Delivery of Care

Waiting for a technological Godot or someone like him

In the third oversight hearing investigating the dismal rollout of the $364 million UHIP, a major problem pinpointed by providers was the apparent removal of “human” from the Department of Human Services

By Richard Asinof
Posted 1/2/17
There were two conflicting narratives at the oversight hearing held on Dec. 20 about the flawed implementation of UHIP: one by service providers, who described in detail how the lack of payments was disrupting their ability to survive and to care for patients; the other an optimistic view from Gov. Gina Raimondo’s team that things were getting better. The legislators found it difficult to reconcile the disparate views, saying that a credibility gap existed.
Does the state have a plan in response to the proposed strategy to repeal and replace Obamacare by President-elect Trump and the Republican Congress? Is the state willing to finance the expansion of Medicaid on its own? What is the status of Rhody Health Options, a program recommended for elimination in a budget proposal from R.I. EOHHS, including a $35 million cut in administrative fees for Neighborhood Health Plan of Rhode Island in FY 2018? Will the state of Rhode Island seek damages from Deloitte to hold them accountable for flaws in the software system? In turn, will Raimondo hold any of the current staff at R.I. EOHHS accountable for the problems with the problematic roll out of UHIP? How will legislators pursue their continuing questions about the problematic UHIP roll out? How will the future demographics in Rhode Island, with its growing population of “old old” residents, impact the demand for skilled nursing facility care?
On Dec. 27, in the middle of the hiatus between the holidays, the R.I. Executive Office of Health and Human Services released its 72-page Accountable Entity Program Roadmap, a detailed look into the way that the agency is seeking to change the delivery of Medicaid services. The major new programmatic thrust as part of the roadmap is plans to develop an accountable entity for long-term care services under Medicaid.
Given the disastrous roll out of UHIP and its devastating impact on long-term care facilities, creating a backlog of payments and eligibility determinations, coupled with the lack of positive outcomes from Rhody Health Options under the Integrated Care Initiative and the uncertain results from the initial Reinvention of Medicaid regarding rebalancing efforts, the proposed accountable care entity for long-term care deserves a long and careful look by the R.I. General Assembly, if they have the gumption to do so.

PROVIDENCE – Five days before Christmas in 2016, in Room 35 in the basement of the State House, ConvergenceRI witnessed a strange, choreographed drama.

The stage was a joint hearing held by the House Finance Committee and the House Oversight Committee.

The testimony was as surreal as any script from a Eugene Ionesco play.

In Rhinocerous by Ionesco, a conversation in a coffee house between two friends is interrupted by the sudden appearance of a rampaging rhinoceros. Soon, all of the town’s residents are transformed into rhinoceroses, a metaphor for what happened in Europe in the events leading up to World War II and the rise of fascism and communism.

In this modern-day version of the theater of the absurd, no rhinoceroses were observed rumbling and rampaging through the State House – yet.

Competing narratives
But there were two conflicting narratives, two separate realities, regarding the botched launch of the $364 million Unified Health Infrastructure Project, or UHIP.

One, from service providers, described a litany of backlogs and snafus in being paid, increased financial burdens, breakdowns in communications and continued disruptions caused by the problematic implementation of the new integrated eligibility software system built by Deloitte.

The service providers offered their views from the outside looking in, witnesses to – and victims of – the financial chaos and havoc caused by the glitches and failings of the new software system.

The other, from Gov. Gina Raimondo’s team, acknowledged that yes, there were problems, but testified how the state was working hard to resolve any outstanding issues and to ensure timely payments, saying that the state was moving ahead on the right track.

What the witnesses on both sides of the competing narratives told the legislators left many of the lawmakers sputtering to find the right words to express their own anger and frustration – a reflection, perhaps, of their own inability to arrest the breakdown of the state’s safety net as a result of the technological glitches caused by the launch of UHIP on Sept. 13.

One called it “inexcusable”; another said it left him “perplexed”; a third called it borderline “disgusting.”

Hearing what was said
At times, the legislators themselves took on a distinct resemblance to the good citizens of Ionesco’s small town, arguing whether or not to believe that there were rhinoceroses on the rampage, despite what their neighbors had witnessed and reported to them.

