Lack of Transparency at the Oregon Health Plan: Simple Questions, Difficult Answers
Summary
Before Oregonians are asked to approve any expansion of state-sponsored health care, we deserve to know how existing state programs are working. Transparency is crucial to government accountability for tax dollars spent.
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Before Oregonians are asked to approve any expansion of state-sponsored health care, we deserve to know how existing state programs are working. Transparency is crucial to government accountability for tax dollars spent.
The Oregon Health Plan (OHP) is a tax-funded program utilizing state general fund and federal Medicaid dollars, in a 40%-60% split, to provide medical coverage for eligible low-income Oregonians. OHP is a prioritized, rationed system. All medical services and diagnoses have been itemized, then numerically prioritized. The legislature sets the level of available services. The 2007-2009 total funds budget for the program covering the portion of the population that is low-income qualified, but not otherwise mandated to receive Medicaid funds, is $477 million. This program, known as OHP Standard, represents slightly more than 10% of the total health care spending administered by the Department of Human Services (DHS). The legislature can set the caseload total for this program based on budget considerations.
In an effort to assess OHP Standard for accuracy, errors and adherence to eligibility requirements, we asked DHS the following questions (The full written questions and answers from DHS are posted here.):
Q. Are mistakes (errors) made in OHP eligibility?
A. Yes. DHS states, “Due to the complexity of eligibility rules for medical programs, mistakes can be made in determining eligibility.”
Q. If there are errors, how many?
A. “It would be difficult to provide a number of errors on medical programs at any given time.”
Q. What percent of caseload is currently not eligible?
A. “Again, this isn’t a statistic that is available.”
Q. Do the errors cost tax dollars? If so, how much?
A. DHS does not know the impact. Errors in eligibility are not reported as a budget impact. “Many case reviews find families ineligible for the program they are currently in, but in many cases they are still eligible for another program.”
Q. Are management actions taken to monitor and/or follow recommendations for more accurate eligibility?
A. “[P]rogram integrity continues to be a priority.” However, DHS does not share a plan for this effort or show improved error accountability.
Q. Can this information be more readily available to the public?
A. Shouldn’t it be? But DHS disagrees. “It would be difficult to provide information based on reviews of cases from the OHP Statewide Processing Center….The intent of the reviews is for performance evaluations and to identify training needs.”
The DHS responses to these simple questions represent a serious lack of transparency and accountability on behalf of one of Oregon’s largest government agencies. Before any expansion of health care programs is attempted, these failures must be corrected.
Due to the failure of DHS to answer questions regarding current program accuracy, we referred to past years for error information. In 2002 the Oregon Secretary of State Audit Division completed its first and only review of new eligible clients in OHP and published their report (#2002-03), “Department of Human Services: Oregon Health Plan Eligibility Review.” The report states:
“We recommend that the department strengthen its management controls over the OHP eligibility determination process. The department should develop policies and implement procedures to ensure that coverage is limited to eligible individuals….
“We estimate the annual cost of covering ineligible recipients in the three high-risk populations we tested to be $4.3 million, of which 2.9 million would be preventable….
“In addition, allowing a self-declaration of United States citizenship on the mail-in application for OHP increases the risk of providing full OHP coverage to ineligible non-citizens. We estimate the annual cost at $1.7 million, if 1 percent of the adults receiving full OHP coverage are, in fact, ineligible non-citizens.”
The verification of citizenship became a federal requirement in 2005 and was implemented for OHP in September 2006. The projected $1.7 million cost over 4½ years, until the implementation of mandated citizenship review, can be projected as $7.65 million misspent tax dollars. It is unclear if the projected $4.3 million cost continues, due to lack of a comprehensive follow-up plan from DHS after the 2002 audit. (The DHS QC FFY2002 Annual Report states a 10.5% error rate; the FFY2003 Annual Report states a 10% error rate. Both report failure to determine eligibility based on income as the greatest reason for errors, consistent with the Secretary of State audit.)
The Secretary of State audits are website available. Locating DHS website info concerning eligibility errors is currently more difficult and is never posted in terms of cost to taxpayers.
As we demand transparency from government, we must have access to information to make informed decisions. DHS needs to conduct thorough eligibility reviews of OHP and publish an annual error report on the Internet. Further, DHS needs to define errors as potential misspent tax dollars, not just as a percentage of cases. As the Oregon Health Fund Board, the governor and the legislature look for ways to expand health care access, they should not rely on the Oregon Health Plan as a model until the Department of Human Services solves its transparency and accountability problems.
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Why doesn’t Shirley go public with this information?
I think the public should know.
Also, for CAWEM cases - is there any documentation at all regarding the work history for applicants? Americans can have their wage screens checked. They must also submit a Social Security number. Must illegals even prove they are here working at all? I think the original intent of CAWEM was to cover WORKERS. How can births be also covered?
If CAWEM cases are treated differently, should the Supreme Court hear of it? They are always expounding about the notion that all the people should be treated the same. However, illegals should be treated differently?
We cannot make grand exceptions (allowing illegals to live here and receive benefits) and make claims about equal treatment under the law.
If they are being given benefits with fewer questions asked, Americans are treated as less than equal.
