Delivery of Care

What drives innovation? The community, or the state?

Draft of State Health Innovation Plan released

State of Rhode Island

A draft of the State Health Innovation Plan is now being distributed, although it is only about 30-40 percent of the plan, missing financials, according to government officials.

By Richard Asinof
Posted 10/28/13
As much as Lt. Gov. Roberts has promised transparency in efforts to shape the State Health Innovation Plan, there are critical areas that were discussed in the stakeholder group sessions that did not make it into the final draft, leaving gaps wide enough to drive a truck through.
Substance abuse, maternal and children’s health, integration with evidence-based community health programs at the R.I. Department of Health, and community-based health IT innovations are missing. Instead, the plan seems to endorse existing large statewide programs.
The underlying dilemma, not given voice in the plan, is how innovations occur. Are innovations that are developed from the bottom up better suited for Rhode Island, a state of neighborhoods, more effective? Or, does the state need to exert a one-size-fits-all approach to knock down existing silos? Why are the efforts of the evidence-based community health initiatives developed by the R.I. Department of Health apparently being excluded from the development of community health teams, a big part of SHIP’s proposed plan? And why has the problem-plagued Currentcare been given such an unqualified endorsement by SHIP?
Perhaps the most innovative program now underway in Rhode Island – one that connects health care and housing to economic well-being and removal of environmental hazards – is the R.I. Alliance for Healthy Homes. It is a partnership of the R.I. Department of Health, the R.I. Office of Energy Resources, the R.I. Department of Human Services, the R.I. Housing Resources Commission, Rhode Island Housing, and the Green & Healthy Homes Initiative.
By addressing the issues of asthma and lead poisoning and energy efficiency in a comprehensive fashion, improving the homes that people live in, provides the most cost-effective, evidence-based and outcome-driven results.
It is very much a bottoms-up, innovative construct using existing community resources.

PROVIDENCE – At the end of December, Rhode Island will file its application for a potential $30-$50 million award in federal funds from the Centers for Medicaid & Medicare Innovation to implement its newly created State Health Innovation Plan.

The plan was prepared by Southwind, the Nashville-based division of The Advisory Board Company, a consultant working under the direction of Lt. Gov. Elizabeth H. Roberts’ office. The plan’s stated goal is to “lead the state in the transition to value-based health care delivery and payment models.”

A draft of the State Health Innovation Plan, also known as Healthy Rhode Island, had its unofficial debut before community stakeholders on Thursday, Oct. 24, first at Save The Bay headquarters in the morning, and then again at Child and Family offices in Providence, in 90-minute presentations led by Dan Meuse of Robert’s staff.

A more formal, public presentation will be made again twice this week – first before the R.I. Healthcare Reform Commission on Tuesday, Oct. 29, and again on Friday, Nov. 1, before the R.I. Health Care Planning and Accountability Advisory Council.

The plan will be posted online for public comment at the Healthy RI website for three weeks, from Nov. 1 through Nov. 21. The final version of the plan will be submitted to the Centers for Medicare & Medicaid Innovation before the Dec. 30 deadline, according to Meuse. He boasted to the assembled audience at the morning session at Save The Bay that Rhode Island would be the only state to include public comments with its application.

Meuse admitted that what was actually being presented to the stakeholder group was only about 30-40 percent of the plan. No financials were attached. His deck of 22 PowerPoint slides differed in both format and content from the written draft that had been circulated in advance of the meeting.

Glaring omissions
Despite the plan’s lofty language, the actual blueprint doesn’t appear to contain very much that was innovative, according to a number of health care professionals that participated in stakeholder groups.

More worrisome were glaring omissions in the draft plan, according to a number of stakeholders.

• While the plan touted as an “innovation” the development of community health teams to coordinate geographically-based care, there was no mention in the plan of integration with any of the numerous evidence-based programs for patient engagement now being run by the R.I. Department of Health, according to Dona Goldman, a team leader for Chronic Care & Disease Management at the Division of Community, Family Health and Equity at the agency.

When Goldman spoke up at the morning meeting, asking Meuse about this omission, which had been discussed in detail at the stakeholder group meetings, Meuse assured her that it was indeed an omission and would be corrected in the final report.

There are no actual community health teams currently operating in Rhode Island. There are two pilot programs now under discussion, one in Pawtucket and one in South County, and the R.I. Department of Health has not yet been invited to participate in those discussions.

As Goldman explained to ConvergenceRI in an interview after the meeting, in the patient engagement area, people needed to have the skill set to better manage their chronic diseases – something that doesn’t happen in the doctor’s office. “What I was saying at the meeting was that [the R.I. Department of Health] has been developing an evidence-based, disease management and lifestyle team to support patients. This effort has really come into place, we are building a community health network, we are rolling it out now to provide easy access for patients and for practices, working very closely with patient-center medical homes.” What I was asking was, she continued, “Please consider adding this [as a component] to the innovation plan.”

• While SHIP found that “behavioral health related diagnoses and claims represent the highest concentration and spending in Rhode Island, higher than the national average, and the plan proposed creating a high-risk patient care team to manage the 5 percent of Rhode Island’s population that was deemed to have “complex illnesses and multiple co-morbidities,” there was no mention of substance abuse intervention in the plan.

