Emergency rooms flooded with people mentally ill or on drugs. A mental health program poorly managed. Agencies and health systems dumping people’s problems on each other to improve bottom lines.
Instead, Multnomah County, the state’s largest, has come to the verge of divorce with the main reform group set up to care for low-income residents in the region, documents and interviews show.
Clashes over money and control in the mental health system caused the Multnomah County’s near-breakup with Health Share of Oregon, the nonprofit organization founded by five competing health systems to oversee care for the Oregon Health Plan. The systems include almost all the region’s hospitals.
Multnomah County officials were so frustrated that in February, they hired a consultant for $83,000 to explore pulling the agency out of the group.
County officials told the consultant Health Share used its clout to pressure Multnomah County mental health to pay inappropriate claims from hospitals, thus shifting their costs to the county.
The mistrust is mutual. Health Share officials were so exasperated that they threatened to impose an outside manager over Multnomah County mental health services, according to county officials. (Health Share denies that assertion.)
The simmering dispute, which was not discussed publicly until late June, is a high-profile threat to reforms spearheaded by Gov. John Kitzhaber.
A breakup would have punted to Health Share the nearly $50 million-a-year program that provides for the mental health needs of more than 100,000 low-income county residents, leaving the already fragmented system even more so.
For now, the county has decided to try to negotiate a more favorable contract with Health Share.
But first it must counteract years of sloppy fiscal management, according to a report by County Auditor Steve March in April. He found that if the county doesn’t better track its own spending under the Health Share contract, the new arrangement could cost taxpayers.
March likens Health Share to an arranged marriage with state funding the dowry.
“I’ve seen arranged marriages by government before,” he said. “Sometimes they work, and sometimes they don’t.”
To understand how health reform is supposed to improve health outcomes of all kinds while reducing costs, consider the case of a homeless Multnomah County man with an alcohol problem as well as schizophrenia.
Under the old system, he’d be picked up by police over worrisome behavior: being threatening or suicidal while under the influence. He might be covered by the Oregon Health Plan for low-income residents, but he’d be dropped off at a hospital emergency room because alternatives are scarce and require more paperwork than the officer can handle.
The hospital would keep the alcoholic man under a mental health hold for up to five days, sending him back to the street with his underlying problems unaddressed.
The county and the hospital would be left fighting over the bill. If the county found that the man was in the ER because of alcoholism, the hospital would pay. If the hospital successfully argued it was mental illness, the county would be on the hook.
Before long, the man would be back, picked up for more worrisome behavior.
In the new world of health care reform, the state makes one entity, Health Share, responsible for the well-being of the homeless man with alcoholism and mental illness.
Rather than let him slip through the cracks while the county and hospitals discuss who pays for his hospital stay, Health Share is supposed to get providers to work together to keep him out of costly emergency rooms. Health Share also is supposed to save money by paying for care that will be more effective in improving the man’s long-term prognosis: supervised treatment programs, say, preferably coupled with housing.
But a June report by a consultant for Multnomah County paints a different picture of Health Share’s focus.
Instead of seeking lasting solutions for the homeless man, the Massachusetts-based Technical Assistance Collaborative report — as well as other documents and interviews — depicts a year of strife during which Health Share tried to make Multnomah County deny fewer claims from hospitals.
Susan Myers, the county’s just-departed human services director, told Multnomah County commissioners in a June 24 briefing, “Health Share believes that we deny too many claims for payment, with most of the complaints being from our hospital partners.”
Why is Health Share doing this? The consultants suggest the reason is that the group’s board of directors is dominated by providers, mainly hospital executives.
The consultants’ report flagged this “unusual” arrangement as one the county might want its lawyers to review.
Multnomah County Mental Health, which receives state funding to care for 100,000 residents who are Oregon Health Plan members, conserves this money by denying what it considered inappropriate claims from providers.
What’s changed under health reform is that the county’s state funding under the Oregon Health Plan now passes through Health Share. And Health Share is using its new authority to question decisions by the county about whether or not to reimburse providers.
The consultants wrote that the county’s new relationship with Health Share has led to “considerable tension and concern” among county staff as well as “political pressure” to pay claims that county employees considered improper.
The consultants said Health Share had circumvented the county’s policies for bringing grievances and intruded on county cost controls, “undermining the county’s ability to appropriately manage care.”
Last fall, Health Share threatened to bring in an outside overseer to “take over” Multnomah County mental health, Myers told the board of commissioners.
County auditor March, a former lawmaker well-versed in healthcare policy, attributed Health Share’s pressure to a basic fact.
“Providers tend to want the highest reimbursement rate possible,” March said. “And they don’t want anyone scrutinizing it too much.”
Health Share responds
Health Share, for its part, says it did discuss bringing in an outsider reviewer but never made a decision to follow through.
The group’s leadership noted that outside reviewers overturn county denials of services at a high rate. Health Share officials suggested the statistic showed the county was being too stingy and denying too many claims.
Janet Meyer, chief executive officer of Health Share, said the group is working to better coordinate care to make sure clients’ needs are met, but it will take time to work out kinks in the system.
“What we’re trying to do as a company is figure out how we work with all our partners and the available funds to make sure clients get the services they need,” she said. “We’re working it out.”
She agreed that the short hospital stays faulted by the consultant are a longstanding problem but denied the group’s focus is on payments for hospitals.
“We don’t disagree that these clients that are cycling through on these really short stays need to get connected to outpatient services in the community,” Meyer said. “That’s a part of what we are working with our partners about… It’s obvious that there are hospitalizations that can be avoided.”
Asked whether the Health Share board has a conflict of interest when it comes to its staff pressuring the county to be more lenient with its payments to hospitals, she said the board stays out of operational issues and “meets the legislative requirements” of health reform.
County management issues
The county’s consultants concluded that before the county tries to negotiate more favorable terms with Health Share, it should address management issues of its own.
Multnomah County doesn’t just serve Oregon Health Plan members.
It receives funding to care for indigents, employs case managers for the mentally ill, and operates services open to anyone like the 24-hour crisis line. It has mixed state, federal and county funds as needed in the past to support the integrated program, the consultants wrote.
In the end, the consultants suggested the county negotiate better terms with Health Share while hiring new managers and purchasing a data management system to better track and justify spending.
They said if the county pulled out, the growing power of Health Share and other coordinated care organizations would put the county in danger of being shut out of important decisions.
County Chairwoman Deborah Kafoury said she didn’t know about the conflict with Health Share before she took office in May but agrees with the consultants’ recommendations. She said she would monitor Health Share closely.
“We will need to up our game,” she said. “We can’t be afraid to challenge the way we do things. These are people’s lives at stake.”