Mental Health Association of Portland

Oregon's independent and impartial mental health advocate

Private study finds lower Medicaid costs for residents of Bud Clark Commons

Posted by admin2 on 10th April 2014

From the Oregonian, April 10, 2014

Monthly health care costs for Medicaid recipients who live at the Bud Clark Commons in Portland plummeted 55 percent after moving into the alcohol-and-drug-tolerant public housing project, according to a new study.

But those savings were inflated by 9 percentage points because two high-needs residents apparently died almost immediately after moving in.

Home Forward, the housing authority that operates the commons, funded the $50,000 study. The report touts its findings as an indication that supportive housing had a “profound and ongoing impact on health care costs” for the people who live there.

READ – Integrated Housing & Health; a Health-Focused Evaluation of The Apartments at Bud Clark Commons (PDF)

The study found across-the-board cost reductions for people who moved into the 130-unit studio apartment project, said Bill Wright, associate director for research of the group that conducted the study.

But Wright cautioned there is not a cause-and-effect relationship between living in the commons and lower health care costs.

“Moving in was associated with a reduction,” he said. “That doesn’t mean it’s a direct cause.”

Read the rest of this article here.

READ – Health care study explores the impact of housing on health care use, costs and outcomes, press release from Health Share Oregon


Report Conclusions

COST SAVINGS

Residents with Medicaid coverage saw significant reductions in medical costs after moving into BCC: the average resident saw a reduction of over $13,000 in annual claims, an amount greater than the estimated $11,600 it costs annually to house a resident at BCC.

Importantly, this reduction in claims was maintained into and beyond the second year of residency, suggesting that supportive housing had a profound and ongoing impact on health care costs for those living at BCC. We examined historical, pre-BCC claims data for residents to determine whether some reduction in costs might have been expected in this population even in the absence of housing.

We did not find evidence of a natural “regression to the mean” in costs for the population BCC serves; indeed, their health care costs steadily rose for the 2.5 years prior to moving into BCC, peaked just prior to move-in, and then immediately fell to a much lower level after move-in. In the absence of a formal experimental “control group” to compare out-comes, this represents the best available evidence that cost reductions are likely attributable to the acquisition of housing and would not have been expected to happen in its absence.

SHIFTS IN UTILIZATION

We examined utilization data in order to understand the mechanism by which costs were reduced. We found evidence that residents maintained connections to outpatient behavioral health, primary care, and pharmacy after moving in, but saw significant declines in inpatient and ED utilization. This suggests that cost savings among the BCC residents came from efficiently managing health care in appropriate settings, helping to reduce acute health crises and avoid more expensive types of utilization.

We also examined self-reported utilization data in order to determine if similar patterns held true for non-Medicaid residents. We found patterns in the self-report data that matched those in the claims: continued engagement in outpatient care accompanied by a reduction in acute events.

Hospitals absorb significant uncompensated care costs for such events. Given these costs, the “true” savings associated with housing at BCC are likely considerably higher than our Medicaid-only estimate.

ACCESS, HEALTH, & TRAUMA

Residents saw significant declines in unmet health care needs, and significant improvements in self-reported physical and mental health, after moving into BCC. There was also a significant increase in overall happiness.

Trauma histories were very common among BCC residents; even after moving in many residents still face traumatic events in their lives. Understanding the link between trauma survivorship and health care utilization/costs will be a key component of caring effectively for this population.

CHALLENGES

Our interviews with residents also revealed some challenges of the supportive housing model. Some residents told us that getting clean and sober was actually more difficult than they expected in an environment where others are still actively using. Others mentioned feeling unsafe or threatened by others living in the building, which sometimes hampered their involvement in social activities or use of other services. New strategies to overcome these challenges will help residents fully engage in the BCC model.

IMPLICATIONS FOR REFORM

These results suggest that health care reformers would be well served to think carefully about the relationship between housing and health, particularly in vulnerable populations such as those served by BCC. Among those in our study, getting into stable housing resulted in a significant reduction in total health care costs; these savings were greater than the estimated annual cost of housing someone at BCC, do not appear likely to have reflected natural regression to the mean, and were maintained over time. Housing also im- proved self reported health outcomes. In this acutely ill and vulnerable population, supportive housing was effectively a health care intervention, and it appears to have worked.

Additional research can help replicate and substantiate these findings. For now, however, these results suggest that Oregon’s commitment toward a broader view of health care — one that thinks beyond service delivery and encompasses the social determinants of health — may have real potential to help bend the cost curve. Policy and funding pathways to support and expand such models should be strongly considered as part of Oregon’s ongoing transformation effort.

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Increased Medicaid coverage expected to overwhelm mental health services

Posted by Jenny on 19th February 2014

mental-health1TDN.com, Feb. 17, 2014

As millions of Americans gain health coverage through the Affordable Care Act’s Medicaid expansion, experts say their higher rates of mental health and substance abuse disorders will be difficult to treat due to a lack of counselors and behavioral therapists who accept Medicaid patients.

In the District of Columbia and the 25 states where the expansion is under way, nearly 1.2 million uninsured adults newly eligible for coverage will have substance abuse problems, according to federal estimates, and more than 1.2 million are projected to have some sort of mental illness. An estimated 550,000 of those will have serious mental disorders that impair their everyday functioning.

As these patients seek treatment for any number of problems, a shortage of caregivers — from physicians to dentists — will pose a major challenge for Medicaid, the federal-state health program for poor people and those with disabilities. The lack of providers may be most acute in the area of mental health services.

