Delivery of Care

More details emerge about the rats nest that is UHIP

More than just flaws in a broken software system, the latest legislative hearing reveals how a culture of arrogance at EOHHS was allowed to fester under Gov. Gina Raimondo

By Richard Asinof
Posted 3/6/17
As the House Oversight Committee dug deeper into the quagmire that is UHIP, a number of key revelations emerged: how broken the UHIP system was; how a culture of arrogance at EOHHS rebuffed concerns from providers; how deep the financial morass was; and why just fixing UHIP, if it can be fixed, will not solve the problems.
How will the continuing saga of the botched UHIP rollout cloud the future aspirations of Gov. Gina Raimondo? When will the R.I. General Assembly own up to its responsibility to increase revenues for long-term care services under Medicaid, instead of just trying to cut costs? What does it take for providers to be heard and listened to within EOHHS? Which elected officials will speak out on behalf of the poor, frail elders who are being victimized by the UHIP snafu? If state agency leaders had to wait in line for paychecks and access to health services, how would that change their priorities?
Within the health care industry sector, much has been made about the effort to train and bring into the workforce new community health workers as a way to conduct outreach to those with limited access to services. However, the reality is that about half of all Rhode Islanders who are licensed to become Certified Nursing Assistants, or CNAs, do not end up practicing, often because of the low wage scale offered in Rhode Island. To improve health care outcomes, what would happen if the focus was improving the wage scale for CNAs and skilled nurses working in the provision of care for seniors?

PROVIDENCE – It was a busy news day, with lots of bright, shiny objects to follow in the never ending search for truth, justice and the American way.

U.S. Attorney General Jeff Sessions announced that he was recusing himself from any investigations into Russian attempts to influence the 2016 Presidential election, less than 24 hours after it was revealed that he had met twice with the Russian ambassador during the election campaign, which Sessions somehow had failed to mention in response to questions during his confirmation testimony under oath before the U.S. Senate.

Further, the R.I. State Police released a trove of documents related to its 38 Studios criminal investigation, replete with uncorrected spelling errors, sending reporters scurrying to examine the contents. [Hint: it is Costantino, not Constantino.]

So it was understandable if much of the news emanating from the latest hearing by the House Oversight Committee about the botched rollout of the $364 million Unified Health Infrastructure Project, held on Thursday, March 2, in Room 101 at the State House, may have been overlooked.

Yet there were a number of significant revelations to be gleaned from the lengthy testimony by providers about the continuing financial fallout from UHIP. [For the record, the usual suspects – Providence Journal reporter Alisha Pina, WPRI’s Susan Campbell and ConvergenceRI – were there to capture and to report on what was said.]

The good news: providers said they felt more “hopeful,” because it seemed they were finally being consulted and listened to, for the first time in months if not years, by the new, interim leadership team at the R.I. Executive Office of Health and Human Services and the R.I. Department of Human Services.

The bad news: the dramatic change in culture, from one of arrogance to one of apparent collaboration, had not changed the enormity of financial problems caused by the failure of the software system designed by Deloitte. To fix the broken system, the providers testified, will require a continued major commitment by the state to repair the damages caused by UHIP and vigilance by state legislators.

Gail Sheehan, owner of Consistent Care in Jamestown, a home health care agency that recently celebrated its 25th year in business, testified: “If you thought 38 Studios was bad, it is a walk in the park compared to what you’re dealing with right now.”

Sheehan described a litany of breakdowns and snafus that she attributed to the Raimondo team’s mismanagement of the UHIP rollout.

Sheehan said she had not gotten a single referral from DHS for six and half months. “The hospitals are getting clogged, the nursing homes are unable to discharge patients because they cannot guarantee [home] care,” she said. “Thousands, thousands are going without services.”

Meanwhile, the state bureaucrats, Sheehan continued, “receive their salaries on schedule, whether or not they are competent.”

Sheehan added that the failure by the state to pay livable wages to home health care workers was exacerbating the problem.

Nicholas Oliver, the executive director of the Rhode Island Partnership for Home Care, was just as blunt in his testimony. “We need assurances from Gov. Raimondo that the Medicaid program [for home health care] will be repaired.” What was needed, Oliver continued, was a definitive timeline for action. “Home care providers can no longer afford to carry the state’s debt on these cases.”