One legislator, Rep. Robert Jacquard, the Speaker Pro Tempore, complained that some of the provider witnesses were coming across as “extremely guarded” in their testimony, failing to provide legislators with the necessary details to take action. “It’s really white noise, unless you give us some kind of visual on this,” Jacquard said.

[Did Jacquard really expect that the providers, who were professional and decorous in their testimony, would suddenly jump up and shout, “J’accuse!” at Elizabeth Roberts, secretary of the Executive Office of Health and Human Services, who was sitting behind them? Any more than Jacquard would do the same to House Speaker Nicholas Mattiello?]

Rep. Michael Chippendale answered Jacquard, saying that providers are “on the outside looking in, doing what they’ve always done, and not getting the same results.” As a result, he continued, it was awkward to expect them to know the inside details of what had gone wrong.

After listening to the conflicting narratives, Rep. Antonio Giarrusso said that the providers and Raimondo’s team sounded as if they were “living on two different planets.”

In the first two hearings, Giarusso continued, legislators had been told that things were improving, and there was a little more work to do. “As I am listening to the providers, it’s like the sky is falling. Where is the real truth?”

Rep. Patricia Morgan expressed disbelief with what the Raimondo team was saying: “There’s a credibility issue with what I am hearing here. It’s great to express sympathy, but that doesn’t pay the bills.”

Call it a credibility gap, a term made popular during the Vietnam War.

Then: a short history lesson
For those who were born after 1965, here is a short history lesson.

In late 1967, in the midst of growing doubts about the Vietnam war, the top U.S. general there, William Westmoreland, came back to the U.S. to perform in the role of optimistic cheerleader for the conflict, promising that there was a light at the end of the tunnel. Meanwhile, the grunts fighting on the ground and the reporters covering the war told a far different, pessimistic tale.

At that time, the American military strategy was to conduct a war of attrition, attempting to kill enemy soldiers faster than they could be replaced in “search and destroy” missions. American success was measured by counting the number of enemy troops killed, which were then offered up by the Pentagon as a sign of war’s success and dutifully reported by the news media, even as those on the ground disputed the accuracy of “kill ratios” and body counts.

In an address at the National Press Club on Nov. 21, 1967, as part of public relations offensive launched by President Lyndon Johnson’s administration, Westmoreland said that the communists were “unable to mount a major offensive.” Westmoreland continued, saying that in his view the enemy was losing: “We have reached an important point where the end begins to come into view.”

Yet, on Jan. 30, 1968, only eight weeks later, in what became known as the Tet Offensive, the North Vietnamese and the Viet Cong launched attacks at more than 100 cities and towns across South Vietnam, the largest offensive conducted in the war to date, severely undercutting the Westmoreland’s argument. The fallout from the credibility gap created by the Tet Offensive eventually led to President Lyndon Johnson’s withdrawal from the 1968 Presidential election.

[There are, of course, some who still vehemently argue that the U.S. was the ultimate victor in the Tet Offensive, because so many enemy combatants were killed. There is a black marble memorial wall in Washington, D.C., that provides a poignant counterpoint to the validity of calculating success by body counts and “kill ratios.”]

Now: thrashing through technological weeds to get paid
As evening enveloped Providence on the darkest night of the year on Dec. 20, the House Finance Committee and the House Oversight Committee held its joint hearing, a session that lasted more than three hours. The brightly lit Christmas tree in the Rotunda seemed to exist in a galaxy long ago and far away from the chilly basement hearing room.

It was the third such hearing; at the previous hearings, one on Oct. 20, and the other on Nov. 28, the legislators had grilled Raimondo team officials from the R.I. Department of Administration, the R.I. Department of Human Services, and the R.I. Executive Office of Health and Human Services, demanding answers for a series of screw-ups in benefits created by the launch of the new software system built by Deloitte. [See links to ConvergenceRI stories below.]

For the first time, the legislators heard testimony directly from providers such as nursing homes, childcare facilities and home care services, talking about payment snafus they have encountered since the launch of the $364 million Unified Health Infrastructure Project on Sept. 13.

