CRANSTON – Entering the veritable city that is the John O. Pastore Center, and then navigating around the campus to find the new location of the headquarters of the R.I. Executive Office of Health and Human Services in the Hazard Building, where the R.I. Division of Elderly Affairs used to be located, served as a visual reminder of the once and future institutional architecture that is state government.

On any given workday, the Pastore campus is a busy hive for thousands of worker bees, a separate entity unto itself. By 8:15 a.m., the parking lot for the Hazard Building and other nearby offices is nearing capacity, although there are still a few spaces open for visitors.

A prison loudspeaker cuts through morning sounds of birds and the distant hum of traffic from the highway, a reminder that the hive serves a multitude of indigenous state populations.

ConvergenceRI is on the way for sit-down interview with Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services, and Anya Rader Wallack, director of the state’s Medicaid office.

It has been a year since ConvergenceRI had the opportunity to sit down in person and talk with Roberts, who has spent much of that time involved with the challenges of transforming the way that her agency works and reinventing Medicaid.

That said, ConvergenceRI and Roberts have frequently crossed paths, either at public meetings at the State House, at the Department of Administration building, at Rhode Island KIDS COUNT events, at news conferences, and at Olga’s Cup + Saucer, a hub of innovation [and caffeination].

Climbing the concrete steps to the second floor of the Hazard Building, there was a strong visceral reminder of the temps perdu that ConvergenceRI had spent reporting on the happenings and occurrences within other institutional settings.

In response, ConvergenceRI tried to re-imagine the Pastore campus as a hub of innovation, where conversations flowed freely, where pedestrian traffic intersected in random patterns, where ideas collided. It was a tough assignment.

Two peas in a pod
In many ways, Roberts and Wallack are much like two peas in pod. [Often, during the interview, they would finish each other’s sentences.] That observation, when suggested to them near the end of the interview, produced peals of laughter from both.

Roberts: “It depends on the day.”

Wallack: “We do our best to be effective.”

ConvergenceRI: “Both of you seem to display a dynamic nature, like jazz musicians, tending to riff off each other.”

Roberts: “One of the things we have, which is really valuable in this work, is a good sense of humor. [Laughter.] There are days, there are days when there are too many challenges in front of us, but we’re able to laugh.”

One of the goals in my professional life, Roberts continued, “is that I take my work seriously, but I try not to take myself too seriously, and that helps me get the work done.”

“But I have to say, having Anya here has been incredibly helpful, because she has exactly what you’re talking about, which is that sense of mission combined with purpose. We have so many challenges that we have to deal with, that it’s good to have someone with that level of energy.”

And, Roberts added, “A sense of humor, so that each day we can come back with a smile on our faces.”

Wallack: “I’d say that neither of us has a huge ego, we just want to get the job done. We work well together to break down the problems and figure out how we can best solve them.”

Roberts: I have enormous confidence in Anya, which is a great place to be in. It’s too big an agency; I have not desire to micromanage it. I want to be here to pick up those things that need support and assistance.

Roberts continued: “If I can, [I try] to pull some people into the conversation that need to be pulled in, that I hope is a help to Anya. I’m [kind of like] her big sister.

Wallack: “We actually look a bit like sisters.”

Those shared insights into the working relationship that Roberts and Wallack have forged together created a way to frame the conversation that preceded it, a deep dive into the mechanics of reinventing Medicaid and the challenges ahead. [Michael Raia, the communications director for R.I. EOHHS, sat in on the interview.]

Here, then, is the ConvergenceRI interview with Elizabeth Roberts and Anya Rader Wallack.

ConvergenceRI: What are the latest developments with the efforts to create pilot accountable entities as part of the Reinvention of Medicaid effort? How will the savings work?
WALLACK: The savings will be built into the programs. There will be savings in the budget for both FY 2016 and FY 2017.

Five entities have come in. We are working with how they contract with the MCOs [managed care organizations, such as Neighborhood Health Plan of Rhode Island].

If you really want go into detail with that, it might be good to set up a separate time, because we could talk for hours on that.

