Delivery of Care

The big fix: addiction, recovery at UHIP

Raimondo apologizes for the mess at UHIP, but blames others; Anya Rader Wallack steps in to serve as acting director at RI EOHHS

By Richard Asinof
Posted 2/20/17
The admission by Gov. Gina Raimondo that the UHIP system designed by Deloitte was defective, if not broken, comes after six months of continued, persistent complaints. The resignation of Elizabeth Roberts coupled with the demotion of top deputy, Jennifer Wood, are strong moves, changes that some would argue were long overdue. Raimondo framed the story as one where Deloitte’s reputation was at risk; so, too, is Raimondo’s.
Were there flaws in Raimondo’s management style that prevented bad news from being heard by the Governor? Did the aggressive communications strategy to promote Raimondo’s management prowess backfire with UHIP? How much will it cost to fix the broken UHIP system, and who will pay for it? Would it be better to fire Deloitte, sue them, and hire a new contractor to build a new system? Who gets to participate in that conversation? And will the decision-making be transparent?
The idea that better health IT will improve health outcomes is still an economic argument that has yet to be proven in the marketplace. Listening to patients in a patient-directed system of care is still the elusive goal. One benchmark would be to measure how nurses, who are on the front lines of health care, participate in the decision-making around health care investments in technology and in health care delivery. Another benchmark would be to measure the two-way flow of communications between patients and providers.
One survey that might be worthwhile to conduct is the amount of time that doctors and executives and agency administrators have to wait in line, compared to patients and those receiving benefits and services.

PROVIDENCE – Call it a belated, forced intervention. After more than six months of denial, Gov. Gina Raimondo finally admitted that the software system built by Deloitte that was the IT architecture underpinning of the $364 million United Health Infrastructure Project was “defective,” if not broken.

The larger question was: what took the Governor so long? And why did she wait until now to remove the leadership directing the project?

A new 21-page report, written by Eric Beane, the acting director of the R.I. Department of Human Services, which had been commissioned last month, was the first time Raimondo said that she had received “a truly unvarnished, not rosy picture of the situation.”

Beane’s report, Raimondo explained at a news conference on Feb. 15, had really “gotten under the covers” to reveal to her exactly what was going on. “[UHIP] was more broken than I realized.” Really?

Had Raimondo somehow not believed the frequent news reports that documented the breakdowns in services caused by glitches in UHIP over the last six months for so many of Rhode Islanders most frail, vulnerable residents?

Or, had she not believed the providers, including childcare agencies, home health care agencies and nursing homes, which had complained bitterly about not being paid?

What part of a $40 million backlog in payments to nursing homes for Medicaid long-term services was not credible evidence of a crisis?

Given the attention paid by her administration’s communications team to provide weekly briefings on UHIP numbers, Raimondo appeared to have been very much aware of the problems.

However, Beane’s report, it seemed, had finally jarred loose the cotton in her ears, to help her understand that the problem was much larger than managing the messaging and putting a positive spin on it. Things were not getting better.

Raimondo was adamant that she still believed that the problems with UHIP could be fixed, but it will take 12 months or longer to overhaul and rebuild the existing broken system.

Raimondo promised that the contract with Deloitte would be renegotiated, but she ducked answering the question about how much the actual cost of fixing the system would be, and who would be responsible for paying for the additional expenses.

Yes, Raimondo said, suing Deloitte was an option on the table, which made for a “tense situation.” Their reputation, she told reporters, “is on the line; they know that they delivered a product which is not consistent” with Deloitte’s reputation as a top-tier firm.

So, too, in many ways, is Raimondo’s reputation.

Roberts resigns, Wood demoted
A day earlier, Raimondo had accepted the resignation of Elizabeth Roberts, the secretary of the R.I. Executive Office of Health and Human Services.

In her place Raimondo named Anya Rader Wallack to serve as the temporary acting director while a national search was conducted. Wallack, who had served under Roberts as the director of the Rhode Island Medicaid office, and earlier as director of HealthSource RI, was to be the source of “fresh eyes” sought by the Governor.

Also, the deputy director, Jennifer Wood, who had served as top aide for Roberts at R.I. EOHHS, was demoted.

Saying you’re sorry, but still blaming others
“I apologize,” Raimondo said, saying she was sorry for the snafus caused by UHIP. “If I had known in September what I know today, I would not have let the system go live.”