Comment by A. Question — 7/10/2008 @
I returned to Oregon in 2005 with 2 10 year-old daughters after losing my husband, my career, and everything we owned (my family first came here in 1965 and my sister, oldest daughter and her husband, and 4 grandchildren are here) and also disabled, injured, and unable to work. In the ensuing 3 years we have “temporarily” been staying with my oldest daughter making 3 adults and 9 children, ages 14, 14, 9, 7, 20 months, and 8 months, in a small 3 br 1 bath home. The State of Oregon Human Services sends me in circles about housing help, no longer providing even lists of low rent providers. I received a letter after 2 years and a dozen inquiries in person and by phone saying I was on the “waiting list” for low income housing but not to call about where I was on the list because no one would be able to give me any information. Last month I was given 5 phone numbers to call, they all either had only answering machines and did not return calls or said they were not the right department or, in the case of HUD, said my name and social security number were not in their computer and I would have to make it from Beaverton to SW Ash downtown Portland to find out why. The State automatically turned down my original request for Social Security Disability twice although I paid into “the system” for 35 years on a major scale. I have been waiting now 2 years for a hearing date to be set for my appeal. The only income of my daughters and I has been the SDI payments they get because their father became permanently disabled in 1999, in the amount of $261 each. We also make about $500-700 a month stuffing newspapers for the Oregonian, a job I could not do without my two daughters doing the heavy lifting and carrying of the stacks of papers. I was formerly a senior computer business technical specialist making $100,000 a year. The cumulative effects of my former husband’s debilitating cognitive disorder left us with nothing.
Even so, I did not qualify for the Oregon State Health plan although my two children do. With no alternative in 2005 I lifted and carried all of our belongings through 3 moves (all of our belongings were then stolen or trashed the last time by the movers) and spent three years on a dislocated ankle and broken leg with no medical treatment. I am also bipolar II. Finally after 2 years I learned about the FHIAP subsidy plan which approved me for 95 percent payment of the cost of a Blue Cross health care plan. I also had to be insured through OMIP because of my pre-existing medical conditions, no regular insurance company will insure me. In October 2007 I was finally able to get an operation on my left ankle which took care of the ankle but left me with two large pins through the 4 bones which were scheduled for removal in 2 days, this Wednesday August 27th 2008. They are very painful and when I walk the pins move and the bone is wearing away slowly when they move. Also, because they hold all 4 bones, if I make a turn or pivot on my left leg the pain is excruciating. I still owe well over $1,000 total for the first operation, the remains of my deductible and 20 percent of my own responsibility. On the other hand, I CAN walk without crutches for the first time since July 30th 2004.
In May of this year the State of Oregon removed the funding for FHIAP, a private plan, because it came from SCHIPPS (spelling?) the plan for parents to purchase insurance for school aged children, which most parents I have ever known have never purchased because their children are covered under their own health plans, including myself when I was employed. It would have been double coverage. The State of Oregon took this funding away from FHIAP because they are unable to cover the costs of their own overly ambitious social engineering. They “generously” approved six months of OHP Standard for those of us that lost the FHIAP funding.
This morning I received a phone call from my orthopedic surgeon’s office telling me that the State of Oregon has denied coverage for the operation to remove the pins from my leg, stating that it is “under the threshold” of medical needs that OHP will pay for.
As a side issue, I have had no dental care at all since early 2005 before returning to Oregon. The OHP will only cover a dental visit for me if I have “excruciating pain” and then will cover only “relief of pain or pulling the affected tooth, whichever the patient chooses.” They will NOT cover a filling, but they will pull my teeth presumably until I have none left.
In my opinion the entire OHP is a farce and has proven useless for someone like me. I went to work at age 17 and worked steadily for 35 years in increasingly responsible positions. I raised one child as a single parent and then raised prematurely born twins while taking care of a totally disabled husband who was unable to be left alone or handle his own money and as early as the year the twins were born could only be sent to the store with a newspaper picture of the ad showing what he needed to buy and return home with and the correct amount of money. The vaunted OHP and legend of Portland being promoted across the country as “the most ‘progressive’ city in the country” which I heard constantly during my 20 years as a road warrior is unable to provide my family with a place to live or the most desperately needed of health care after I have had a series of personal disasters which have left us with nothing at all. I have the ever-increasing fees, licenses, and taxes of the State of Oregon for the better part of 30 years while being told of the wonderful advantages I enjoy because of them. I have watched the public transportation system turn from a way to get anywhere in Portland with a single bus transfer downtown in far less than two hours to a bankrupt (without admitting it) debacle in which to travel from my daughter’s house near 217 and Allen Rd. to my doctor downtown I am supposed to walk nearly a mile (when I couldn’t go a block on crutches without becoming exhausted) to the nearest bus stop in order to pay $2.60 to take a bus to a “transit center” to catch light rail to the nearest approach to my doctor, a trip taking by Tri-Met’s own figures 1-1/2 hours (assuming a normal walking gait) and another $2.60 and the reverse process to return home.
The Oregon Health Plan is not only totally unaccountable for where the money goes, it does not actually provide services for those it claims to serve.
If there is anything I can do to help bring this to light in hopes of making changes, I would be pleased to know. Thank you for your time.
Marina D. von Linsowe
Comment by Marina D. von Linsowe — 8/25/2008 @