Profile of Office of Medical Assistance Programs
(Oregon's State Medicaid Agency)
Department of Human Services
Oregon was one of the first states to use managed care for the Medicaid population. In planning for the 1995 inclusion of seniors and people with disabilities into Medicaid managed care under the Oregon Health Plan (OHP), advocates, legislators, and other concerned officials assumed there would be some risk to those vulnerable populations in a managed care world. To help seniors and persons with disabilities navigate through the managed care delivery system, Oregon established an ombudsman program and located it in the Office of Medical Assistance Programs, Department of Human Services.
This program was created with legislation, which required:
"In providing medical assistance services . . . the Department of Human Services shall also provide the following:
(1) Ombudsman services for eligible persons who are aged and described in ORS chapter 413 or who are blind or disabled and described in ORS chapter 412. An ombudsman shall serve as a patient's advocate whenever the patient or a physician or other medical personnel serving the patient is reasonably concerned about access to, quality of or limitations on the care being provided by a health care provider. Patients shall be informed of the availability of an ombudsman," (Oregon Revised Statutes §414.712).
In late 1995, Oregon's Medicaid program surveyed the seniors and people with disabilities. The survey showed that people loved the services of the ombudsman program, but disliked the term "ombudsman." Eventually the program got a new name, the Client Advocate Services Unit.
The advocacy program has continued to evolve since its inception, as Oregon has questioned some of its initial program assumptions. For example, though program designers had assumed that seniors and people with disabilities would have the greatest needs for client advocacy, they found that this was not always the case. People with disabilities are often great self-advocates, knowing more about their disabilities and potential treatments than many providers and often knowing their rights and appeal processes. Seniors also often have strong advocacy skills, and they can get help from advocates such as AARP and SHIBA (called SHIP or HICAP in some states, these are counseling programs for the Medicare-eligible population). Most in need of assistance, the Client Advocate Services Unit found, were families newly insured under the expanded OHP― adults and couples who had always used emergency rooms as their health care delivery system before but who now had health insurance for the first time and needed help in the new managed care system.
Another initial assumption was that Medicaid managed care enrollees would have the greatest needs for advocacy. Managed care members' needs have changed over the last nine years as managed care plans have become more established in Oregon and have developed case management and care coordination systems. In contrast, people in fee-for-service Medicaid have much less care coordination available and often need assistance from the state, so Oregon's Client Advocate Services Unit now serves all Medicaid beneficiaries. The state has also recently initiated an intensive case-management service and a disease-specific patient management service through a private contractor for fee-for-service clients.
Currently, the Client Advocate Services Unit assists consumers in the following ways:
The Client Advocate Services Unit has 14 full-time staff to perform these customer service functions for 440,000 OHP clients. The unit receives over 40,000 calls per year on its toll-free hotline. These calls fall on a continuum ranging from general questions to minor complaints to major grievances. The unit now focuses on handling minor complaints and questions by coaching clients on how to resolve issues themselves. This kind of coaching often prevents the issue from becoming a grievance, provides information to decrease call recidivism, and encourages self-sufficiency when clients move from public assistance to private insurance. The majority of calls received by the Client Advocate Services Unit can be addressed in a single intervention by providing information, educational materials, and coaching.
More serious issues requiring investigation, such as grievances due to a denial of care or alleged misuse of power by government officials, are referred to the Governor's Advocacy Office, located in the office of the Director of the Department of Human Services. This investigative unit's separation from Medicaid gives it more objectivity and allows it to handle investigations of non-health issues within the Department of Human Services as well. The Client Advocate Services Unit and the Governor's Advocacy Office enjoy an excellent rapport that encourages cross-referrals, database sharing, and collaboration on behalf of departmental clients.
