A 9-year-old boy waited in a hotel room for more than 100 days while waiting for mental health care. A 16-year-old girl with a history of sexual exploitation and drug abuse went to a hospital emergency department for five days of drug detox.
These are the nameless people who languish and fall through the cracks in Oregon’s mental health care system. Oregon auditors don’t believe they are isolated failures. Instead, specialists in the Secretary of State’s Office found widespread and systematic problems in the state’s mental health system in an 82-page report released Wednesday.
They identified wide-ranging, chronic problems: The Oregon Health Authority fails to monitor $158 million in taxpayer money that pours into county mental health services; the agency lacks consistent leadership and a strategic plan. Mental health laws have loopholes that allow funding to go elsewhere. The system also lacks accountability and is unable to identify community needs and gaps in service.
These are among the key findings of the audit, a scathing but unsurprising rebuke of a behavioral health system that advocates and outside observers have called woefully inadequate for decades.
The report also stood out for its number of recommendations: 22.
In its response, the health authority agreed with them and insisted that it had started correcting many of the deficiencies.
“The failures of our behavioral health system to meet the needs of the people of Oregon come at devastating human and financial cost,” behavioral health Director Steve Allen wrote in the authority’s response to the audit. “These impacts are even worse for our communities of color because they experience an even deeper chasm between what they need and what there is.”
Oregon’s mental health crisis has been noted for years by the nonprofit group Mental Health of America, which ranked Oregon last for effective adult mental health services in its 2020 report. It put the state at 47th for youth mental health services.
The mental health system in Oregon, accounting for about $3.2 billion in public spending in the current two-year budget cycle, is layered with bureaucracy and red tape The health authority contracts with 15 coordinated care organizations, all 36 counties and oversees more than 250 behavioral health contracts so low-income Oregonians on Medicaid have access to mental health care.
“It’s really helpful to have an outside entity with fresh eyes take a look at what we’ve got,” Allen said in an interview with The Lund Report. “What it told us, frankly, is what we already know. This system needs work and it’s about time to do it.”
The problems aren't new. The audit references nearly two-decade old reports about the same challenges that Oregon state agency leaders and lawmakers have repeatedly failed to address. It’s a familiar cycle for advocates who have followed Oregon’s mental health crisis for decades. Jason Renaud, a volunteer and advocate with the Mental Health Association of Portland, put it bluntly. “There’s lots of people who are capable of studying them, but very few who are capable of fixing them,” he said, adding “we’ve studied this to death.”
System Fails To Help Vulnerable
The report flagged multiple problems throughout the state’s mental health system.
For example, auditors found the system overly fragmented among entities such as the authority, coordinated care organizations, counties, working groups, providers and others.
High turnover, cited in a 2001 report remains a problem.
Children are served by overworked direct care workers who frequently quit, the report said. “Some of Oregon’s most vulnerable children are left without the adequate services to treat their mental health,” auditors wrote. “Without addressing the challenges presented from this fragmentation, children will continue to face higher health risks and an increased likelihood of adverse health outcomes into adulthood.”
Auditors gave specific examples. In one case, a 9-year-old boy stayed in a hotel for more than 100 days while in child welfare custody while awaiting intensive mental health services. Providers in his network didn’t treat him treatment even after his coordinated care organization recommended unsecured residential treatment, citing medical concerns. After the health authority signed off on more intensive residential treatment, the boy could not get treatment from an out-of-network provider because his care team had not approved it.
A 16-year-old girl with a history of sexual exploitation and drug use ran away after she was discharged from a hospital. She went on to use heavy drugs again and suffered a delay in care because the hospital failed to make a timely referral to psychiatric residential treatment. After child welfare workers found her, the girl was treated at five different facilities, including two emergency departments. An out-of-state residential treatment facility denied her care for complex needs. Instead, the girl had a five-day stay at a hospital emergency department to detoxify from drugs.
The siloed parts of mental health care also mean less accountability that goes back decades. The 2001 report found insufficient access, particularly for children, auditors wrote, adding nothing appears to have changed: “These issues, first identified in 2001, have persisted.”
Indeed, auditors found that Oregon could consolidate its “chronic fragmentation” if the state considers taking similar steps as New Jersey did. That state has a single point of access for behavioral health care for any child, regardless of insurance and consolidated authority with New Jersey’s Department of Children and Families.
Report Cites Data Problems
Due to faulty data, the health authority cannot access the need or level of participation in mental health care, auditors found. The state’s system also cannot track data adequately through its Measures and Outcomes Tracking System, which was intended to be a comprehensive data solution. Instead, the authority is at risk of failing to comply with state law, auditors warned. Those problems started to grow worse in 2012.
Oregon’s Medicaid data has gaps, and the state cannot use them to identify intensive services and supports. Washington state, in contrast, has more capabilities, auditors wrote. Data in Medicaid claims, for instance, is too “incomplete and inconsistent” to be reliable, the report said.
The problems run deeper than technology shortcomings. The authority hasn’t even defined its desired outcomes for serving children and youth. Auditors tied this lack of definitions to children who languish in the system and the need for early interventions.
“Appropriate interventions can mean avoiding more intensive services and hospitalization later,” the report said. “A failure to intervene early negatively affects children and families. Multiple reports have described Oregon’s how inadequate mental health services for children have resulted in children languishing at inappropriate levels of care.”
Auditors found that the authority is unfamiliar with its own data. Health analytics staff at the authority and the behavioral health unit have met to talk about how to track complex Medicaid data, but failed to reach an agreement.
