Q&A with the Oregon Health Authority
1. OHA implemented some signiﬁcant restructuring within the past few months. What were your goals with taking that action? How would you evaluate progress toward those goals at this point?
OHA’s goal is to accomplish the best health outcomes for Oregonians and provide high-quality care while curbing the rising cost of care through health system transformation. OHA created an organizational structure to advance these goals. This functional structure creates accountability for leaders, managers and staff, and clear expectations for our dedicated employees.
OHA aligned its structure with the coordinated care model and created a results-driven management structure to support all agency efforts, including health equity, health policy and analytics, external relations, public health, health systems (formerly MAP and AMH), and quality client services at Oregon State Hospital and the Pendleton Cottages.
The new structure is an enhanced customer and partner experience with clear contact points, timelines for deliverables and improved communication. OHA has eliminated duplicative positions and the divisions are working with each other to support the agency’s mission. OHA uses best practices tools such as dashboards to be accountable for the work. We have received positive feedback from partners that we’re making progress achieving goals, including improved communications and clear points of contact.
2. One of your strengths has been your background of serving youth with behavioral and mental health challenges. What steps have you been able to take to address those same challenges with youth who are served or could be served by OHA?
OHA is working to address behavioral health issues. Through the coordinated care model, we’re making progress improving coordination between physical and behavioral health and are looking forward to building on this work.
In late 2015, Sen. Sara Gelser, D-Corvallis, and Oregon Health Authority Director Lynne Saxton traveled the state to hear from adolescents, adults and families who have had difﬁculties accessing mental health and substance use disorder treatment in Oregon. They heard from approximately 550 consumers and family members over the course of seven town hall meetings across the state.
Through these town halls, OHA heard there are not enough services and supports to meet the needs of Oregonians. There is a provider shortage resulting in long wait times and not enough specialty services for children. Service integration is insufﬁcient to ensure that cross-agency and inter-agency communication happens. Housing, employment, and transportation are in short supply. Consumers do not receive the quality, coordinated care and support they deserve.
People are also reported being relieved that they ﬁnally have insurance coverage and are hopeful that recovery is now possible. Adult consumers who have access to services and providers are generally satisﬁed. Regarding holistic supports, many people remarked that peer support and supported employment programs are working well. Accordingly, we heard requests for expanding these programs. We have made signiﬁcant gains in the past few years, as the data is just beginning to show. However, we still have work to do. It is important that we stay the course and continue to make strategic investments in programs that deliver results. You can read more here.
OHA’s next step is launching a behavioral health mapping tool process. This will be a data-driven process that will provide state- and county-level population, service, ﬁnancial and outcome data regarding the functioning of Oregon’s behavioral health system. This will ensure that youth and young adult data will be captured in the behavioral health mapping tool as speciﬁc subsets of the population in order to strategically focus on the needs of these populations.
Beginning May 2016, OHA will convene a behavioral health system collaborative comprised of key stakeholders and partners from multi-sectors. The collaborative will use qualitative and quantitative information about Oregon’s behavioral health system to frame a policy platform upon which decisions and strategies can be built during the 2017 legislative session. The child, adolescent and young adult needs and service array will be an important conversation during this effort. You can ﬁnd more information and the full report here.
OHA is also making an effort to analyze capacity needs and fee-for-service rates for higher-intensity child and adolescent service system. This work is underway.
3. The CDC reports that rates of autism in our country are increasing — now 1:68 — with Oregon typically having a
higher-than-national average. What are your plans for addressing OHA-funded services for individuals with autism and the associated costs?
OHA will continue to provide services on the prioritized list. There is some helpful information about what the list is, what’s covered, and more. You can ﬁnd the full list of covered services here.
OHA offers many services for children with autism including but not limited to speech, occupational and other therapies such as applied behavioral analysis (ABA). The cost of funding these treatments can be considered an important investment in lives of children with ASD and their families, as early intensive interventions have been shown to signiﬁcantly improve the developmental trajectory of some children with autism. This is turn can lead to long-term savings in the cost of care. ABA cost data over the past 15 months demonstrate that it is a beneﬁt growing at a gradual and steady rate. This relatively predictable growth pattern allows us to increase funding for these services at a similar pace.
For a summary of other Medicaid-funded services for children with autism, please see the "Autism Spectrum Disorders (ASD): State of the States of Services and Supports for People with ASD" here (pages 313-320).
4. Current estimates indicate that a little more than half of children with autism have also been diagnosed with a developmental disability. How are OHA and DHS coordinating the respective Medicaid-funded services for these children and other individuals with a dual diagnosis? Do you predict that this coordination will achieve cost savings?