Ironically, at the morning session, ConvergenceRI sat next to Sen. Joshua Miller, one of the proponents of a new pilot program to change the way that police handle situations involving people who are detained for intoxication. Instead of being transported to the emergency room, where they are allowed to sober up and then are discharged, without treatment, a new law creates a pilot program to allow police to transport these individuals to a designated community treatment facility.

As Miller told ConvergenceRI, these situations create some of the most egregious repeat high-use cases, with some individuals going to the emergency rooms 50 to 100 times a year, sobering up, being discharged, and never receiving treatment – at huge expense to the health care delivery system. There are no such designated treatment facilities up and running in the state, and an RFP is being prepared, according to Miller.

• There was no specific mention of children’s or maternal health innovations in SHIP, which Meuse acknowledged at the afternoon session was an oversight and once again assured stakeholders that it would be corrected in the revised final version.

In particular, despite the attention of rolling out the R.I. Chronic Care Sustainability Initiative as a potential model of primary care for all Rhode Islanders, no mention was made of CSI Kids, an expansion of the CSI-RI now in the developmental stages.

The lack of focus on children’s and maternal health in terms of prevention was surprising to a number of stakeholders, given the overall objective of the plan to move 80 percent of the state’s population to value-based care in the next five years.

“I didn’t hear any mention of children,” Goldman told ConvergenceRI. “I didn’t hear anything about maternal and children’s health efforts – about the [innovative] home visiting program,” she said.

The absence of children’s health within SHIP may also reflect in part the point-of-view of the consultant, The Advisory Board Company. The firm’s chief research officer, Chas Roades, has been a frequent lecturer here in Rhode Island, describing the current health care reform efforts as the change in the distribution of risk from the insurance companies to the hospitals and providers, through population health management and global payments and Accountable Care Organizations. The focus is on payment transformation, and children don’t pay the bills, whatever their health care risk may be.

• A far more troubling part of the plan is the proposed Rhode Island Care Transformation and Innovation Center, a slide that Meuse “inadvertently” left out of his morning presentation at Save The Bay headquarters and also ducked a question about at the same session.

The proposed center would create another large statewide quasi-public agency that would be given responsibility to coordinate technical assistance in contracting and measuring population health management outcomes, provide technical assistance to analyzing data, and provide support for re-training the workforce. The proposed center would also manage funding of future innovation programs and serve as a convener of resources. It would be a new entity largely outside the purview of state government and the R.I. General Assembly.

Health care IT will clearly be at the center of population health analytics needed to measure outcomes in a value-based payment system. The problem is that despite Meuse’s promise that SHIP “will not be picking winners,” the plan offers a full-throated endorsement of the Rhode Island Quality Institute’s Currentcare program. Under the plan, Currentcare is positioned to be a key component of the state’s innovation plans, despite persistent operational problems.

The number of Rhode Islanders who have enrolled in Currentcare remains only about one-third of the state’s population, about 340,000, despite incentives offered to practices that sign up patients.

The actual number of continuity of care documents, or CCDs, available in Currentcare’s database remains questionable. A former R.I. Quality Institute employee told a stakeholder group meeting in July that there were only 19,000 such CCDs; another source said that the number was reported to be under 200,000.

One of the proprietary EHR vendors, eClinicalWorks, used by Coastal Medical, allegedly cannot directly link up with CurrentCare, according to a number of sources. The problem is being addressed, but limited funds at the R.I. Quality Institute are allegedly hampering the effort, according to sources.

Further, despite Southwind’s promise to make a full inventory of health IT resources, no one ever visited Blackstone Valley Community Health Care in Pawtucket, which has one of the most sophisticated health IT systems in the state, integrating data at the point of care, having trimmed about $9 million over the last two years from the medical cost curve.

Finally, a number of work products that are currently contract deliverables that the R.I. Quality Institute is supposed to achieve by July of 2014 – such as a statewide provider directory – are included as innovative objectives under the state’s plan. The translation of such work products into the SHIP’s future proposals would seem to demand more scrutiny by state officials.

Don’t expect the state to fade away
Among the targets of SHIP are to bring the state employees, municipal employees and retirees into the net of payment transformation and care models. Exactly what that would mean is not yet detailed in the plan, other than the potential inclusion of these workers into an Accountable Care Organization model as practiced by hospitals or large group practices, through an expansion of the multi-payer patient-centered medical home model under CSI-RI.

In other words, it would appear that state and municipal employees and retirees may be “encouraged” to seek health care through a limited, tiered network of providers, buying plans through the state’s health insurance benefits exchange.

Another focus of the state’s innovation model is future workforce needs, in order to better coordinate education and training on “value-based principles.”

A big emphasis is placed on “clarifying” the state regulations about the role of community health workers who would serve as members of the community health teams. At a time when the Rhode Island Nursing Institute Middle College is building an innovative pipeline to encourage those entering the nursing profession to pursue more education, not less, the plan’s emphasis on workforce training appears to be a very big disconnect with those efforts – as well as the efforts of the R.I. Governor’s Workforce Board to retrain workers.

Finally, in the draft plan that was circulated, but not in the slide presentation, there was specific mention of the state’s efforts to address the dual eligible population in nursing homes, in a concerted effort to have them enroll in a controversial new program, Rhody Health Options, managed by Neighborhood Health Plan of Rhode Island.

Before endorsing this effort as part of the innovative approach the state is seeking to achieve, it may prove more prudent to evaluate the results after the initial Nov. 1 deadline for enrollment ends.

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