The scope: what was revealed, what remains unsolved
The hearing began with the presentation of a slide deck entitled, “UHIP Turn Around Effort,” a review of the long-term care program, issues and planned actions undertaken by the new interim leadership team. Much of the initial part of the hearing focused on the status of overdue payments owed to long-term care service providers under Medicaid.

Among the details revealed, in response to questions from committee members, included:

Jennifer Wood, the former deputy director who after being demoted is now serving just as general counsel for the R.I. Executive Office of Health and Human Services, is still receiving her current full annual salary of $176,361.90, as listed in the state’s transparency portal.

“She still has more than a full-time job at EOHHS,” Eric Beane, the acting director of the Department of Human Services, testified, in response to a question about he size of her salary.

The last day on the job for Elizabeth Roberts, the former secretary of R.I. EOHHS, was March 3. However, she will be using leave time accrued during her stint as a state employee for an unknown period of time. Translated, she is still technically a state employee until her leave time is completed.

Anya Rader Wallack, the temporary acting secretary at R.I. EOHHS, is officially on leave from her position from Brown University, to which she will return once her current assignment is completed.

The moniker, bestowed with apparent affection by long-term care service providers on Eric Beane, the acting director of the Department of Human Services, is “sucker.”

In February, some $26 million in interim, bulk back-payments were made to nursing homes and nursing facilities for long-term care services owed under Medicaid. At least another $10 million is still owed under the backlog created by the botched UHIP launch in September of 2016, according to Beane. That number was a guess; it could be larger, he admitted.

Those payments are being made with state funds, not with federal matching funds, according to Beane. A total of some $51 million such back-payments have been made in the last six months. [Such payments have necessitated facilities to create a second set of accounting books.]

[Editor's note: The cash payments do not stop the clock from ticking. While the $26 million in payments made in February alleviated the cash crunch faced by many facilities, it is a short-term fix. There are some 2,000-3,000 long-term care eligibility determinations that are still undecided. The amount owed to providers, estimated to be more than $10 million, will keep multiplying each month until the system is fixed.]

There is no way to track the number of pending applications for long-term care services under Medicaid under the current UHIP system, because they are all lumped in together with other Medicaid services under the heading “medical,” according to Beane, in response to a question from Serpa. To correct that, a system fix is needed.

Prior to the UHIP go-live date of Sept. 13, the number of pending applications was around 800, according to Beane. “We [believe] that it is somewhere in the neighborhood of 2,000-3,000 now,” Beane said, as much as a four-fold increase.

Further, the state law enacted last year that took effect on July 1, 2016, which created presumptive eligibility for long-term care Medicaid applications that were pending longer than 90 days, was never coded [emphasis added] into the Deloitte software system for UHIP, according to Beane.

An unsigned, handwritten note on an envelope was received by Rep. Patricia Serpa, chair of House Oversight Committee, as well as by other committee members, which said that without Jennifer Wood testifying, the committee hearing would be “an incomplete dance card.” Beane did not directly answer a question from Serpa about whether Wood would be made available to testify in the future.

Beane announced that an agreement had been reached between the union, Local 580, and the state, to bring back a number of state workers as part of a “preferred recall list” for some 60 FTE positions at DHS who had been laid off the month before the launch of UHIP in September of 2016. The intent, Beane continued, was to bring back those with “institutional knowledge” of long-term care services.

“I admit, we have a bandwidth problem. We don’t have enough staff workers,” Beane testified, describing problems with ongoing communications issues between agency providers and DHS.

The lack of what Beane called “a worker inbox,” supposed to be functional when the new software system designed by Deloitte went live, to enable DHS workers to check the box when an application was now fully transferred to their responsibility, had never worked. Deloitte is now working on fixing the problem, with a functional worker inbox supposed to be ready by April 1.

Compounding the problems
Next up were three representatives of home health care agencies, including Oliver, and Vincent Ward, owner and president of Home Care Services of Rhode Island, based in Woonsocket.

Ward testified that his agency had received no referrals from DHS since last August, that the DHS in Woonsocket was operating as a mere shell, and that he had spoken with just two caseworkers during that time – in each case, Ward was the one who had “precipitated” the phone call, in one instance waiting on hold for an hour and a half to speak with someone.

“There may be Woonsocket residents who have not been able to fill out applications,” Ward suggested, saying it was a significant problem for DHS not to have enough caseworkers.

