Oregon health leaders prepare for future Medicaid changes to improve care

Oregon’s health care system is at a crossroads as it faces a series of challenges and lofty goals. 

The state has a behavioral health crisis that is exacerbated by a lack of qualified providers to treat people. The health care system is complex and difficult for vulnerable people on the margins of society to access, whether for primary care or treatment for a drug addiction. And the Oregon Health Authority and state leaders want to eliminate inequities in health care in six years.

 In a forum Wednesday in Portland, Oregon health care leaders said the state has opportunities to improve the system and should look for ways to bring about substantial change rather than accept the status quo. About 300 people attended the event, which was organized by the Oregon Health Forum, a nonprofit and affiliate of The Lund Report, a news outlet that covers the health care industry. The event was moderated by Emily Harris, a journalist and senior advisor for the Oregon Health Forum.

The panelists were: Dr. Sejal Hathi, director of the Oregon Health Authority; former Gov. John Kitzhaber; Rep. Rob Nosse, D-Portland; Dr. Bruce Goldberg, former director of the health authority; and Mary Monnat, president and CEO of Lifeworks NW, a mental health and addiction treatment provider in the Portland region.

The Oregon Health Plan, the Medicaid-funded program that insures more than 1 million low-income Oregonians, plays a key role in the state’s goal to improve the care of Oregnians. The plan provides free medical, dental and behavioral health care to Oregonians through a network of 16 coordinated care organizations, which contract with the state and insure people through regional networks of providers. 

The state’s now planning changes for the next version of contracts with the coordinated care organizations, which will go into effect in 2027. For Oregonians, the changes could determine how providers and the insurers invest in the regions they serve, how they will provide health care for Oregonians and how they will guide people to other services that improve their overall health, like housing assistance. 

As that work unfolds, the Oregon Health Authority aims to eliminate health inequities by 2030 so that people in different communities and races aren’t impacted disproportionately by ill health or access to providers. Hathi, director of the Oregon Health Authority, said the agency plans to release a strategic plan in June mapping a path to that goal and other innovations which experts say have been a hallmark of the state’s use of Medicaid federal and state dollars. 

“We know it’s a mission,” Hathi said. “And we know that it’s aspirational, but this is a goal that we absolutely have to set and we will achieve it if we work together.”

Hathi said the authority and the health care system cannot meet their goals on their own of eliminating health care inequities. Other partners, like academia and the business sector, will need to help, she said. 

 Panelists call for less bureaucracy 

For the average Oregonian, coordinated care organizations are an obscure and behind-the-scenes part of the health care system. But they have access to millions of dollars and the ability to put money into community projects to aid the overall health of Oregonians.

Oregon obtained permission from the federal government to organize the state’s Medicaid system under the Oregon Health Plan, with one or more coordinated care organizations responsible for patients in each region. Kitzhaber, a former emergency room doctor, shepherded that organization, along with Goldberg and others, with the idea that local organizations would best be able to rein in costs and improve health care outcomes for those in their regions.

Kitzhaber said regulations gradually increased and made the state’s relationship with coordinated care organizations less of a partnership working for the most effective innovations to a top-down, unbending and sometimes confrontational relationship. 

“I think we need to figure out how to have a balance” between regulation and flexibility, he said.

Hathi agreed, saying the current administrative requirements are burdensome for the Medicaid insurers as well as local public health authorities and others in the health sector. 

“We need to arrest that cascade of administrative burden and do more to distill and to synthesize so that these communities are all rowing in the same direction,” Hathi said.

Nosse, who chairs the state House Health Care Committee, has listened in hearings to complaints from coordinated care organization leaders. He said if the state could cut back on te forms and paperwork, that would help ease frustrations. 

“If we can whittle that down a little bit, there’s more possibility to provide care or do things that we want the model to actually do,” Nosse said. “Somebody’s really important report is somebody else’s really dumb thing.” 

Workforce challenges 

Panelists also said the limited behavioral health workforce makes it challenging to set up and maintain programs, even with more state money.

Goldberg, a former health authority director, said the wait times for people to access mental health care are strikingly different compared to other health care problems.

“You show up at a hospital emergency room with a heart attack and you’ll get care within three minutes,” he said.

But if you show up at an emergency room with a mental health problem, he said, you may get treated in a week to a year. 

Panelists also recommended Oregon consider drastic ways to transform the system. Goldberg suggested the state provide a financial incentive to award coordinated care organizations for providing mental health or drug addiction care within 24 hours.

Currently, the state has a program that awards insurers based on improved health outcomes in about a dozen areas, such as health assessments, dental care and treatment for high blood pressure. Goldberg suggested that list be whittled down to just one metric of timely mental health and addiction treatment. 

The crowd applauded.

“Maybe we would actually start to move the needle,” Goldberg said. “It’s not going to be overnight, but we don’t have any accountability for who’s going to do that.”

Another idea: create more incentives to attract people to enter the behavioral health field. Monnat, president and CEO of Lifeworks NW, suggested the state pay people to go to school so they don’t need student loans. At Lifeworks NW, there are about 100 job openings right now, Monnat said. 

Hathi said the $1.5 billion the state has invested in behavioral health in the last four years is great, but “it’s a drop in the bucket.”

“At the end of the day, we can’t just throw darts at a board and hope that we strike the panacea,” Hathi said. “We need a real vision and a strategy for how we’re going to transform the system.”