ConvergenceRI: That would be good. What I’m trying to understand is how that will impact the current risk-sharing agreement that the state has under Medicaid [with the MCO], which I believe is something like 70-30 percent. If there were savings, say, of $21 million in 2015, about $17 million would go back into the state’s general revenue fund. How will the new accountable entities change the numbers in shared savings?
WALLACK: [drawing an impromptu graph on paper] We have a predicted rate of growth and expenditures. If the combination of the MCO and the accountable entity come in below that, they are going to share in what otherwise would have been the MCO’s share of the savings. They split this with the MCO.

Our deal would have been previously, around the top line [on the graph].

ConvergenceRI: Will it undercut the previous $17 million share the state was getting?
ROBERTS: Which is why [we are creating a different arrangement. We’re not the only state working on this. Minnesota also has [been working to develop] a partnership with their MCOs and Medicaid accountable entities, so they are doing something similar.

WALLACK: The idea is that you now have organized provider groups that are trying to achieve savings.

ConvergenceRI: My understanding is that there have been five accountable entities that have applied to be part of the pilot program. Will any be dropped by June, when the regulations are officially promulgated, if that’s the right term?
WALLACK: I don’t think so. There are two that are probably better developed, so I think there may be some lag in the full development of the model on the part of some participants in the program. It might affect their ramp up and how much they achieve in savings.

ConvergenceRI: Shifting gears, you have taken on this big task called reinventing Medicaid. What is the learning curve in the process? How will it reflect the iterative nature of the work?
ROBERTS: You’ve been following this since we began this process a year ago. I think the question is: how do we build innovation into the process of how we run our Medicaid program.

It’s about how do you run a high-quality program that results in high-quality care, that looks into new approaches, in the range of areas that Medicaid is responsible for.

We’ve begun some initiatives, we’re building on those going forward, and we be assessing their effectiveness, managing the programs and the budget going forward.

To us, I think, Medicaid should become what reinventing Medicaid is overall; hopefully, that term goes away, because we should be running all of our programs with a continuous improvement connection, working with our stakeholders and our consumers.

You’ll also see added savings from taking [programs] to scale. As with any innovation, some [efforts] are going to more successful than others, and we will building on those strengths and continue to be effective managers.

That’s one of the things that Anya and her team are going to be responsible for: how do we know what’s working and what’s not working? How do we have our ear to the ground about how providers are engaging? We now have a new chief of analytics for the agency…

ConvergenceRI: Kim Paull.
ROBERTS: Yes, Kim Paull. We haven’t always done a great job in assessing the quality of performance in our programs. We’re going to be doing that now as part of our general management process.

ConvergenceRI: In developing the metrics and the tools for measuring outcomes, there have been ongoing discussions about how you harmonize those metrics – and how you include metrics around the social and economic determinants of health.
ROBERTS: One of the things we have been doing over the past several months, both at EOHHS, as well as with our private partners in the community who have metrics, is to make sure that these conversations connect with each other.

We’re working on the performance measures for the hospitals and nursing homes, we’re looking at the work that is coming out of the SIM, and the work that is coming out of Medicare, so that are aligning as much as possible the goals of providers.

WALLACK: I think that we always have, there will always be at Medicaid, an interest in the metrics that are particular to our population. For example, if you look at the measurements around accountable entities and the integrated health homes, they are much more focused on behavioral health.

The common metrics are going to be of particular interest to us, and I think in terms of the disparities, it is incumbent on us to slice and dice our data so we can look at those, and better understand them.

ROBERTS: As Nicole [Dr. Nicole Alexander-Scott, director of the R.I. Department of Health] continually reminds us, this is who we serve – that a lot of people who suffer from those disparities are the people that we serve.

It’s important that as we have access to date, and as we reach out to an agency in another department, to make those connections. That’s what hasn’t happened in the past very effectively.

ConvergenceRI: There have been some new rules promulgated regarding housing and home stabilization and Medicaid. Can you talk about how that effort fits into the reinvention of Medicaid?
WALLACK: I think that’s a great example of how the analysis into addressing the fundamental factors that drives so much of health care use we’re paying for can work.

Home stabilization is about providing coverage for a new array of services through a – not new, but new to the Medicaid program – to help people stay in housing.

By doing that, we are hypothesizing, and I think the evidence is pretty clear, that they will use the hospitals less, that there will be greater continuity of care, and that they will have fewer emergency department visits.

Particularly, if we can do that that in combination with better mental health care, it could have a real impact on the very high need, high cost population.