One nursing home administrator, Kelly Arnold, of the 190-bed Riverview Healthcare Community in Coventry, testified that she was still carrying more than $1.4 million in uncompensated care for Medicaid patients, dating back to February, because the state had not yet determined their eligibility.

It required a constant, stressful juggling on the cash flow, Arnold continued, figuring out which vendors would get paid and which would not.

Even though a lump sum, unallocated, off-cycle payment of some $515,000 had been made by the state on Nov. 25, that payment had created an additional accounting burden – the need for a second set of financial books, because it had not been linked to any specific patient cases, according to Arnold.

The payment, while welcome, will require the books to be reconciled once the actual specific patient data is made available.

Postcards from the edge
From across a spectrum of services, the news delivered by providers was damaging to the illusion that despite a bumpy start, things were getting better with UHIP:

• Kelly Lee, vice president of engagement for the PACE organization, which seeks to provide care for frail elders to keep them in the community, framed her comments by saying: “Timing is everything when seniors are in crisis. They need care when they need it.”

Determining eligibility under UHIP, she continued, “has gone from a two-week turnaround to up to a 90-day turnaround for someone who wishes to enroll in the PACE program.”

• Jim Nyberg, the director of LeadingAge RI, said that while the long-term care industry is used to operating with a degree of “uncertainty” around payment issues, the issues have been “exacerbated dramatically” by UHIP and the layoffs at the R.I. Department of Human Services.

The delays in pending claims have been difficult for providers but also for families, Nyberg said. “The families don’t know what is going to happen in terms of care for their loved ones.”

The bottom line, Nyberg continued, is that providers are not getting paid in a timely fashion. Many nursing homes, Nyberg testified, employ direct care workers, “so cash flow is really a key issue. They are all small businesses.”

Nyberg, along with others, brought to light that there is a “communications” problem between UHIP system, built by Deloitte, which determines eligibility, and the MMIS system, built by Hewlett Packard Enterprise, which is how the state handles its billing and processing of claims. When providers try to bill for services for an individual who has become Medicaid eligible, they are often denied payment, because of glitches in data transfers from UHIP to MMIS, according to Nyberg.

• Kathleen Kelly, executive director of the Rhode Island Assisted Living Association, offered legislators two flow charts as a show-and-tell illustrating the complicated parallel processes involved in determining eligibility for Medicaid services in assisted living.

“It’s just one program, start to finish, just the approval process,” Kelly said. One takes place at the R.I. Department of Elderly Affairs, the other at the R.I. Department of Human Services.

According to Kelly, whose organization represents 51 of the 61 assisted living facilities in Rhode Island, the problems include software systems problems with UHIP, the layoffs at DHS, which made the situation worse, and the disconnect between UHIP and MMIS.

“Even if you fix UHIP, if [the data connection to] MMIS isn’t fixed, then the providers still aren’t going to be able to be paid,” Kelly said.

Further, Kelly continued, under the Neighborhood Health Plan of Rhode Island contract for the Integrated Care Initiative, there is a pilot program in assisted living to develop more home and community options. “We can’t move forward on that project because we can’t get the existing providers paid.”

A failure to communicate
Long before the official launch of UHIP on Sept. 13, which had been postponed from July, there were breakdowns in communications between providers and R.I. Department of Human Services regarding the lag in determining Medicaid eligibility for patients in long-term care.

Virginia Burke, president and CEO of the Rhode Island Health Care Association, patiently laid out the back story of the UHIP debacle for legislators.

Delays in processing applications for Medicaid for long-term care services have always been a problem, Burke explained, since nursing homes provide care without compensation until the application is approved. The problem has waxed and waned over the years, but she testified that the problem escalated dramatically during the year leading up to UHIP's implementation.

In February of 2016, DHS’s response to complaints about the growing “backlog” was to send out a letter to providers, asking them to stop calling about pending applications, Burke testified.

What nursing homes were told to do instead, Burke continued, was “to submit a written request” for information. “You have one chance to do this, on the 15th of every month, and 30 days later, you’ll get an answer to your question,” Burke said, describing the department’s instructions.

In April of 2016, in a meeting with DHS Director Melba Depeña Affigne, Burke said she and her members explained that a crisis was approaching. “We can’t go months and months of uncompensated care,” Burke said, warning the director.