As OHA works to achieve better health outcomes for all Oregonians, coordinating care for all OHP members — including those with autism spectrum — is a priority. This means coordinating with all the different aspects of the system that a family may interact with. OHA coordinates with the systems that provide care to these individuals in a variety of ways, including ODDS and school staff in workgroups, facilitating discussions between systems of care and CCOs (coordinated care organizations), and opening up billing codes that allow OHP providers to bill for team conferences with other care providers. These efforts are ongoing and will remain a priority as we work toward better health outcomes.
5. The use of the Prioritized List is meant to increase access to preventive services and thereby save long-term costs. Do you believe that it is necessary for more individuals to receive Medicaid-funded preventive services either through the eligibility or authorization process now for necessary long-term costs savings to be achieved in the future?
Preventive care is key to the coordinated care model’s effectiveness and is a critical step toward curbing the rising cost of care. OHP members have access to preventive services through the prioritized list.
Since Oregon implemented the coordinated care model, OHA has maintained good access and patient satisfaction scores even while increasing OHP enrollment by more than 450,000 through Medicaid expansion. Since the coordinated care model has been implemented, satisfaction with health plans customer service increased by 8 percent. There have also been marked improvements in quality and outcomes, including:
- Decreased emergency department visits by 23 percent;
- Decreased admissions for short‐ term complications with diabetes by 32 percent;
- Decreased hospital readmissions by 23 percent, and
- Increased primary care home enrollment by 61 percent.
You can ﬁnd more data related to access of care and patient-centered primary care home enrollment here.
6. With early intervention key to successfully addressing behavioral and developmental challenges OHA has been working to identify children with these diagnoses as early as possible. Has OHA been able to gather data on how successful this initiative has been? What can be done within OHA and within the medical and behavioral care system as a whole in Oregon to improve the rates of early diagnoses and intervention? What kind of cost savings does OHA predict can be achieved through early diagnoses and intervention?
Coordinating care continues to be a priority. OHA is excited about the input gathered in the fall of 2015 and the next steps we’ll be able to take to address behavioral and developmental challenges. Please see question number two above for more details.
We don’t have these speciﬁc data you’re requesting at this time, but you can ﬁnd related data in our CCO metrics report here.
7. Of course many of the individuals and families receiving OHA and/or DHS services have little resources to navigate the complex state systems to access services. What is OHA doing to help these individuals learn about what services are available and how to request them? Do you have any kind of idea of the percentage of individuals and/or families who would qualify but typically do not apply for services?
Today, more than 95 percent of Oregonians have health insurance. This results in coverage for needed services. And with Medicaid expansion, OHA now covers more than 1 million of these Oregonians. Those enrolled in a CCO have access to a range of services.
The majority of Oregon Health Plan members are served in one of the 16 different CCOs around the state. CCOs coordinate care and educate members about the different beneﬁts that are medically appropriate for them, as well as how to access them.
Accessing medical care in Oregon may be challenging due to many factors but has improved with the transfer of the non-emergency medical transport beneﬁt to the CCOs. This means that a member's medical care and transportation needs are now coordinated within their CCO.
Determining how many individuals might qualify for a range of beneﬁts but are not accessing them is a difﬁcult calculation. There are many reasons why a family or individual does not access beneﬁts they are qualiﬁed for. This calculation could be estimated for a particular service and a speciﬁc diagnosis and severity, but is very difﬁcult to do with a spectrum diagnosis such as autism and with the many differing services that are available to an individual with that diagnosis.
8. It can be challenging for individuals and families to gather the type of documentation which is necessary to qualify for services. What systems are in place to help individuals and families understand how to appeal for behavioral, medical or developmental disability services which have been initially denied?
We have not seen evidence that documentation has been an issue.
Providers provide all supporting documentation for services requests. Appeal information is available through the member’s CCO customer service. If the member requests an administrative hearing, they will be contacted by a Hearing Representative who will explain the hearings process and answer any questions related to the denial.
9. Do DHS and OHA currently collect data on the number and types of appeals received by DHS, the CCOs or
DMAP? In Oregon, DHS and OHA make the ﬁnal determination about whether or not a claimant's Administrative Hearing Request qualiﬁes to be sent on to the Ofﬁce of Administrative Hearings for a Medicaid fair hearing. In contrast, I've heard that the vast majority of other states leave this determination to an Administrative Law Judge. Can you tell me a little bit about why Oregon differs in this practice?
Different states have different procedures. This is the procedure Oregon follows.
10. To wrap this up — what is OHA doing and what is yet to be done, in your estimation, to balance the priorities of access to services and cost-savings?
OHA is committed to using evidenced-based interventions to improve the health and well-being of all Oregonians. We’ve taken bold and innovative steps to transform our state’s health care system through our waiver and CCO system, but there’s more work to be done. We’re committed to improving access to behavioral health services across the state and making Oregon’s behavioral health system more patient- and family-centered.