Delivery of Care

A peek behind the curtain at reinventing Medicaid 2.0

What folks heard promised at the news conference may bear little resemblance to what may actually happen

Photo by Richard Asinof

Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services, discusses the Reinvention of Medicaid 2.0 at the Nov. 28 news conference, before a full house, including most of the leaders of the health care industry sector in Rhode Island.

By Richard Asinof
Posted 12/5/16
The promises proclaimed at the Nov. 28 news conference announcing the Reinvention of Medicaid 2.0, with an infusion of $129.7 million in new federal funds, may not result in the expected deliverables. A careful reading of the 117-page Special Terms and Conditions attached to the agreement raises some important questions.
How will the entrance of a new commercial insurer as a Medicaid managed care organization create new administrative costs in time and personnel for those providing the care? Who will then pay for them? Why were details about the money and how it would be spent not included in the news release or the news conference? How will the latest plans by Congressional Republicans to “repeal” Obamacare and then “delay” its replacement affect the flow of money to states for accountable entities? Why was there no mention of the efforts under the new agreement to expand support for family planning services for eligible women?
Three days after the news conference, Chuck Jones, the president and CEO of Thundermist community health center, announced that he was leaving Thundermist as of Feb. 22, 2017, to take a new job as CEO of Harbor Health Services, Inc., a community health agency based in Dorchester, Mass. Jones had replaced former Thundermist CEO Maria Montanaro.
While excited by the challenges of the new job, Jones said he greatly valued the opportunities to work collaboratively and think creatively about health care in Rhode Island. “You can achieve a lot more when you have those relationships,” Jones told ConvergenceRI, talking about easy access to discussing issues with other health care leaders.

PROVIDENCE – What you see is what you get, or wysiwyg, is a computer software term first used in late 1970s and early 1980s.

It referred to programs that allowed the developer to see what the end result would look like while the interface or document was being created.

The news conference to announce the Reinvention of Medicaid 2.0, held in the State Room at the State House on Nov. 28, was a kind of wysiwyg in reverse: what you heard promised may bear little resemblance to what will actually happen.

Instead of transparency, there was a cloudy opaqueness and a distinct lack of clarity about exactly how the new federal award of $129.7 million over five years from the Centers for Medicare and Medicaid was going to be spent.

The three-page news release handed out at the event contained no details about how the money was going to be invested, or in what amounts, even though the deal was apparently signed, sealed and delivered in an Oct. 20 letter from CMS, following lengthy negotiations tied to the state’s Medicaid waiver.

The full details of the agreement, published in 117-page “Special Terms and Conditions” attachment to the letter, explained in part why the state might not have wanted to talk about some of the details.

Translated, CMS and EOHHS did have a very clear idea of how the money would be spent, including deadlines and penalties if the objectives were not achieved, but, for the most part, the public and the news media were being kept in the dark and fed slogans, much as if they were mushrooms.

[Some health care leaders, it appeared from conversations after the event, had received advanced briefings, with details.]

And, the slogan being used to brand the Reinvention of Medicaid 2.0, “better care, healthier people and smarter spending,” repeated by Sen. Sheldon Whitehouse from the podium at the news conference on Nov. 28, still sounded remarkably similar to a fast food pizza ad about better ingredients and better pizza, in ConvergenceRI’s opinion.

Details, details, who’s got the details?
After the news conference, Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services, surrounded by a media scrum, apparently provided a few more crumbs about the scant details regarding where the flow of the money was destined.

Some 5 percent of the money, or about $6.5 million, will be targeted toward training initiatives for the future healthcare workforce, according to Roberts.

At the news conference, the academic workforce initiative was championed by Frank Sanchez, the president of Rhode Island College, Meghan Hughes, the president of Community College of Rhode Island, and Donald DeHayes, the provost of the University of Rhode Island. Indeed, that part of the initiative seemed to dominate the news conference, even if it was going to receive the smallest share of the money.

In an inverse ratio, the academic leaders were allowed the most time talking at the podium, compared to the amount of money they will be receiving.

This money targeted to workforce training, however, is a temporary solution, according to CMS. As it was described under the 117-page Special Terms and Conditions: an amendment to the existing Medicaid waiver was approved that would provide “federal funding of Designated State Health Programs that promote healthcare workforce development to ensure access to trained health care professionals for eligible individuals. This DHSP funding will be phased down over the period of the demonstration, as the state develops alternative funding sources [emphasis added] for these programs.”