The Medicaid expansion extends coverage to adults who earn up to 138 percent of the federal poverty level. Those with behavioral problems will be treated at community mental health agencies and health centers that serve low-income patients. This new expansion population will strain the limited resources of these facilities, many of which already have staff shortages and waiting lists for behavioral treatment.

Further complicating the problem: Most mental health therapists in private practice won’t treat Medicaid patients because of the program’s low reimbursement rates.

And now that the health care law has made mental health treatment a mandatory, or “essential,” benefit for millions of people with private coverage, the demand for therapists and counselors will increase, making it even harder for Medicaid’s community-based providers to recruit and retain behavioral health professionals.

“As more people are insured, more people are also going to be seeking services,” said Rusty Selix, the executive director of the California Council of Community Mental Health Agencies. “Our biggest concern is more competition for a limited number of professionals and the cost pressures that’s going to create. We’re going to have to pay more to retain people. It’s supply and demand.”

Already, the demand far outstrips the supply.

Americans live in federally designated mental-health-professional shortage areas, where there’s only one psychiatrist for at least every 30,000 residents. That’s compared with only 59.4 million who live in primary-medical-health-professional shortage areas and 46.7 million who reside in dental-health-professional shortage areas.

Fifty-five percent of U.S. counties — all of them rural — have no psychiatrists, psychologists or social workers, according to the U.S. Department of Health and Human Services.

Filling the needed positions nationally would take 1,846 psychiatrists and 5,931 other professionals, federal estimates show.

“That’s a critical problem. And the Medicaid expansion will make that even worse,” said Susan Mandel, the CEO of Pacific Clinics, the largest community mental health agency in Southern California.

Joel Miller, the executive director and CEO of the American Mental Health Counselors Association, said he was expecting to see “pretty significant increases” of 20 to 25 percent in the numbers of psychologists, mental health counselors, social workers, and marriage and family therapists over the next five years, based on student enrollment trends.

“I’m very much an optimist,” he said. “But sure, if you look at the current capacity, there are holes. There are gaps in inner cities and in rural areas.”

Most of the expansion enrollees will be single, childless adults, a group that Medicaid traditionally has declined to cover. Among this group, military veterans, the homeless and former jail inmates are expected to have higher rates of mental illness.

For many, the Medicaid expansion will provide their first opportunity for health coverage as adults. After living for years with untreated or undiagnosed disorders, their pent-up demand for care might trigger a run on Medicaid services.

“I think we’re going to see a pretty good uptick, an increase, right off the bat,” Miller said. “Based on what we’ve looked at in states that have increased coverage for people who were uninsured with a behavioral health condition, we expect there’ll be a pretty significant increase right from the get-go.”

When Oregon’s Medicaid program began accepting childless adults in 1994, for example, the new enrollees logged three times as many mental health and substance abuse treatment visits as the program’s low-income parents.

At Yakima Neighborhood Health Services, a community mental health agency in Yakima, Wash., 40 to 50 percent of the several hundred homeless Medicaid-expansion clients who’ve enrolled since October have had some sort of mental illness, said Rhonda Hauff, the agency’s chief operating officer.

The most common problems are depression, anxiety and post-traumatic stress disorders, along with more serious problems such as bipolar disorder and schizophrenia, Hauff said, adding that a fourth full-time behavioral specialist was needed.

Medicaid providers are likely to face similar pressure in Minnesota, where an estimated 30 percent of uninsured, expansion-eligible adults suffer from some form of mental illness and 19 percent have serious mental illnesses, according to federal estimates.

In Delaware, Ohio, West Virginia and Vermont, roughly 1 in 4 uninsured expansion-eligible adults have mental illnesses, federal data shows. Those states — along with Iowa, Rhode Island, Kentucky and Oregon — have double-digit rates of serious mental illness among that group.

“When the new enrollees get coverage, there’s a real opportunity to engage them in treatment, but there needs to be capacity in the system to do so. And that, I would say, is one of the challenges,” said Allison Hamblin, the vice president for strategic planning at the Center for Health Care Strategies, a nonprofit resource center.

Finding psychiatrists is one of the toughest problems faced by Mandel, of Pacific Clinics. The number of practicing psychiatrists in the U.S. declined by 2 percent from 2000 to 2010, according to the Association of American Medical Colleges, even as the population increased by nearly 10 percent. Retirements by an aging workforce are a big part of the problem. Nearly 57 percent of U.S. psychiatrists are 55 or older, the group reported in 2012.

Recruiting younger ones is hard, Mandel said, because most newly trained psychiatrists don’t want to relocate.

“When people go to medical school and go into their residency, they tend to put down roots in that community,” she said. “They marry. They have kids. So if you don’t have a medical school with a department of psychiatry in your neighborhood, it’s very hard to recruit people.”

Not everyone, however, is fretting about the situation. Matt Salo, the executive director of the National Association of Medicaid Directors, said the new expansion patients weren’t likely to arrive en masse but probably would seek treatment gradually, making them easier to accommodate.

“And we really don’t know who’s going to come in,” Salo said. “It’s hard to quantify people who haven’t shown up yet.”

The real problem may not be a lack of providers but a lack of funding, said Jennifer Mathis, the director of programs at the Bazelon Center for Mental Health Law, a national nonprofit advocacy group in Washington. From 2009 to 2012, states cut a collective $4.4 billion from their mental health budgets, according to the National Association of State Mental Health Program Directors.

Since the federal government will pay all the medical costs for Medicaid-expansion patients in 2014, 2015 and 2016, states have an incentive to offer greater mental health benefits, Mathis said.