Oliver argued for a return to the previous model of caseworkers before the launch of UHIP. Oliver questioned the accuracy of numbers predicting the need for home health care services developed by the Case Estimating Conference in November, saying that the need had been dramatically underestimated because there had been no referrals from DHS, which in turn had the effect of “lowering” the projected budget.

Oliver recommended that there be a position created so that home health care agencies had a direct point of contact to communicate with within DHS.

More interest in detecting fraud than in serving patients
As part of the next group of providers who testified, Mary Benway, RN, president of Community Care Nurses located in West Kingston, questioned the state’s priorities when it came to providing home care. Her small business provides skilled nursing and home health aides to more than 100 homebound individuals each week.

“Without adequate support for home care,” Benway said in written testimony, “more of Rhode Island’s oldest, sickest and poorest citizens” will be forced to leave their homes and live in nursing home settings.

Among the many problems with the implementation of UHIP were the significant delays in patient authorizations for services, according to Benway, preventing caregivers from entering the homes of patients and blocking the ability to enter claims for timely payment.

As a result, Community Care Nurses has changed its policies regarding the number of Medicaid patients it will accept for care, waiting for documented patient authorization, not only on paper, but also in the payment and verification system known as Sandata.

Benway also criticized the manner in which an “employer wage pass through program” was being administered by EOHHS, delaying anticipated wage increases for nursing assistants.

Benway blamed EOHHS for not providing the necessary information for providers to be able to comply with the program; according to Benway, the EOHHS response has been, “We’re working on it.”

“Skilled nurses are not addressed whatsoever in the wage pass-through program,” Benway said in her written testimony. That makes it the 20th year, she continued, “with no Rhode Island Medicaid rate [increases] or wage relief for skilled services for the nurses who provide them.”

Instead, the emphasis by EOHHS seemed to be placed on conducting provider integrity audits, which in 2016 showed no fraud or improper billings for services, according to Benway.

Benway joined Sheehan and Oliver in being blunt: “The Governor and EOHHS staff from the top down are ill-prepared for, and incapable of, repairing UHIP.”

Being heard
In her testimony, Virginia Burke, the president and CEO of the R.I. Health Care Association, with 67 skilled nursing facilities in Rhode Island as its members, talked about the problems of being heard by state officials.

“We are 19 percent of the state Medicaid budget, but I can’t seem to get our voice heard,” Burke said.

The goal of the skilled nursing facilities, she explained, is “to provide good care” for the vulnerable elders entrusted to them. “But EOHHS seems to make that more difficult to do.”

For years, Burke continued, their suggestions and concerns have been ignored to the point where “it feels like there is an indifference to not just our facilities but the people they care for. UHIP is only the latest in a series of problems.”

At length, Burke told the story about how her concerns about UHIP and the mounting backlog in eligibility determinations had been rebuffed, discounted and ignored by the former leadership team at EOHHS and DHS.

It was a similar story to what happened in 2013, when Burke raised concerns about the launch of Rhody Health Options, the first phase of the Integrated Care Initiative. Burke predicted the lack of successful outcomes, which was finally acknowledged in the proposed FY 2018 budget, with the proposed reduction of more than $12 million in administrative fees paid to Neighborhood Health Plan of Rhode Island because the program’s lack of success.

Looking to the future, Burke raised questions about plans to create accountable entities for long-term care services under Medicaid as part of the Reinvention of Medicaid.

While she was encouraged by the change in attitude by both Beane and Wallack in being willing to listen to and consult with providers, what was needed was a fundamental culture change by state government around priorities.

Beyond the money
During the testimony, it was reported that four home health care agencies providing services had been forced to close down, due to financial difficulties, caused to some degree by the botched UHIP launch.

Rep. Michael Chippendale asked: What happens to all those people being cared for? Where do they go when the doors close? Are they put out on the sidewalk?

The answer from the providers: they were going to go without care, or with families providing the care, or more likely, they were going to end up in a more expensive facility.

Michael Bigney, the administrator and co-owner of Home Health & Hospice Care of Nursing, closed his testimony by saying: “It’s not about the money; that’s not why we’re here [testifying]. Bigney continued: “It’s the [broken] system, and it’s about the care that these people are not getting.”

Sheehan concurred: “It’s not a matter of the money. It’s about people crying on the telephone to you, and when you can provide services, they hug you and kiss you and say that they haven’t seen anybody in over six months.”

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