Translated, the least amount of the new federal money is going to be spent on developing the health care workforce initiative, focused on the future talent pipeline to the health care industry, with specific requirements documenting the professional’s potential impact on serving the Medicaid population.

But the money is a temporary fix, to be phased out. More problematic, perhaps, is the lack of accurate data and metrics in Rhode Island to benchmark the changing needs within the health care sector, as the focus of health care employment shifts from inpatient to outpatient and community settings.

Another temporary fix
The second smallest amount of the $129.7 million award, some $20.5 million, will go toward the funding of a Medicaid incentive program for hospitals and nursing homes. The incentive program was created under the first version of the Reinvention of Medicaid, which was to be funded in large part by cutting reimbursements to hospitals and nursing homes.

Apparently, despite the frequent trumpeting of success of the first reinvention by Gov. Gina Raimondo and her team, including the claim in the news release that accompanied the news conference that the version 1.0 of Reinventing Medicaid was “on track to cut costs by more than $100 million,” a source of additional money was needed to fund the proposed new investments in incentives.

[As Ted Nesi wrote on Dec. 3 in his newly renamed “Nesi Notes” Saturday morning post, most of the money touted in reinvention savings under the 1.0 version did not come from how care was being provided but from cuts and increased taxes: “$19 million was from lower payment rates to hospitals and nursing homes, $13 million was from higher taxes on hospitals, $9 million was in cuts to managed care, $7 million was from maximizing federal funding, and so on.”]

Or, as one health care leader told ConvergenceRI, “Just because the Reinvention of Medicaid was implemented, and the state is paying less for Medicaid, doesn’t mean that there is causation in the way that care is being delivered.”

The total payments “for the Hospital and Nursing Facility Incentive Program, which are not to exceed $20.5 million, will be made on or before Dec. 31, 2017,” according to the 117-page “Special Terms and Conditions” document.

Translated, CMS is willing to make only a one-time, one-year investment in the incentive program. It’s another temporary fix to cover the apparent lack of state revenue to invest in the program.

How will the one-year, $20 million actually be spent? Roberts talked infrastructure needs, such as expanding electronic health care records for nursing homes; another rumored possibility would be creating ways for home health care nurses to access a patient’s electronic health records while visiting patients in their homes.

Instead of building out the technology infrastructure, wouldn’t a better way to spend the money be to put the extra dollars increasing the wages of the home care health workers employed by the state, as a way to stabilize the workforce and improve care? Good question.

Accountable to whom?
The biggest slice of the new CMS money, about $100 million, is destined to fund the “accountable entity” program under Medicaid, enacted into law 2015 by the R.I. General Assembly in its Reinvention of Medicaid statute.

The state Medicaid office, under the direction of the R.I. Executive Office of Health and Human Services, has implemented criteria and certified a number of new accountable entities under that state law, with Roberts proudly proclaiming at the Nov. 28 news conference that there were now more than 100,000 covered lives under the program.

The problem is that under the four pages of the accountability entity definitions and “roadmap” described in the 117-page “Special Terms and Conditions” document, from pages 41 through 44, the details appear to call for an entirely new framework, organization and infrastructure of these existing entities under the federal auspices of CMS.

Translated, CMS must first approve the “roadmap” document before any payments from the $100 million in new federal funding will be approved.

The “roadmap” is defined as follows: it “is not a blueprint, but rather an attempt to demonstrate the State’s ambition and to outline what [the state of Rhode Island] and its stakeholders consider the payment reforms required for a high quality and financially sustainable Medicaid delivery system.”

In other words, the new infusion of cash to help pay for the accountable entity program begun under the Reinvention of Medicaid 1.0 will carry with in an entirely new set of bureaucratic hoops and administrative hurdles to jump through on the federal side.

What that means to the current certified accountable entities already up and running in Rhode Island in terms of new bureaucratic hurdles and extra administrative costs is anyone’s guess. Can you spell snafu?

The state’s current accountable entity program, which designated two kinds of such entities, one focused on an inclusive view of population health, a second on targeting specific populations, such as those with persistent mental health issues, has encountered some difficulties in translating how the promised rewards and incentives would be actually realized by the participating accountable entities, according to a number of participants in the program.

Translated, the pot at the end of the rainbow might not be there for all the accountable entities participating in the program, depending on how tough the state, through R.I. EOHHS, wants to be around the benchmarks and metrics of incentives.

There is a 10 percent penalty if R.I. does not submit its accountable entities “roadmap” document, including details of an accountable entities-specific health transformation project by June 1, 2017.