“It remains to be seen whether there’s an actual shortage of providers,” she added. “I don’t think we have data to suggest one way or the other, really.”

In California, Selix said his organization was working to loosen licensing regulations for counselors so a broader segment of people could be hired.

“There’s a lot of people that have valuable experience but they don’t have mental health licenses, and we want to be able to use them for services as much as possible,” Selix said.

As an example, he cited “peer support” counseling, led by instructors who are recovering from their own mental health struggles.

“Using people who have been through that to help others navigate through it reduces the amount of licensed clinician time we need,” Selix said. “Plus it’s less expensive, so we’re trying to expand that.”

Efforts nationwide to place counselors, social workers and others with behavioral health credentials in clinics and other safety-net facilities will help provide greater access to counseling in primary care settings.

In Kentucky, where more than 14 percent of uninsured expansion-eligible adults are estimated to have substance abuse problems, the new Medicaid benefit presents their best hope for recovery — if the providers are available.

“We know that there’s a significant number of people that need substance abuse services who’ve not had a way before to pay for it,” said Tony Zipple, the CEO of Seven Counties Services Inc., which treats mentally ill Medicaid patients in the Louisville area. “Whether that becomes a problem for us depends on how many people come in, for what services and over what period of time.

“I may eat my words and we may be surprised tomorrow, but I really do think this will happen in an incremental enough way that we’ll be able to handle it reasonably well. But only time will tell.”

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Iowa Senator makes Oregon Medicaid prescriber data available

Posted by Jenny on 17th June 2013

By Jenny Westberg, June 17, 2013

ZyprexaWho are the state’s top prescription writers for widely abused drugs like Oxycontin and Xanax?

How much does Oregon’s Medicaid  program pay for expensive mental health drugs like Seroquel and Zyprexa?

The data obtained by Sen. Charles Grassley (R-Iowa) may not provide every answer about Oregon clinicians’ prescribing practices, but it does shine a light on previously obscured information.

Grassley, who is ranking member of the Senate Committee on Finance, wrote to Bruce Goldberg, director of the Oregon Division of Medical Assistance Programs, in 2010 and 2012, expressing concern about heavy prescribing by a subset of providers and the possibility of waste and fraud.  In particular, Grassley asked about certain high-priced and often overprescribed antipsychotics, as well as common drugs of abuse that can wind up on the black market or lead to addiction and even death.

In response, Goldberg produced listings of the top 10 Medicaid prescribers of specified drugs, for 2008, 2009, 2010 and 2011.

The information covers the following second-generation “atypical” antipsychotics:

  • Abilify
  • Geodon
  • Seroquel
  • Zyprexa
  • Risperdal

and these frequent drugs of abuse:

  • OxyContin
  • Roxicodone
  • Xanax

The top 10 prescribers for each form of each drug (brand name, generic, long-acting, etc.) were identified with their 10-digit NPI numbers, along with total number of prescriptions and total cost to Medicaid for every entry.

As a service to journalists, researchers, and others interested, the Mental Health Association of Portland went through the raw data, found names for the NPI numbers, added up the numbers for different forms of the same drug, and matched data for the same provider appearing in different places.  We have entered it all on a spreadsheet on Google Drive, with several reports to show the data various ways (reports are on separate sheets you can see by clicking the tabs at the bottom of the spreadsheet).

It is important to remember that this is very specific information that applies only to the top 10 prescribers for each drug, and only for prescriptions billed to Medicaid.  For example, you might see a provider with totals for two drugs.  This does not necessarily mean they didn’t prescribe Drug #3.  But for the third drug, the provider wasn’t in the top 10.  Likewise, if a provider does not appear on the lists, it does not necessarily mean they are prescribing more conservatively; it could be that this provider does not take Medicaid patients.

Also, keep in mind that the antipsychotics have been coming off patent the past few years, so prescriptions could stay high while total dollar amounts dipped.

Finally, we did not include the data from 2008 in our spreadsheet.  During that year, many prescriptions had no NPI number. Another identifier was being used – but not always, and when there was no identifier, pharmacies recorded “999999.”  Since the 2008 data would not be comparable, we only worked with 2009-11. 

From the data alone, it is impossible to draw conclusions; a high-volume prescriber may be overprescribing — or busy.  We hope others will take these numbers and provide some context, so all of us can benefit from this store of information.

Read or download the Oregon prescriber data spreadsheet:  https://docs.google.com/spreadsheet/ccc?key=0Arv37LTwMHQHdFJJdUVyUWlzcEJsdVJ6bU5sWENLSnc&usp=sharing

 Correspondence and Raw Data (PDFs)

Letter from Sen. Grassley to Oregon DHS chief Bruce Goldberg 2010
Bruce Goldberg responds to Sen. Grassley 2010
Bruce Goldberg responds to Sen. Grassley 2010 with additional info
Letter from Sen. Grassley to Bruce Goldberg, asking for update 2012
Bruce Goldberg responds to Sen. Grassley 2012
DHS – Oregon Top Prescribers List 2008-2009
DHS – Oregon Top Prescribers 2010
DHS – Oregon Top Prescribers 2011

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Marianne Udow-Phillips on Oregon Medicaid study: Mental health is health, too

Posted by Jenny on 12th May 2013

By Marianne Udow-Phillips, Bridge Magazine, on MLive Media Group, May 12, 2013

girl-happyRecent reports about a Medicaid experiment in Oregon reveal a major disconnect we have in the health care world: we make a historic — and unwarranted — distinction between “physical health” and “mental health.” Worse, that distinction actually interferes with both our investment in mental health treatment and patients’ willingness to seek treatment.