According to Raimondo, she was the one who was asking the critical questions about the project before pushing the button to go live on Sept. 13. “I was the one who was saying, ‘Are you sure this was ready?’ I asked Deloitte: ‘Can you guarantee me that it won’t be like Kentucky?’”

But the Governor refused to shoulder full responsibility for the problems that had occurred. Instead, she placed the blame on Deloitte and on her leadership team led by Roberts.

[Raimondo also claimed that she was under pressure from leaders in the R.I. General Assembly to make the system operational, a claim that had to be walked back later under sharp questioning from the House Oversight Committee members later that day.]

“We paid [Deloitte] a lot of money, and we didn’t get what we paid for,” she said. “They represented to us that [the new software system] was in much better shape than in fact it was.”

But Raimondo had apparently ignored reports of serious problems with Deloitte’s software system that caused some $9 million in cost overruns in 2014 at HealthSource RI that needed to be fixed with manual overrides, documented in a briefing book submitted by Christine Ferguson, then director of the agency. [See link to ConvergenceRI story below.]

Instead, Deloitte was asked to serve as the pro bono facilitator of the Reinventing Medicaid workgroup sessions.

“It is regrettable that we are where we are,” Raimondo continued. “It is regrettable that I was provided [with] poor information and made a bad decision [as a result].”

Still, Raimondo was unwilling to concede that her management style, which apparently prevented internal questions and concerns about UHIP by high-level staff at EOHHS from reaching her, may have made the problems worse.

“I do have a bias toward action, no doubt about it,” Raimondo said. But she rejected the idea that she needed to change her management style.

“I want you to know that we’re going to get this right,” Raimondo promised. “I am more committed than ever to doubling down and getting this right.”

“We’re going to fix this,” Raimondo continued. “And, we believe, when we get to the other side, the system is going to be better than where we were when we started.”

Yet, the possibility that the entire software system may need to be scrapped was not under consideration, according to Raimondo.

When asked by ConvergenceRI during the news conference what lessons she had learned, Raimondo said: “One thing is crystal clear – we didn’t have enough high-quality IT state staff to hold Deloitte accountable. We were overly reliant on them.”

As a result, Raimondo continued, “One of my takeaways is that I’m putting a pause on all major IT rollouts for the state. We need to rethink how we do IT.”

The facts, according to Raimondo
A 21-page report, prepared Beane, entitled: “An Assessment of the Unified Health Infrastructure Project,” was presented to the gaggle of news media crowded into the fourth-floor executive conference room at the R.I. Department of Administration, providing a diagnosis of the shortcomings and a short-term action plan.

In the analysis by Beane, the following were given as “facts”:

Deloitte did not adhere to industry best practices; it delivered an IT system that was not functioning effectively; and the state relied too heavily on Deloitte’s industry expertise.

UHIP was not ready to go live in September of 2016; layoffs were made too soon, before the state could evaluate the impact of the rollout; and the staff did not receive enough training to prepare them to manage the system.

The short-term action plan put the emphasis on the following priorities:

Improve the payment process for childcare providers and the processing and payment for Medicaid long-term care applications; fix problems with the worker portals; identify and address top root-cause data issues; and provide comprehensive training on UHIP to DHS staff.

The report’s conclusion states that the UHIP project needed “more time, more people and more training before it went live.”

In order to meet the challenges of fixing the system, the report promised, “The state will act with greater urgency and transparency.”

The conclusion makes clear that it still maintains the underlying belief in the concept of the UHIP project: “As significant as the current problems are, the UHIP system does have the potential to substantially ease the process for everyone involved, even if it takes longer than expected to get there.”

A nuanced history
Beyond the question of how best to fix the broken software system is a more fundamental question about whether the investment in the technology to develop a single entry portal for the way that more than 300,000 Rhode Islanders apply and access benefits was warranted: would it save money, improve access, and improve health outcomes?

The origins of the project date back to 2011, when then Gov. Lincoln Chafee created the R.I. Healthcare Reform Commission to oversee the implementation of the Affordable Care Act. The commission recommended that the Rhode Island create a state-based exchange, later known as HealthSource RI.

