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Mental Health Discussion Reveals Disagreements About Oregon’s Best Path Forward

Though fellow panelists at Wednesday’s Oregon Health Forum breakfast seemed to agree with Congressman Earl Blumenauer’s defense of the Affordable Care Act, they shared wide-ranging views on how specifically to improve care for the state’s mentally ill.
May 31, 2017

Oregon may see itself as a national healthcare leader, but when it comes to meeting the needs of people with mental illness and addiction the state ranks dead last, behind every other U.S. state and also below Washington, D.C. And government programs will be crucial to improving that dire situation, local agency leaders, a the CEO of a Portland-based clinic, and U.S. Congressman Earl Blumenauer all agreed on Wednesday.

But getting to agreement on the specific steps necessary to care for the mental health needs of Oregonians seemed a nearly insurmountable challenge at the Oregon Health Forum’s May breakfast panel, which officially asked the question, “Can CCOs and Counties Work on Better Mental Healthcare?”

Going far beyond that relatively narrow topic, nonprofit consultant and moderator Jason Renaud led panelists Blumenauer, Multnomah County Health Director Joanne Fuller, Health Share of Oregon CEO Janet Meyer and Kartini Clinic CEO Morgan O’Toole through two hours of conversation centered on the challenges facing this state’s mental health safety net.

Blumenauer Offers Hope in Face of Republican-Led Efforts

Blumenaeuer, a liberal Portland Democrat known for his quirky bowtie and vocal support of bike lanes and marijuana legalization, spoke first at Wednesday’s forum, focusing on the role federal legislation plays in Oregon’s ongoing efforts to improve access to physical and mental health.

With the Republican-backed American Healthcare Act now through the U.S. House of Representatives and facing an uncertain future in the Senate, the congressman urged advocates for mental healthcare to fight against drastic cuts and revisions to the Affordable Care Act, and to recognize the ways the ACA has served mentally ill populations.

“One in three people enrolled in Medicaid either have a mental illness, a substance abuse disorder, or both. Putting that at risk, I think, is immoral, and I think ultimately we are going to be successful in protecting it,” Blumenauer said.

“Being able to extend care through the Affordable Care Act to this population has made a very important shift. It is saving money and improving treatment. We are able to deal with people in an appropriate clinical setting, rather than when they spin out of control,” he continued. “Unless or until my Republican friends are willing to repeal the legislation that requires emergency rooms to take all comers and treat them – unless they are willing to do that – efforts at restricting Medicaid are not going to save any money. It just shifts the costs to inferior treatment, and leads to cascading effects through other institutions.”

He praised the ACA for its role in improving care in jails and prisons, which provide perhaps the most mental health treatment in the U.S. Obamacare relieved financial pressures on these institutions by expanding Medicaid access to their populations, Blumenauer said.

He also noted that even as national headlines focus on the bill sometimes nicknamed “Trumpcare,” the U.S. Congress continues to consider smaller legislation that could quietly improve mental health coverage opportunities.

“The Helping Families in Mental Health Crisis Act is a step in the right direction, because there had been more engagement in congress than in the 20 years prior,” he said, though the bill – passed by the U.S. House last year – has not cleared the Senate. He also touted legislation that would allow more people to qualify as mental health providers, that would authorize loans for construction and renovation of psychiatric and substance abuse centers, and that would eliminate the current 180-day lifetime limit on Medicare coverage for inpatient psychiatric hospital services.

Blumenaeur urged the roughly 150 people attending Wednesday’s breakfast to get or stay politically engaged in the debate over mental health and ACA reform.

“We need to expand this conversation to not only include providers. How do we make sure we include the courts, the police, families , and patients, into a much broader partnership?” he asked. “I am hopeful that people get a little charged up. I’m glad that they are outraged about this thrust to try and not just eliminate Obamacare, but to limit access to healthcare generally -- 14 million would lose their healthcare next year under this sad excuse for legislation. But we’re watching.”

Clinic Leader Says the System Makes No Sense

Despite Blumenauer’s complimentary comments about Oregon’s coordinated care organizations, Kartini Clinic CEO O’Toole said his eating disorder treatment program’s experiences navigating post-ACA mental health reimbursement and CCO contracts have been far from praiseworthy.

“The Kartini Clinics sees people from all over the state and all over the country, and some who are international, and right here what we see is a lot of confused people,” he said. “When you ask them who their insurer is, they say OHP. There are 16 CCOs, open cards, a host of counties, other plans. The edifice we have constructed is baffling to the people it is intended to serve.”

Each CCO develops its own provider network, many require credentialing and certification, as do counties. These efforts come separately from the credentials physicians must already obtain from medical boards and through the state. The administrative processes involved create huge burdens to providing mental healthcare, without improving that care’s quality or access, O’Toole said.