ROBERTS: At the same time, the Governor has asked me to partner with the Housing Resources Commission to reinvigorate the interagency council on homelessness, so that we’ve got all the relevant partner directors as well as Rhode Island Housing at the table, talking about these issues from the policy direction as well.

ConvergenceRI: Can you talk about the newly proposed Accountable Health Community entities that are part of a new CMS initiative and how that fits into everything else that’s going on?
ROBERTS: I wasn’t at that meeting, so I’m going to let you answer that.

WALLACK: So, the purpose of the federal grant program, which is called Accountable Health Communities, I believe, is to augment all the other stuff that that the federal government is supporting in this space, such as provider-driven change models, and the shared savings [Medicare] accountable care organizations, and the state-based projects like SIM.

The new element is the funding will be given to providers and community groups to do a better job screening people through the health care system for their social support needs.

A lot of organizations in Rhode Island were very interested in this. What we tried to do was pull together all the interested parties to work together, in the hope that we would be more likely as a state to get at least one funded application. We encouraged them to partner together.

Part of the meeting was each of the organizations explaining what they had in mind, kind of like speed dating.

It was also an opportunity for us to say, here are out priorities, we’re working on Medicaid accountable entities, we’re working on everything that’s funded by SIM, we’re going to look more favorably on proposals that show a strong linkage to this. And, because we as the Medicaid have to sign onto any application that goes in, we thought it was important to convey that.

ConvergenceRI: The applications are due at the end of the month, which is a quick turnaround, isn’t it?
ROBERTS: CMS has just extended the application deadline until late May, I believe.

ConvergenceRI: How do you see, as part of a broader perspective, your role in braiding all the resources together?
ROBERTS: With the federal government, one of the best things over the past several years is that they have taken on a partnership role in helping to fund and to support innovation and change, as opposed to a more regulatory role. There is much more interest about investing dollars in change.

What I like about this [change in approach] is that it brings in, more directly, what I’ll call the non-medical providers. Rhode Island has its health equity zones that do this as well.

There is no question that health care providers and entities need to part of [this new partnership, but this explicitly asks for a community wide focus.

We talked about housing, for example. There are organizations that are not part of the medical system that have huge impacts on health. I like that this program is focused on what we know to be true: your health is not tied to the medical system, it’s tied to the community.

WALLACK: If you think about federal funding, and the money they put into housing, big time, into fuel assistance, into SNAP benefits, there’s not a lot of coordination of that in most states. So, I think it’s a recognition that you need to connect the people who are using the health system with a whole lot of social services in a coordinated way.

One of the best ways to have a nexus with them is through the health care system, per se, but it’s not the health care system.

ConvergenceRI: Are there new ways to use the metrics and measuring tools to develop a different kind of indices, such as a way to measure the quality of life in Rhode Island?
ROBERTS: We’ve been working the Governor’s office, as well as internally, around the measures that we see as particularly important, such as the rebalancing of long-term care and access to health coverage. We’ve got a range of issues.

WALLACK: Appropriate use of emergency rooms and hospitalizations.

ROBERTS: We have a number of approaches; this is not just through EOHHS. The administration as a whole is putting together a series of metrics around population of the state. I don’t think it’s complete.

And, there’s no doubt that Nicole has really stepped in and said, ‘It’s been a while since the state has said: Here are our population health goals, and here’s what we’re going to start measuring.

ConvergenceRI: In terms of analytics, there are a lot of competing agendas around what systems to employ to measure population health. What do you see as your role here?
ROBERTS: I’m measuring outcomes, not process. I want to the process to work. We have different EHRs, of course. That doesn’t mean that the data doesn’t need to come out of them.

One of the reasons why Kim is here is to help us navigate that system. What I want is the information to assure that we’re doing a good job in meeting peoples’ needs and changing peoples’ lives [for the better], and that’s what we’re trying to do.

ConvergenceRI: What are the metrics for success by which you’ll measure Rhody Health Options going forward?
ROBERTS: Cleary, some are going to be about the rebalancing piece, for people who are most at risk of institutionalization. That’s going to be a metric that we’re able to follow.

And also about access to services in the community, which is much broader than rebalancing. Are you able to say independent? That times into some of the home stabilization issues.

We’re really going to look at whether people can live the life that they’ve choosing to live; we will be developing a series of metrics to look at that.

WALLACK: The feds require us to measure it up, down and sideways.