The Oregon Medicaid study is about the impact that Medicaid coverage has had on a group of low-income individuals who obtained health insurance coverage for the first time several years ago. Researchers have been studying Oregon because of a unique set of circumstances that resulted in some uninsured adults being randomly selected to receive access to Medicaid, while others were not. That circumstance enabled a randomized controlled trial to be done in the “real world” — a rarity in health services research.

The experiment’s initial set of results, which relied on self-reports by the participants, were released last year. In the first year of the study, those with Medicaid coverage reported better health than those who were in the control group. In the most recent report, which includes second-year findings, researchers used actual health measures for cholesterol, high blood pressure, diabetes, and depression. This second set of data resulted in a more nuanced and complicated conclusion than the first-year report.

Specifically, the researchers found no impact in the two years with regard to cholesterol and high blood pressure; an increase in diagnosis and treatment of diabetes but no impact on blood sugar levels; a significant reduction in depression; and a significant improvement in financial stability for those with Medicaid coverage compared to the control group.

Because these findings were released while many states are still considering whether or not to expand Medicaid, the Oregon story was reported across multiple media outlets. Headlines ranged from the fairly neutral (New York Times: “Medicaid Access Increases Use of Care, Study Finds”) to the more judgmental (Forbes Magazine: “Oregon Study: Medicaid ‘Had No Significant Effect’ On Health Outcomes vs. Being Uninsured”). Some commentators have said that the study and resulting headlines were almost like a Rorschach test about what one believes about the Affordable Care Act and the Medicaid expansion. But, even articles and publications that are generally favorable to the Medicaid expansion often reported that the study showed that the Oregon experiment had no impact on health.

These headlines are stunning in several ways. First of all, they generalize a few measures over a relatively short period of time to a sweeping conclusion about health insurance. But, beyond that, they seem to entirely discount the improvements in mental health as a “health outcome.”

Mental Health is ‘Health,’ too

In the Oregon Medicaid experiment, the rate of depression dropped by more than 9 percentage points and the relative improvement compared to the control group was 30 percent. Why is it that we don’t identify the significantly lower rates of depression as a significant health outcome?

For years, we have had research on the causes of depression and other mental health conditions. While the causes are likely multifactorial, including a combination of genetics, environment, biology and psychology, the National Institute of Mental Health describes “depressive illness” as a “disorder of the brain” —not a personal weakness.

More than 10 years ago, visionaries at the University of Michigan, under the leadership of Dr. John Greden, established the country’s first Depression Center. Dr. Greden reasoned that until we treat depression like we do cancer — as a disease that requires focused, team-based research and collaboration — we will not make the kind of progress in understanding this disease that we need to. Today there is a National Network of Depression Centers that includes 21 of the nation’s top academic institutions.

It is disappointing to realize that 10 years of this kind of work has not erased the distinction between “physical” and “mental” health. If we had, the headlines about the Oregon experiment would have been something like this, “Medicaid coverage shown to have significantly improve health relative to being uninsured.”  We should only be so lucky to find a health impact as large as this in other areas of the Oregon health experiment.

Marianne Udow-Phillips is director of the Center for Healthcare Research & Transformation and a former director of the Michigan Department of Human Services.

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‘Oregon experiment’ shows Medicaid expansion improves mental and financial – but not physical – health

Posted by Jenny on 1st May 2013

News release, Harvard School of Public Health, May 1, 2013

120504_health_care_overhaulNew findings from the Oregon Health Insurance Experiment show that Medicaid coverage had no detectable effect on the prevalence of diabetes, high cholesterol, or high blood pressure, but substantially reduced depression, nearly eliminated catastrophic out-of-pocket expenditures, and increased the diagnosis of diabetes and the use of diabetes medication among low-income adults. The Oregon Health Insurance Experiment is the first use of a randomized controlled study design to evaluate the impact of covering the uninsured with Medicaid and provides important evidence for policy makers as the U.S. undertakes Medicaid expansion in 2014.

The study, led by Katherine Baicker, professor of health economics at Harvard School of Public Health and Amy Finkelstein, Ford professor of economics at MIT, appears in the May 2 issue of the New England Journal of Medicine.

“This study represents a rare opportunity to evaluate the costs and benefits of expanding public insurance using the gold standard of scientific evidence—the randomized controlled trial. Without a randomized evaluation, it’s difficult to disentangle the effects of Medicaid from confounding factors like income and health needs that also affect outcomes,” said Baicker, co-principal investigator of the study.

In 2008, Oregon held a lottery to give additional low-income, uninsured residents access to its Medicaid program; about 90,000 individuals signed up for the lottery for the 10,000 available openings. Approximately two years after the lottery, the researchers conducted more than 12,000 in-person interviews and health examinations of lottery participants in the Portland, Oregon metropolitan area, and compared outcomes between those randomly selected in the lottery and those not selected in order to determine the impact of Medicaid.

Some of the key findings:

Physical health

  • Medicaid had no significant effect on measures of hypertension or high cholesterol, or on the rates of diagnosis or use of medication for these conditions.
  • Medicaid increased the probability of being diagnosed with diabetes after the lottery by 3.8 percentage points (compared to the 1.1% of the control group who were diagnosed with diabetes) and increased the use of diabetes medication by 5.4 percentage points (compared to the 6.4% of the control group who used diabetes medication), but had no effect on glycated hemoglobin (a measure of diabetic blood sugar control).

Mental health

  • Medicaid reduced rates of depression by 9 percentage points (compared to the 30% of the control group screening positive for depression) and increased self-reported mental health.