Burke said she pointed out that there were vacancies in the long-term care offices at the department that were not being filled.

Depeña Affigne’s response, according to Burke: “I am not going to fill those positions until I know what kind of staffing we need for UHIP.”

At that point, UHIP was supposed to begin operation in July, and Burke testified that she told Depeña Affigne that “three more months of operating with these backlogs could be catastrophic for our facilities.”

The vacancies remained unfilled, but Depeña Affigne agreed that the process of “one day a month you write us a question and then get an answer the next month, wasn’t an adequate solution,” according to Burke.

In response, what was known as an Excel “escalation tool” was developed, to be exchanged back and forth between providers and the department., with four DHS staffers assinged to the work group.

Burke continued: The first wave of escalation tools was submitted by providers in August, but before the responses were due back, three of the four workers on the team had received pink slips. “The member of the group who was most instrumental in developing the tool and had trained her colleagues on it, is now working at Starbucks,” she testified.

Summing up the bad situation, Burke said: “Providers are still being asked to bear the brunt of [the problems with implementing UHIP] and the cost of it. If you know how many are pending, and how much you owe us on the applications, never mind the problems with the software interface: pay us, pay us. You’re causing a catastrophic cash flow problem.”

In fairness, Burke added, the off-cycle payments made have helped, but they have gone to fewer than half the facilities. and “they don’t solve the problems.”

The missing “humans” at DHS
One of the promises made by Raimondo’s team was that the new UHIP system would create an online portal to process applications for long-term care Medicaid services, beginning on Sept. 13. That portal has never worked, and in mid-October, nursing facilities were told to stop trying to use it and send the paper applications to DHS.

However, because of the layoffs made as part of the process of implementing UHIP, much of the human expertise around long-term care no longer exists – with the result that more paperwork is often pushed back onto providers.

Some of the denials are the result of the way that information has been inaccurately scanned into the system, resulting in a new category of glitches, according to testimony at the hearing.

The lack of staffing as a result of the UHIP implementation has also affected childcare providers. At the hearing, Tyla McCaffrey-Pimentel, adult services director at the Genesis Center, in Providence, said they had to close one of their four classrooms partly because of UHIP, and they are using money that is supposed to help struggling adults to cover missing payments from the state, as reported by Alisha Pina of The Providence Journal.

Referencing staff laid off by the state Department of Human Services after UHIP went live, she added that the employees Genesis leaders used to reach out to at DHS “are no longer there to help.”

Waiting for a technological Godot
At the root of the problem with UHIP, beyond the problems with the glitched-filled software built by Deloitte and its apparent inability to connect with MMIS software system built by Hewlett Packard, is the belief that a one-size-fits-all integrated eligibility system for government benefits will produce cost savings and improve the delivery of care.

What is missing from that equation is the recognition that the quality of health care and human services is built on relationships – the ability to talk and connect with knowledgeable care providers, often about life and death issues.

On paper and in flow charts, and by crunching the numbers of processed claims, week-by-week and month-by-month, the claims that progress is being made [with the promise that money will be saved through efficiencies] are often difficult to refute. Just as it was difficult to refute the Pentagon’s claims by the best and the brightest that, according to the body count numbers, the U.S. was indeed winning the war in Vietnam.

The service providers gave legislators an earful about the ways that huge holes in the safety net for those dependent on benefits had been torn by the implementation of UHIP.

Of course, the legislators and the government officials – as well as many of the reporters covering the hearings – are not the ones who have to wait in line for hours to receive services and benefits.

Two days after the hearing, on Dec. 22, there was a two-and-a-half-hour wait at the customer service center for HealthSourceRI in East Providence just to meet in person with a representative. The waiting line snaked out past the elevators; it included many mothers with young infants. As one older woman wondered out loud, tapping her fingernails impatiently on the chair, having been waiting to hear her name called for more than two hours: what would happen if Gov. Gina Raimondo had to wait in line for hours just to talk with someone?

It’s a question that promises to reverberate in the upcoming gubernatorial election campaign in 2018. As Rep. Patricia Morgan said at the hearing: “It’s mind-boggling that somebody made the decision that you were ready to launch this system.”

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