The state went ahead, with the federal government paying 90 percent of the cost, to build out the health IT infrastructure needed for the state exchange as the first phase of what became known as the Unified Health Infrastructure Project. In January of 2013, the state signed a contract with Deloitte. [In what remains one of those amazing Rhode Island stories, the same person overseeing the contract with Deloitte was also responsible for the managing the contract with Hewlett Packard for the problematic IT upgrade at the R.I. DMV.]

The second phase, which expanded the scope of the functionality of the UHIP system, sought to create a unified database for both HealthSource RI and the R.I. Department of Human Services. It was originally scheduled to go live in July of 2015; then the start date was delayed until July 1, 2016; then it was postponed until Sept. 13, 2016.

The push to fix the broken UHIP system comes at a time when the largesse from the federal government to invest in health IT buildups under the Affordable Care Act is certain to disappear under the new Trump administration, with its plans to repeal, replace and repair Obamacare resulting in a major reduction in funds flowing to Rhode Island to support Medicaid and Medicare members.

As yet, there are no plans of action being developed by the Raimondo administration or by the R.I. General Assembly on how it will respond to the economic tsunami that such reductions will create. The state appears to be in a reactive mode, without any emergency plan.

The removal of Elizabeth Roberts and her top aide, Jennifer Wood, will have profound repercussions on much of the work now underway in health care “reform” in Rhode Island.

What will become of the $20 million State Innovation Model campaign, much of it had been being coordinated by Wood, and its efforts to transform the state’s health care delivery system?

The overdose death toll in Rhode Island has reached 321 – and counting – for 2016, an increase of at least 51 deaths over the 2015 death toll. A new study by Shannon Monnat found that Rhode Island led the nation in the number of deaths by young white adults because of drugs, alcohol and suicide between 2010 and 2014, at 59.8 percent.

Is a change in strategy required, which had sought to reduce the number of overdose deaths by one-third by 2018? Roberts had been responsible for overseeing the R.I. Department of Health and the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, the two agencies coordinating the work of the Governor’s taskforce.

Rhode Island is under a federal court consent decree to meet its responsibilities for care of the developmentally disabled. The work had been a central part of Wood’s responsibilities in the last few months, attempting to stave off the potential for millions of dollars in fines. Who will now take over that responsibility? And, how will the problems of developmentally disabled young adults, caught up in the UHIP glitches, become a priority?

What will become of the plans to develop accountable entities under the Reinvention of Medicaid, as mandated by state law?

Once again, Wood was a major player in developing the road map for where accountable entities would go, as a way to invest in health care by value, not volume. While Wallack is intimately familiar with the details of accountable entities, having served as director of the state Medicaid office, it is unclear whether accountable entities will remain a priority moving forward, given the projected reductions in federal Medicaid funding.

Pushing the reset button
The divide in health care has often been described about the gap between the wealthy and the poor and the ability to access services. Perhaps a better dichotomy, as illustrated by the botched UHIP rollout, is about the gap in entitlement: between those who have to wait in line, and those who don’t.

It is a humbling experience to wait in line, often for hours. If Raimondo and her leadership team [as well as members of the R.I. General Assembly] were the ones who had to bear the indignities of waiting in line for services, or were the ones who had to argue that the computer system had made a mistake, would it have taken six months to recognize that the software system built by Deloitte was broken?

Raimondo was correct in identifying one flaw in the government’s thinking: that they had become too reliant, too dependent on the contractor, Deloitte, for technical advice.

Technology, however, may not be a panacea in addressing health care needs. Dr. Michael Fine, the former director of the R.I. Department of Health, an advocate of developing Neighborhood Health Stations in Rhode Island, with two in operation, one in Central Falls and the other in Scituate, offered the following observations about the need to reset the conversations around health care delivery in the wake of the botched rollout of UHIP.

“This is what happens when you allow a medical services market to be manipulated by lawyers, bureaucrats, politicians, administrators, lobbyists, and community organizers – people who have never been at the bedside – instead of allowing a health care system to be designed by patients, nurses and clinicians,” Fine said.

Since Fine has returned to providing patient care at Blackstone Valley Community Health Care community health center, he continued, “I’m aghast when I see all the useless hoops the bureaucrats have invented for us – hoops that take our attention away from listening to patients.”

But, to some extent, Fine said, the blame also extends to health care workers. “Health care workers are also responsible for this mess, because we’ve let it happen without protest. So it’s time for health care workers to act up, to make our voices heard, to become experts with attitude, and to take the health care system back from the health care profiteers.”


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