Financial hardship

  • Medicaid virtually eliminated out-of-pocket catastrophic medical expenditures (defined as out-of-pocket medical expenditures in excess of 30% of household income) and reduced other measures of financial strain.

Utilization and access

  • Medicaid increased health care use, including use of physician services, prescription drugs, and preventive care.

“The study highlights the important financial protections that Medicaid provides, as well as the substantial improvements in mental health, but does not provide evidence that Medicaid coverage translates to measurable improvements in physical health in the first two years,” said Finkelstein, co-principal investigator of the study.

The current study is part of an ongoing research program gathering a wide array of data sources to examine many different effects of Medicaid, and represents a collaboration between non-profit and academic researchers and state policy makers. A previous study looking at data collected about a year after the lottery found that Medicaid substantially increased health care use, increased self-reported health, and reduced financial strain. More information can be found at http://www.nber.org/oregon.

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Senate President Courtney calls for ‘game-changing’ funding increase for children’s mental health

Posted by Jenny on 9th March 2013

By Christopher David Gray, The Lund Report, March 5, 2013

childrenA pathway has appeared to the game-changing funding levels that Senate President Peter Courtney signaled for community mental health — at least for children – when the increased funding made a list of priorities when the co-chairs released their two-year spending plan Monday morning.

Courtney’s proposal called for a funding increase of $331 million for community mental health, including $46 million for children and adolescents — $28 million more than what Gov. John Kitzhaber had earmarked.

“We’re gonna get there or we’re gonna get close,” said Courtney’s spokesman Robin Maxey after the press conference.

Part of that increased money would be included in the $4.3 billion dedicated to human services, while the rest would be part of the $275 million in new taxes by eliminating some unspecified corporate and individual tax write-offs.

“We should treat our tax expenditures and deductions the same way as we see our regular expenditures,” said Sen. Richard Devlin, D-Tualatin.

The co-chairman’s budget projects $75 million from these new resources for children’s mental health and other healthcare priorities such as the tobacco prevention program, the Farm to School program, the Oregon Health & Science University Rural Scholars Program, mandated physical health education and an increase in payments to home care workers.

The details for the budget still must be worked out through the various Ways & Means subcommittees and could definitely change, according to Devlin.

That budget also keeps the funding levels consistent with the governor’s budget for coordinated care organizations and the state mental hospital. The proposal also presumes the Medicaid expansion will take place, giving Oregon Health Plan coverage to 250,000 newcomers next year however those dollars will come from federal coffers, not the state’s general fund.

Devlin and fellow co-chairman Rep. Peter Buckley, D-Ashland, called for a $16.6 billion discretionary budget over the next two years, which assumes $705 million in savings to the Pubic Employee Retirement Savings — which is more modest than the $865 million in the governor’s budget.

“It’s trying to thread a needle in the dark,” Devlin said. “We need to find a path that is both fair and proposals that will have both short-term and long-term savings. … Higher levels that don’t hold up in court don’t do anyone any good.”

The budget also assumes the savings projected by Kitzhaber from prison reform.

Education funding would be $6.55 billion over the next two years, an increase from Kitzhaber’s $6.15 billion and local districts would realize $50 million less in savings from PERS reforms than the governor proposed. Meanwhile, the human services budget would bump up by 9 percent.

The minority Republicans also presented their own budget proposal, one that would hold revenues at current levels while promising $1.8 billion in PERS savings, despite the tricky legality of scaling back public employees’ promised pensions.

Republicans including Rep. Dennis Richardson of Central Point and Sen. Doug Whitsett of Klamath Falls said they were shut out of the budget discussions brought forward by the majority Democrats, unlike last session, when the House was split between the two parties.

“I think it’s unfortunate that the Republicans have chosen to politicize the co-chairs’ budget,” said House Speaker Tina Kotek, D-Portland.

The Republicans matched the Democratic co-chairmen’s numbers on education funding but sought to hold the line to roughly 2 percent annual increases for human services, roughly the current rate of inflation.

Richardson argued that the number of people seeking social services should decline as the economy recovers. “The caseloads should be decreasing,” he said.

He pointed out that human services represented 21 percent of the budget in 2005-07, yet absorbed 26 percent of the general fund last biennium because of the 2008 economic collapse. At the same time, the percentage of discretionary funds spent on education has declined from 44 percent to 38 percent.

“We’re placing the expansion of social programs on the backs of our children,” Richardson said.

Rep. Mark Johnson, R-Hood River, said the Republicans would be hard pressed to support any tax increases as Oregon’s unemployment rate clung to 8.3 percent.

But while tax increases require a bipartisan three-fifths majority vote, allowing tax expenditures already scheduled to lapse to actually expire does not require a similar majority.

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Oregon, California tell insurance companies to stop denying transgender health care

Posted by Jenny on 22nd January 2013

Transgender symbolBy Jonathan J. Cooper, Associated Press, Jan. 16, 2013

Regulators in Oregon and California have quietly directed some health insurance companies to stop denying coverage for transgender patients because of their gender identity.

The states aren’t requiring coverage of specific medical treatments. But they told some private insurance companies they must pay for a transgender person’s hormone therapy, breast reduction, cancer screening or any other procedure deemed medically necessary if they cover it for patients who aren’t transgender.

The changes apply to companies insuring about a third of Oregonians and about 7 percent of Californians, but not to people on Medicare and Medicaid or to the majority of Californians who are insured through a health management organization, or HMO.

Advocacy groups said the action is a major step forward in their long battle to win better health care coverage for transgender Americans.

