A new state audit says Oregon is failing to ensure vulnerable children and families are receiving the mental health care they need through the Oregon Health Plan, even as taxpayers shell out millions of dollars in performance bonuses to healthcare administration companies.
Despite the importance of mental health services, auditors say in the report released Wednesday that state health leaders failed for the last decade — under both Gov. Kate Brown and Gov. John Kitzhaber — to set a consistent plan or vision for providing these services, resulting in “system disarray.”
The human consequences of fragmented and delayed mental health care can be severe. Although the auditors examined at how the state is serving all children and families on Oregon’s version of the Medicaid program, they also looked specifically at the experiences of children in foster care.
Oregon child welfare officials have in recent years said they were forced to temporarily house children in state care at government offices, hotels and institutional settings such as converted juvenile jails, in large part because many children had behavior health needs beyond what most foster parents could handle. Advocates for children say improved mental health care, addiction treatment and other services could allow more children to return home to their families sooner or live in a more homelike setting with foster parents.
Auditors described how one unnamed 9-year-old boy in the child welfare system stayed in a hotel for more than 100 days while awaiting recommended intensive mental health services. He was “treated in the emergency department several times, and did not have regular access to needed services and supports,” auditors wrote. Due to a variety of delays, the boy never received residential care that a child psychiatrist said he needed.
An anonymous 16-year-old girl with a history of sexual exploitation and drug use who was involved in the child welfare and juvenile justice systems also experienced delays also experienced poor health care when she most needed it. “After she was found by child welfare, she was treated at five facilities, including twice at the emergency department, but was not able to access Medicaid-funded psychiatric services,” auditors wrote.
Approximately 1 million low-income people are supposed to receive mental health care through the Oregon Health Plan. For that behavioral health care, the state expects to spend $3.2 billion in the two-year budget, auditors wrote.
Auditors traced many of the problems, including the lack of a vision or strategic plan, to a high rate of turnover among elected and agency leaders. After structural changes at the agency in 2015, the “behavioral health director position remained vacant for three years before three interim directors cycled in and out of the role,” they wrote. It was finally filled on a permanent basis in April 2019.
“Without a defined strategy and specific, measurable, departmental goals for behavioral health, (Oregon Health Authority) is unable to effectively assess its desired impacts for Oregonians — especially for children and families,” auditors said.
Auditors pointed out Medicaid administration companies known as coordinated care organizations can receive performance pay if they meet benchmarks set by the state, yet none of those metrics are tied specifically to the quality of mental health care provided to children and youth.
Although Oregon child welfare policy requires children to receive mental health assessments within 60 days of entering state custody, the companies tasked with managing that care — the coordinated care organizations — are judged by the state on a different metric. The Oregon Health Authority only looks at whether children in the foster system receive assessments within 60 days of the state notifying the companies that a child was placed in foster care, auditors wrote. Given significant delays between the time children enter state custody and when the state notifies Medicaid administrators, the companies largely meet their benchmarks even if children wait longer than child welfare’s goal of 60 days for an assessment.
According to data the auditors obtained from the Department of Human Services, “from January 1, 2017, through December 31, 2018, only 49% of children had their mental health assessment within 60 days of foster care entry, and only 58% had an assessment within 90 days of entry.”
Oregon Health Authority’s rating of children’s timely access to mental health assessments was much rosier, with no hint many children wait more than three months just for the initial evaluation. “In 2018, the measure showed 86.7% of children met this target and 13 of the 15 (Medicaid administration companies) received their incentive payment for the measure,” auditors wrote.
The Oregon Health Authority does not track whether children actually receive the mental health care determined to be necessary by those assessments.
“Continuing to reward (coordinated care organizations) for an ineffective measure instead of defining clear outcomes based on public interest is problematic,” auditors wrote, noting the companies received $188 million in performance pay in 2018.
The audit also highlighted what some people who work with neglected, abused and traumatized children have been saying for years: Chronic worker shortages are increasing “system strain and trauma for vulnerable children and youth in residential treatment facilities.”
But with Oregon Gov. Kate Brown and state lawmakers poised to make deeper recessionary cuts to the state budget potentially this fall and almost certainly in 2021, auditors warned that “COVID-19 budget impacts may prevent workforce supplementation.”
Auditors did not specifically include in their 22 recommendations for improvement a suggestion to change the performance metric for coordinated care organizations ensuring children receive good mental health care. However, they did recommend the state work on improving the companies' accountability including addressing reports that some companies did not provide data to the state in a timely manner.
The auditors also suggested the Oregon Health Authority use some of its existing analysts “to determine the extent to which Medicaid claims data can be used to accurately identify and track the number of children receiving mental health services statewide and outcomes.”
State Behavioral Health Director Steve Allen agreed with all the auditors' recommendations.
“This audit recognizes a long-standing challenge within the behavioral health system, which is lack of timely, complete and accurate data,” Allen wrote. “There are legitimate systemic reasons why this is the situation, and (Oregon Health Authority) continues to work on developing the ability to find cost-effective levers that result in improvements.”