requirements for how it expected providers to use it. Providers who wanted a reconsideration of a patient's rating often had to go back to the same reviewer, the audit stated.
Despite the audit, Baden said he’s confident that Comagine can do the work. Baden said the health authority will pilot a new assessment method next year in response to concerns from providers about the accuracy of the Level of Service Inventory. He said the health authority will also launch a new system to determine which patients receive a personal care assistant.
The larger lesson, Baden said, is that in the behavioral system, “The opportunities for people to fall through the cracks or have something happen to them that leads in a direction that doesn't give them the best quality of care are too broad.” He said the health authority is working on beefing up the system, but some changes "can't be made by a snap of the finger.”