Divvying up the managed Medicaid pie
There were roughly a total of about 280,000 Rhode Islanders receiving Medicaid benefits in FY 2016, according to the latest numbers from the November 2016 Case Estimating Conference. The numbers tend to fluctuate during the year, given the churn of former members losing benefits and new members becoming eligible for benefits.

The largest number of Medicaid members received care and benefit under RIte Care, serving children and families, with about 150,000 receiving benefits and care in FY 2016, according to the most recent case estimating conference report. There were another 60,000 Medicaid-eligible adults under the state’s Medicaid expansion in FY 2016.

In turn, much of the actual care is delivered by Rhode Island’s network of federally qualified community health centers, in one of the most efficient, accessible, affordable health care delivery networks operating in the state.

[But, under the new reinvention of Medicaid regulations prepared by the R.I. EOHHS, the definition of an accountable entity has been broadened to include larger health systems within a collaborative framework, including CharterCARE and Care New England.]

Currently, there are two health insurers which serve as the managed care organizations, or MCOs, which “manage” the risk-based programs in Rhode Island: Neighborhood Health Plan of Rhode Island, which serves about 66 percent of the managed Medicaid population, and UnitedHealthcare, which serves about 34 percent.

That, however, may be about to change, big time, with Tufts Health Plan and perhaps Blue Cross & Blue Shield of Rhode Island seeking to capture a share of the managed Medicaid market.

A piece of the pie
If, as Lenny Bruce once said, the only justice in the halls of justice is in the halls, then, as a corollary axiom, the only news at a State House news conference occurs on the street outside the State House.

Which is where ConvergenceRI encountered a senior executive from Tufts Health Plan who had also attended the news conference, and who was, like ConvergenceRI, walking back to his parked car.

The insurance executive shared with ConvergenceRI that Tufts had responded to a state RFP issued earlier this year, to capture its fair share of the state’s managed Medicaid program.

Further, the insurance executive said that Tufts was waiting to hear about the state’s decision, with some anticipation of good news.

It is anyone’s guess whose ox was going to be gored if Tufts gained entry to the managed Medicaid market, depending on the state’s pending decision to the RFP.

Further, it also means that the way that shared savings under accountable entities are going to be divvied up may become a bit more complicated.

Perhaps it speaks to the reasons why the existing accountable entities infrastructure, thrown together in a whirlwind of activity in 2015 and 2016, may be undergoing changes to comply with the apparent new standards imposed by CMS as a condition of more than $100 million into the program.

Under the new agreement with CMS, by July 1, 2018, each MCO must have at least two effective contracts, serving 10 percent of covered lives under Medicaid, with certified accountable entities, as defined by the “roadmap,” in an R.I. EOHHS-approved alternative payment model. If not, the state will be liable for a 15 percent penalty.

What does not seem to be accounted for [pun intended] are the extra administrative costs in time and personnel required to deal with another MCO in the Rhode Island managed care marketplace. Are the accountable entities supposed to absorb those costs by themselves? How would that drive up the cost of care?

A who’s who in health care in RI
The news conference on Nov. 28 in the State Room of the State House, with the events occurring under the watchful eye of the portrait of George Washington, was produced with great stagecraft. It was a full house, the audience a veritable who’s who in the health care industry sector in Rhode Island.

There were, among others: Dennis Keefe, president and CEO of Care New England, Dr. Tim Babineau, president of Lifespan, Richard Glucksman from Blue Cross & Blue Shield of Rhode Island, Peter Marino, the president and CEO of Neighborhood Health Plan of Rhode Island, G. Alan Kurose, the president and CEO of Coastal Medical, Merrill Thomas, CEO of Providence Community Health Centers, Chuck Jones, the president and CEO of Thundermist, Ray Lavoie, executive director of Blackstone Valley Community Health Care, Dr. Ira Wilson from Brown University, and Neil Steinberg, the president and CEO of the Rhode Island Foundation.

Likewise, the news media was there in full force, including: Ted Nesi from WPRI, Kristen Gourlay from RIPR, Lynn Arditi from The Providence Journal, Reynaldo Almonte from Latino Public Radio, Anita Baffoni from WPRO, and Bill Rappleye from NBC10.

What was remarkable was the fact that in the midst of the news conference, Gov. Gina Raimondo was stricken with some kind of ailment. She got up and left the event, and did not return.

Raimondo then had to cancel the public event of her getting a preventive flu shot.

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