“It’s just a matter of fairness,” said Ray Crider, a 28-year-old transgender man from Portland. “I just never felt that I was like anybody else. I see everybody else being taken care of without having to fight the system.”

Officials in both states said the new regulations aren’t new policies but merely a clarification of anti-discrimination laws passed in California in 2005 and in Oregon two years later.

Many health insurance policies broadly exclude coverage of gender identity disorder or classify it as a pre-existing condition. Transgender patients are often denied coverage for medical procedures unrelated to a gender transition, advocacy groups said, because insurance companies deem the condition to be related to their sex reassignment.

Some transgender patients also have trouble getting access to gender-specific care. A person who identifies as a man might be denied coverage for ovarian cancer screening or a hysterectomy. A transgender woman might be denied a prostate screening.

The state insurance regulators said those procedures, if covered for anybody, must be covered for all patients regardless of their gender.

Masen Davis, director of the Transgender Law Center in San Francisco, said he’s unaware of insurance regulators in any other state taking similar action.

The California regulations took effect in September and apply only to insurance products regulated by the California Department of Insurance. The agency primarily regulates preferred provider plans, or PPOs, that covered about 7 percent of the population in 2010, according to data from the California Health Care Foundation.

The agency that regulates California HMOs has discussed transgender care with consumer groups and health plans, “but no regulations have yet been proposed or adopted,” said Marta Bortner Green, a spokeswoman for the Department of Managed Health Care.

The Oregon Insurance Division issued its guidance last month in the form of a bulletin to insurers. It applies to commercial insurance companies that cover about a third of the state’s population; the rest are uninsured, on Medicare or Medicaid, or work for a large employer that’s self-insured.

“This is a very historic bulletin, and it really indicates that the tide is turning on this issue,” said Tash Shatz, transgender justice program manager at Basic Rights Oregon, an advocacy group.

Transgender advocates say gender reassignment, through hormone treatment or surgery, is medically necessary, and they’ve long fought insurance companies that argue the procedures are cosmetic. They hope the new state regulations will mean fewer procedures are refused and make it easier to appeal a denial.

The transgender community has picked up significant momentum securing health coverage in recent years. San Francisco in 2001 became the first U.S. city to cover sex reassignment surgeries for government employees. Seattle, Portland, Ore. and Berkeley Calif., have followed suit.

Large employers are increasingly offering coverage for a broad spectrum of care, including gender reassignment surgeries.

State regulators don’t have authority to force insurance companies to cover specific procedures, like hormone therapy or genital reconstruction. But they’ve told insurers that if they provide breast reduction for patients with back pain, they can’t deny it for a gender reassignment that’s been deemed medically necessary. Insurers could unilaterally exclude coverage of, say, breast implants, but it would have to apply to all policyholders equally, including breast-cancer patients.

“We’ve received the Oregon Insurance Division’s directive to implement this new mandate, and we are working to ensure that our members’ future coverage aligns,” Scott Burton, a spokesman for Regence BlueCross BlueShield of Oregon, said in a statement.

“We’re still assessing the impact of the ruling, and will continue to monitor state and federal guidance on this topic,” said Kathy Born, a spokeswoman for Pacific Source Health Plans, another large insurer in Oregon.

When Ray Crider heard the news, he danced around his apartment with his wife. A 28-year-old transgender man living in Portland, Crider fought a long battle to convince a previous employer to include transgender services in his policy.

Although he was insured, Crider paid thousands of dollars out of his pocket for testosterone treatment and mental health care before winning his fight for coverage of gender identity. He finally got a double mastectomy, covered by insurance, a year ago, he said, but not before the binder he used to flatten his chest required several emergency room trips because it constricted his breathing.

“This was one of the most incredible things that could ever happen,” Crider said, “to know that there’s a state full of people who won’t have to go through what I went through.”

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Can Oregon save American health care?

Posted by Jenny on 19th January 2013

Gov. John Kitzhaber

Gov. John Kitzhaber

In 2011, Oregon Gov. John Kitzhaber faced a vexing problem: The state had a $2 billion hole in its Medicaid budget and no good way to fill it.

He could cut doctors’ pay by 40 percent, but that might lead to them quitting Medicaid altogether. He could drop patients or benefits, but that would only compound costs in the long run. A former emergency room doctor, Kitzhaber remembers culling the Medicaid rolls in the 1980s, when he served as a state senator.

“When I went back home, and went back to the emergency department, I saw a couple of people who came in who lost coverage under that decision,” he said. “One of them was a guy who had had a massive stroke. These people don’t disappear.”

So Kitzhaber did something that many before him have done in desperate times. The governor who favors cowboy boots over dress shoes made a bet that Oregon could not afford to lose.

The deal Kitzhaber struck was this: The Obama administration would give the state $1.9 billion over five years, enough to patch the budget hole. The catch: To secure that, Oregon’s Medicaid program must grow at a rate that is 2 percent slower than the rest of the country, ultimately generating $11 billion savings over the next decade. If it fails, those federal dollars disappear.

Oregon is pursuing the Holy Grail in health-care policy: slower cost growth. If it succeeds, it could set a course for the rest of the country at a pivotal moment for the Affordable Care Act. Under the law, many states will expand Medicaid programs to cover everyone below 133 percent of the federal poverty line, adding 7 million Americans to the program in 2014 and leaving states looking for the most cost-effective way to cover that influx of patients.

In Oregon alone, Medicaid is expected to enroll 400,000 new patients by 2022, nearly doubling its current numbers, according to an Urban Institute analysis.

