Don’t get Pam O’Reilly started on the outfit that’s supposed to drive her to twice-weekly medical appointments.

O’Reilly, 74, lives in a home for seniors in North Portland. For the past four years, she has been getting treatment for a broken vertabra and numerous other ailments across town at Oregon Health & Science University. Some days, those appointments are in South Waterfront clinics; on other days, she goes up Marquam Hill.

The vinegary Chicago native doesn’t drive, so like thousands of other Oregon Health Plan Medicaid patients in the tri-county area, she depends on Health Share: the nonprofit that provides medical services to local Medicaid patients and also must provide non-emergency transportation for their appointments. (In Oregon, the state contracts out Medicaid coverage to nonprofit and for-profit companies that run what are called coordinated care organizations or CCOs. See box, below.)

Health Share’s transportation program, which is called “Ride to Care,” provides 2 million rides a year for Health Share members. Or it’s supposed to.

O’Reilly says the vehicles dispatched by Health Share often show up late or at the wrong location. Sometimes they don’t come at all. She recently missed a physical therapy session when the driver went to the wrong address.

“They don’t care if you miss an appointment,” O’Reilly says. “It causes me a lot of stress.”

Since January 2018, when its only competitor, Family Care, closed, Health Share has enjoyed a monopoly on Oregon Health Plan patients in the state’s three largest counties.

You’d think if there were going to be shortcomings imperiling Health Share’s lock on the market, they’d be botched surgeries or dirty clinics. Instead, it’s something far more banal: transportation to and from medical appointments.

Problems like the ones O’Reilly experienced are so persistent and so serious the
Oregon Health Authority earlier this month threatened to yank Health Share’s license. And the state regulator’s unhappiness with Health Share comes at an inopportune moment—just when a massive for-profit competitor is pushing to bring competition to the local Medicaid market with a green light from the OHA.

Health Share spokeswoman Stephanie Vandehey says the organization is taking action in response to complaints. It will end its current contract with its transportation provider, Gridworks LLC, and hand over responsibility to a new contractor.

Pam O'Reilly. (Briana Ybanez)
Pam O’Reilly. (Briana Ybanez)

Health Share is by far the largest coordinated care organization in Oregon, with revenues of $1.5 billion last year. And by one important measure, transportation, it’s also the most troubled.

After months of complaints about Health Share’s failing transportation services, the OHA notified Health Share on Oct. 14 it was “not in compliance with state law” and issued an order requiring corrective action.

That’s potentially a big stick, carrying penalties “up to and including termination of [Health Share’s CCO] contract.”

Such findings are rare, says OHA spokesman Robb Cowie. The state issued only one other such notice to a CCO this year.

“We know coordinated care works: It gives OHP members better access to primary and preventive care, which keeps people healthier and helps them stay out of the hospital,” Cowie says. “However, it doesn’t work if people miss their appointments because their ride is delayed or does not come at all.”

Dave Daley worked in the medical transportation field for four decades before his retirement. Now he serves on the Multnomah County Aging Services Advisory Council.

For the past year, Daley says, that panel and a parallel group that works with disabled county residents have focused on non-emergency patient transportation. Daley says problems like the ones O’Reilly experienced are all too common.

“The biggest problem is [Health Share’s] call center performance,” he says. “That’s the nerve center.”

Daley says call takers are supposed to respond within a minute, but he says the average wait time has been 15 to 17 minutes and much longer during busy times of day.

“People can’t get a response and so they just give up,” Daley says.

Both county panels expressed concerns to Multnomah County Commissioner Sharon Meieran, an emergency room physician.

“This is a really big deal to people who rely on these transportation services to get basic medical care,” Meieran says.

In late August, Meieran convened a meeting with OHA director Pat Allen and Health Share’s medical director, Dr. Maggie Bennington-Davis.

That meeting included public testimony from patients who told of repeated driver no-shows with health and financial consequences.

“Where we are today is not acceptable,” Allen told meeting attendees. “My role is to hold people accountable.”

That’s what the Oct. 14 letter of noncompliance to Health Share is supposed to do. “Health Share’s average non-emergency complaint rate for the first two quarters is 268 percent higher than the average CCO,” the health authority wrote.

OHA already sent a strong signal it is open to more competition for the benefit of Medicaid patients. Earlier this year, the agency signed a contract with Trillium Community Health Plan, a CCO serving Lane County that wants to compete with Health Share in the tri-county market.

The five hospital systems that provide services to Health Share members—OHSU, Legacy Health, Providence Health and Services, Adventist Health and Tuality Healthcare—have refused to work with Trillium.

Former Gov. Kitzhaber recently penned a letter to Gov. Kate Brown going to bat for Health Share and urging that Trillium be kept out of the local market.

Kitzhaber, an emergency room physician, helped design the Oregon Health Plan as a lawmaker and governor from 1995 to 2003 and pushed for the CCO system when he returned to office in 2011.

“There is little evidence that such competition in the CCO framework of a global budget and quality standards and incentives produces better outcomes,” Kitzhaber wrote in the Sept. 8 letter to the governor. (Kitzhaber tells WW that he wrote the letter of his own volition and is not working for any of the parties.)

On Oct. 26, Trillium provided a response to supporters of the current system, filing a federal anti-trust lawsuit in U.S. District Court in Portland against OHSU, Providence and Legacy.

“The Big Three’s illegal boycott against Trillium is thwarting Oregon’s considered decision to offer choice to Medicaid recipients in the Tri-­County Area,” the lawsuit states. (The defendants say the lawsuit is baseless.)

O’Reilly doesn’t care about legal battles between health care giants. She just wants to know she’ll get to her medical appointments on time.

“They’ve had a long time to fix this,” she says. “The service has got to be a lot better for the patients that need these rides—the patients are the ones in pain.”