Auditors said the authority’s data analysis staff were unfamiliar with the agency’s mental health services and pulled data from the system riddled with inaccuracies. The one staff member who told auditors she was the only person with the “expertise” to answer questions about analysis was unable to do so, the report said. Staff sent auditors data with incomplete addresses, nonsensical dates and couldn’t answer questions about other possible errors. Auditors said the experience “calls into question whether staff have adequate expertise in both data and children’s mental health services to develop performance metrics using existing data.”
Workers Lack Support
The audit also warned that workers who help children needing mental health care need more support. In interviews with workers, auditors found the already-stressful job is compounded by low pay and a lack of adequate support from supervisors and the authority’s leadership. Direct care workers have skipped meal breaks, been unable to take vacations and have lacked adequate training to protect themselves in crises, auditors found. Managers have told employees they are replaceable, some workers told auditors.
They also have gone to the hospital with injuries. Their starting pay is about $14 an hour.
The field is plagued with high turnover. That’s not a new problem, either. Various state reports back to at least 2001 recognize the struggle of retaining staff.
Existing state law is also problematic. For example, laws for mental health programs include the phrase “subject to the availability of funds” in nine different sections, which auditors say is a loophole that can allow money to go to other areas.
Auditors also found a lack of oversight for county community mental health programs, which receive $158 million in state funding from the authority.
The health authority is not tracking county-level costs and expenditures due to a loophole in state law. Health authority leaders told auditors they don’t require counties to send them local plans.
Auditors said the authority cannot monitor for “potential fraud, waste or abuse” with the current system. The authority also cannot see how effective the taxpayer money is for community mental health programs, the report said.
Authority Lacks Strategic Plan
Constant leadership turnover also has left the agency without a sustainable strategic vision, auditors said. Amid changes, plans sometimes get left by the wayside. In 2014, the authority’s addictions and mental health division released a three-year behavioral health strategic plan. But the next year, authority leadership eliminated the stand-alone addictions and mental health division and folded it into the authority’s health systems division. An agency leader told auditors they didn’t know whether the authority even used the plan.
Currently, the authority lacks a strategic plan, auditors concluded.
The audit’s findings struck a familiar chord for advocates, particularly the system’s fragmentation.
“It’s a terrible system that a consumer would never put together this way,” said Kevin Fitts, a mental health advocate and executive director of the Oregon Mental Health Consumers Association, a small policy group.
Fitts said the state needs to look beyond simply the question of whether a person receives access.
“The problem is not access to services,” Fitts said. “The problem is the engagement of people in services and the afterthought of: Is this service benefitting you?”
Allen said the authority needs to hear more from people in the behavioral health system.
"We're working to turn up the volume on the feedback from the consumers of behavioral health care services because frankly, I don't think their voice has been strong enough,” Allen said. “We need to be looking out for their needs because when we get that right, we help them."
Auditors also found shortcomings in the state’s incentive metric system for coordinated care organizations, which sets targets for CCOs to meet so they can receive more funding. One incentive measure weighed the percentage of children in child welfare who received a mental, physical and dental assessment within 60 days of the state notifying the CCO that the child was placed in foster care. That’s one of 17 measures to incentivize CCOs with more money. But auditors say the measure is flawed because it does not track whether the child received the care. The Metrics and Scoring Committee decided to keep the metric in 2019.
Audit Cites Much To Be Done
The audit’s 22 recommendations for the authority are wide-ranging.
For example, it said the authority needs to develop a strategic plan and review the various boards, commissions and advisory groups. Non-essential entities should be dissolved or overhauled, it recommended.
The authority also should develop a process for regular stakeholder input, the report said. The authority has to update its policies and procedures still on the books that reference dissolved divisions at the authority. It also needs to work with lawmakers to change state laws and eliminate loopholes.
Auditors want the state to define the benchmarks for performance measures for children and put more resources, including data analysts in other divisions, toward the task of better tracking children in the system and their outcomes.
The audit called on the authority to develop internal policies and procedures to monitor county use of behavioral health funding.
Authority officials agreed with the recommendations but it’s been hampered by factors like COVID-19, which has disrupted the authority’s finances.
“With the impact of the current pandemic on our economy, we are facing the potential for deep budget cuts to behavioral health and related systems that are already under-resourced and over-taxed,” Allen wrote in his letter, while acknowledging the findings in the audit.
At the same time, work isn’t at a standstill. For example, the authority has consulted with a national expert to define targeted outcomes for children. The authority solicits feedback and works with groups that can help guide its planning, Allen wrote.
Allen stressed that the budget constraints are real, but other areas are lining up to make improvements. One example he gave is the state’s efforts through the CCO 2.0 program to highlight the importance of behavioral health. The CCO 2.0 program is aimed at increasing accountability for the coordinated care organizations that insure Medicaid members. There also is tremendous interest and concern from stakeholders and communities, Allen said.
The authority isn't stopping its work on behavioral health care because of the state budget shortfall, Allen said, but stressed that the work can only go so far if the system faces cuts. For example, the state cannot build out its infrastructure without money, Allen said.
"Peole can't have access to services that don't exist," he said.
For now, Allen and others in behavioral health face a challenge that has eluded Oregon for years. This time, it's during a pandemic and a $4 billion state budget hole. In the end, COVID-19 could end up aiding systemic reforms as communities recognize the need for behavioral health services after months of sheltering in place.
"It's never been a convenient time to reform the behavioral health system," Allen said. "The urgency is there."