As Oregon’s population grows, the state has come to realize that Medicaid is not a bottomless bucket of money. The state’s budget cannot sustain that. Instead, it strives to deliver what health policy experts call “the triple aim”: higher-quality care that leads to better outcomes, all delivered at a lower cost.

“Oregon is trying to change the way that health care is delivered with incentives to deliver smarter, better care, instead of just imposing budget changes that cut back on health care,” said Cindy Mann, director of the Center for Medicaid and State Operations. “They’re doing this statewide and it’s very exciting for us.”

Under the new deal, Oregon does not get a lump-sum payment. Instead, the federal government doles out the $1.9 billion over five years. If the state cannot deliver cost savings up front, while hitting certain quality metrics, it’s cut off. The money it needs to keep doctor salaries stable and patients’ benefits covered dries up.

“In terms of cost-control experiments, the likes of this are something we have never seen in health care,” said John McConnell, a health policy researcher at Oregon Health & Science University who is studying the Oregon Medicaid waiver. “The natural questions are: Is it going to work? Is the state going to fix the budget? And if they do fix the budget, how are those savings accomplished?”

As Kitzhaber sees it, failure isn’t an option. The state’s Medicaid program needs that $1.9 billion to make ends meet now, even if it means paying big dividends back to the federal government later. It’s not unlike a payday loan, with a quick influx of cash and a large obligation to follow.

“There’s no more money,” Kitzhaber said. “This is one where you really have to change how you do business in order to survive.”

The phone started ringing, Kitzhaber said, when he landed that $1.9 billion. Other states wanted to know the trick. Then he explained what he committed to.

“We got a lot of calls, things like ‘How did you get all that cash and how can we get some?’” he said. “They never called back.”

30 years and no solution

Oregon has a long history of leadership when it comes to the Medicaid program, which covers nearly 62 million low-income and disabled Americans nationwide. In the early 1990s, it was among the first to use a federal waiver to expand limited coverage to all Oregonians living below the poverty line. Oregon’s uninsured rate quickly dropped, from 18 percent in 1994 to 10 percent in 1998.

Maintaining a robust health plan, however, hasn’t been easy. The state’s tax revenue dropped during the economic downturn of the early 2000s. To keep the Medicaid program afloat, the state charged significantly higher co-pays for some: $50 for an emergency room visit and $250 for a trip to the hospital.

Medicaid enrollment shrank by 46 percent as patients affected by the changes left the program — likely relegated to the ranks of the uninsured — between February and December 2003, according to research published in the journal Health Affairs.

Separate research has found that when Medicaid premiums rise by 1 to 5 percent of an uninsured family’s income, their odds of participating drop from 57 to 18 percent.

“For the last 30 years, both the private and public sector have done the same things to manage health-care costs,” said Bruce Goldberg, the Oregon Health Authority director who oversees the Medicaid program. “They’ve cut people from coverage, cut payment rates or cut benefits

“It’s been 30 years of doing that, and we haven’t solved the problem.”

This time around, Oregon wanted to try something different. Instead of dropping patients, the goal is to make high-quality health care less expensive.

Goldberg says that a small experiment in Oregon last year gave the state clues about a better way to reduce health spending. It took place at St. Charles Hospital in Bend, a mountain town known for its snowboarding, white-water rafting and microbreweries.

St. Charles noted that 144 patients tended to use the emergency room the most. Taken together, they averaged 14.25 trips each over 12 months. These patients drove much of the area’s Medicaid spending.

Researchers focused on them. Despite the frequent visits to the ER, these patients tended to be disconnected from the system.

More than half did not list a primary-care doctor. Some didn’t even have a preferred hospital: 27 percent had visited multiple ERs. The majority had unmet mental health needs, even though most had Medicaid, which provides mental health coverage.

Much of that seemed to have to do with the fragmented nature of Oregon’s Medicaid program.

“In our old system, we had people who had a physical health plan, a mental health plan and a dental plan,” Goldberg said. Patients would have three insurance cards, one for each type of service.

Where health-care services tended to be siloed, providers in Bend decided to integrate. It stationed community health workers in emergency rooms, who could help assess why patients had turned up.

Behavioral health specialists were embedded in clinics that traditionally dealt only with physical issues, in order to give patients a point of contact when they walked in the door.

The program was not a complete success. Of the 144 patients in the study, only 62 percent agreed to work with a community worker on a plan for their care. The others proved difficult to track down or did not want to participate.

Still, it did significantly change how the most-expensive patients used the health-care system. Emergency department visits fell by 49 percent. On average, the program generated about $3,000 in savings per patient.

Now, the Oregon aims to bring an approach that worked with 144 patients in Bend to Medicaid’s 564,470 patients across the state.

Oregon divided the state into 15 region and gave each one a set amount to care for each patient. These regions can divvy their dollars however they please, so long as patients hit certain quality metrics, like ensuring that adolescents get well-care visits and that steps are taken to control high blood pressure.

The hope is that each of the 15 regions, known as coordinated care organizations, will invest only in the most cost-effective health care. A behavioral health worker who can prevent emergency admissions becomes a lot more valuable, the thinking goes, when Medicaid funding is limited.

In this way, the Oregon plan has some parallels to Republican ideas to “block grant” the Medicaid program, and give states a set amount to run their programs. Both rely, in part, on a fixed budget to put downward pressure on health spending.

“You can call it what Oregon calls it, a global budget, or you can call it a block grant,” said Tevi Troy, assistant Health and Human Services secretary under George W. Bush. “There’s a semantic aspect to it. At the end of the day, we’re talking about putting limits on what we’ll spend on Medicaid.”