“These are self inflicted wounds,” he continued. “Yes, things are not easy. We are dealing with a complex delivery system, a complex product. There’s no question in my mind that healthcare is the most difficult industry product to deliver and deliver well. And yet we have to recognize that we are contributing to the problems we are trying to solve. We are part of the problem.”

O’Toole compared the current credentialing system to another public service – roads – and asked audience members to imagine if they had to get one certification to drive city streets, another for county-run highways, and still a third to access the freeway system.

“And every 12 months or so, your permission to use the roads would have to be renewed. What do you think your commute would look like? What do you think interstate commerce would look like? This isthe system we have created,” he said. “When providers are asked to contract separately and distinctly with 16 separate CCOs just to gain access to Medicaid – this is not what we want. This is no way to run a railroad.”

And these contracts and provider lists do not just create unnecessary expenses and headaches for medical providers, O’Toole said – they also limit access to care.

“There are physical health networks and behavioral health networks, sometimes within the same plan,” he said. “This non-scientific distinction between physical health and mental health impedes care coordination.”

He paused, then, to praise one exception to his frustrations, the Portland-area CCO FamilyCare.

“They really have a system that is simplified to the point of improving clinical outcomes,” O’Toole said. But he urged state leaders go move away from the current fragmentation.

“Oregon should have a statewide single provider network,” he argued. “If you are licensed by the state and you’re licensed by your professional board, you should be able to see any Oregonian who walks through your door.”

Multnomah County Health Director Defends Local Control

Fuller, director of the Multnomah County Health Department, began her remarks Wednesday by acknowledging the trauma of the deadly stabbings that took place last week on a Portland MAX train.

She then addressed one aspect of O’Toole’s complaints, defending the local control the state’s system of 16 CCOs and 36 county-run health departments allows each community to develop.

“In the abstract, people want their government to be generic, but when they go and talk to their individual county commissioners they don’t want it to be generic. They want it to serve the needs of their community,” Fuller said. “I’m an unabashed supporter of counties having a role to play in healthcare, mental health and addiction systems we have in this state.”

She also acknowledged that gaps in the state’s system do occur – and emphasized the role county efforts play in filling those gaps, especially for the very poor and the mentally ill.

“By state statute, counties are responsible to be a mental health safety net,” Fuller said. She pointed to programs in the Portland area that offer walk-in treatment, 24-hour intervention, and that connect people returning to the community after stays in the state hospital. The county also fills gaps when people temporarily lose access to Medicaid programs, she said.

Increasingly, the county-led effort to address mental healthcare needs goes beyond traditional treatment, to look at root causes and exacerbating factors that surround mental health and addiction – including with programs that focus on housing, homelessness and school-based health.

“We’re trying to work our hardest to connect those foundational services in our community with Medicaid services people are entitled to,” she said.

“One of the things we are trying to do in the mental health system across the state is to embrace a recovery model of care. A recovery model of care means that we are not just about providing

healthcare, we are trying to strive to look at wellness and to look at people’s ability to continue to grow as individuals.”

And though she acknowledged that the journey may be bumpy, she took a more upbeat view than O’Toole.

“We are talking about a journey here. Healthcare is not now, and never has it been, in one steady state. We are involved in a process of healthcare transformation in the state. It’s definitely not perfect, but it’s also not finished. We continue to figure out how to make things better. We continue to figure out how to value things that haven’t been valued in the past. And one of those is mental health and addiction service,” Fuller said.

“We start not from a level playing ground or ground zero. We start from below ground and then have to work on improving these systems to make things better,” she continued.

Health Share Exec Touts Coordination

Meyer, CEO of Health Share, the state’s largest CCO, joined Fuller in defending the system that O’Toole criticized as overly fragmented – and touted her organization’s efforts to collaborate and simplify across the greater Portland area.

“When I started my career, I started as a provider network contractor. I went out and built networks of providers in Colorado so we could sell these networks to employers, for some reason. I will tell you: contracted networks of providers are not systems of care,” Meyer said, in remarks that affirmed some of O’Toole’s complaints.

But rather than complicating matters, she argued that Health Share’s role in Clackamas, Multnomah and Washington counties has improved mental health treatment in the Portland area.

“When we started in 2012, we inherited three county-based mental health" plans, each with different and often internally contradictory or overlapping approaches, Meyer said.

“One July 1 last year – it’s been almost a year – the counties took a very bold step,” she continued. “They consolidated as one organization. Under Health Share, we now have a regional network. We have a regional payment system. Counties do care coordination that they are good at, where their deep talents are, and we do the administrative back end.”

She also said that allowing the state’s dozens of counties and CCOs to each chart their own course meas that other regions of the state have taken different journeys.

“The CCOs reflect the counties we operate in and the communities we serve. For some CCOs, their county mental health system was not one they wanted to engage in,” she said. “For example in Roseburg with Adapt, it’s been fascinating to watch the CCOs to connect with the provider directly. I think it has gone right.”

Reach Courtney Sherwood at [email protected].