Democrats have typically opposed block grant proposals out of fear that they could lead states to skimp on care to meet spending targets. Safeguards in the Oregon plan, like the quality metrics, however, have made the approach more palatable to liberals.

“The idea of a global budget is to try to wring those costs without actually making consumers or seniors bear the heaviest burden,” said Neera Tanden, the Center for American Progress president who has advised President Obama on health policy.

Hope in Prineville

At the Mosaic Medical clinic in Prine­ville, a tiny Central Oregon logging town of 9,192, Juana Martinez and Michelle Ortiz are practicing the type of medicine that Kitzhaber thinks could fix the system. They are community health workers, the ones who make sure that patients do not slip through the cracks.

“Back there, you just get patients’ vitals,” said Martinez, motioning toward the exam rooms. “Here, it’s more knowing about them and making sure you can help them.”

That’s what she and Ortiz have done with Rebecca Whitaker. The 53-year-old Medicaid patient moved to Prineville last year, after shuffling through three Arizona nursing homes in six years, while recovering from a stroke.

Doctors had prescribed her 28 medications. Her social anxiety would get so bad that, sometimes, she rubbed her hands raw. By the time Whitaker got to Prineville to live with her cousin, she had given up on the health-care system.

“I tried to make it on my own for three months,” she said. “I was a diabetic without insulin. I wore a size zero pants. I tried suicide twice. I swore I’d never see another doctor.”

At Mosaic Medical, Whitaker received care for her diabetes and blood pressure. She also began seeing the clinic’s behavioral health specialist every week, who helped tend to her anxiety and depression.

Community health workers aided in other ways. They helped to ease her social anxiety by attending bingo night together. When Whitaker expressed an interest in moving out of her cousin’s house, Martinez helped her find an apartment.

“They have been the most moral support I’ve ever had in my life,” Whitaker said. “They cared, and that made me want to care. Little by little, when things got too frustrating in life, I’d see one of them. They changed my whole life.”

Worry in Portland

The governor’s gamble looms large for those who have to execute his plan: When you have a fixed number of health-care dollars, who gets the biggest slice of the spending?

The question weighs heavily on the doctors at Richmond Clinic in Portland, a federally qualified health center that is run by Oregon Health & Science University and sees a large load of Medicaid patients. Doctors there are pleased about the opportunity to be paid for some of the services they wouldn’t now, like having a long talk with a patient about diabetes management.

“What we’re excited about, with this whole transformation process, is having the mental space and time to address our patients’ needs,” said Nick Gideonse, the clinic’s medical director. “If we can get off the reimbursement system that is totally dependent on face-to-face visits, we might have more space to anticipate our patients need, rather than respond to them as they happen.”

The Richmond clinic recently added a behavioral health specialist to its staff. Rather than have the patient schedule a separate appointment at a different location, the specialist can pop in for a visit where a doctor notices unmet mental health needs.

“Almost every day, whoever is on for mental health will come down to the doctor’s pod and say, ‘Hey, does anyone have someone on their schedule we should talk about?’ ” Gideonse said. “They’ll literally go through every provider’s schedule and see who will benefit from a mental health touch.”

At the same time, others at the Richmond Clinic worry about how big their share of the lump-sum payment will be.

“I’m reassured by people talking about the role primary care providers need to play,” said Ern Teuber, the clinic’s executive director. “Still, when we start talking specific dollars, the perception is there isn’t enough money to go around and that somebody has to lose.”

The worry is especially acute for the hospitals that tend to deliver more expensive types of medicine. Their business model has traditionally relied on keeping beds full, as each patient brought in new payments.

“If we can’t reduce the cost of hospital care, we become a cost center rather than revenue generator,” said Greg Van Pelt, chief executive of Providence Health. “If Medicaid is going to grow slower, you have to figure out a way to get it to cost less.”

That process isn’t always easy: Van Pelt notes that he has had to oversee workforce reductions, as the hospital has become more efficient. His providers, for example, started a program to reduce elective Caesarean-section births before 39 weeks, which can lead to costly medical complications. Fewer babies ended up in neonatal care and, suddenly, a smaller neonatal staff was needed.

“There’s some tension since we haven’t figured out how the funding breaks down yet,” Van Pelt said. “Everyone is a little anxious.”

To alleviate some of that worry, Kitz­haber is looking at creating an innovation fund for the state’s hospital, one that rewards steps taken to reduce the care it provides.

“It’s a huge issue, and there’s no doubt that hospital business models are going to have to change,” Goldberg said. “We’ve started an open, frank conversation about that fact.”

Van Pelt thinks the potential rewards make the risks worthwhile.

“The first few years are going to be very difficult financially, politically and culturally,” he said. “It’ll be about hanging in there. We know this is the right thing for us to do. We all complain about health-care spending, but nobody does anything about it. Now, that’s changing.”

For Kitzhaber, the Medicaid experiment is just a beginning. If the state can achieve savings with this population, he could see using global budgets in the health plans that cover state workers and teachers. The private sector might get on board, too, if it sees proof that quality health care does not have to bankrupt employers.

Kitzhaber estimates that, if every state cut its Medicaid costs as Oregon plans to, the federal government would save $1.5 trillion.

“Medicaid by itself isn’t enough to change things,” he said. “For a lot of hospitals, it’s maybe 7 percent of their business. We have another 600,000 people the state covers. If their health-care costs grow slower, it’s just a game changer for state budgets.”

It’s too early in the game to know whether this bet will pay off.

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