Delivery of Care

Another breakdown in trust and transparency with UHIP

Legislator: “What can we do to help?” Owner of a home health agency: “You could impeach the governor.”

Photo by Richard Asinof

Virginia Burke, president and CEO of the Rhode Island Health Care Association. left, Nicholas Oliver, executive director of the R.I. Partnership for Home Care, and Gail Sheahan, owner of Consistent Care, offer testimony at the April 27 hearing of the House Committee on Oversight.

By Richard Asinof
Posted 5/1/17
The apparent failure to come clean and be transparent about the continuing problems with UHIP flared up when news of a $805,197 federal penalty for violations in contract amendments between the state and R.I. EOHHS emerged, in a letter dated Jan. 5, 2017. The House Committee on Oversight members expressed outrage at a April 27 hearing that information about the penalty had not been shared with them by DHS Acting Director Eric Beane.
Will interim R.I. EOHHS Secretary Anya Rader Wallack take Virginia Burke’s advice to heart: it would be wise to listen to us? When will the old system of having a direct contact person at DHS for nursing homes and home health care agencies be resurrected? Will the answer posed by Rep. Chippendale about the amount of resources being devoted to work-arounds as a result of deficiencies in the Deloitte software system be shared? Will the House Committee on Oversight pursue subpoena power to hold state officials accountable? Will the repeated request that former EOHHS deputy director Jennifer Wood appear before the House Committee on Oversight be honored?
One of the lingering questions of responsibility surrounding the botched rollout of Deloitte’s software system was the way that the Raimondo’s communications team presented an over-optimistic framework for UHIP and the problems that were occurring. As competent and talented as the communications team may be in driving home its messaging and promoting the Governor, the latest juxtaposition of “good news” in advance of the April 27 House Committee on Oversight to drive the news cycle raises some questions about what lessons were learned.
The anger and distrust voiced by committee members over the perceived failure to share information with them will continue to reverberate moving forward, exacerbated in part by the positive messaging being put out on the Governor’s behalf.

PROVIDENCE – It got ugly very quickly at the House Committee on Oversight hearing on April 27, focused on the continuing snafus with the $364 million [and counting] Unified Health Infrastructure Project, or UHIP.

Legislators were enraged, to put it mildly, that the facts about an $805,197 federal penalty had never been shared with them, either by Eric Beane, acting director at the R.I. Department of Human Services, or by the previous director, Melba Depena Affigne.

Instead, members of the Committee on Oversight apparently had to learn details about the $805,197 penalty – and efforts by Beane to appeal that penalty and propose an alternative investment of resources – from R.I. Auditor General Dennis Hoyle.

For two hours, legislators voiced their anger and disappointment in their questioning of Beane, much as if they had caught a partner in a relationship in untruths and deception.

“I feel that you have not been totally honest,” Serpa told Beane, warning him that the results of an internal audit will flesh out other potential problems not yet shared. “We want to get to the bottom of this. The least you can do is be entirely honest and transparent with us.”

Instead of a breath of fresh air she had hoped for, following the dismissal of the previous Raimondo team running UHIP, Serpa continued, it feels like a return to the “same old, same old.” Serpa said that she was sick of the “double-speak,” what she termed the usual “blah blah blah blah blah.”

Rep. Jason Knight, an attorney, provided Beane with an impromptu interrogatory of questions that the acting director needed to provide answers for, warning that if satisfactory answers were not forthcoming, Knight would consider asking for subpoena power for the Oversight Committee.

Knight also asked Beane: “Do you need help?” in relation to legal matters. “Don’t be afraid to ask for more resources if you need it.”

Rep. Teresa Tanzi asked Beane to provide data about the number of missing applications, rather than just the reductions in the backlog of cases, saying that a number of her constituents had complained that their applications for SNAP benefits had been apparently misplaced.

Rep. Michael Chippendale asked Beane to provide an accounting of workflow, to understand how much personnel and resources were being devoted to workarounds of the malfunctioning Deloitte system.

Attending the hearing was, in many ways, like witnessing a long, cathartic therapy session. Whether any trust in the ongoing relationship can be rebuilt remains to be seen.

It would be wise to listen to us
The final hour of the hearing served as a kind of forced therapeutic intervention, as providers – including Virginia Burke, president and CEO, Rhode Island Health Care Association, Gail Sheahan, owner of Consistent Care, and Nicholas Oliver, executive director of the Rhode Island Partnership for Home Care – engaged in direct conversation with Beane and Anya Rader Wallack, the interim director of R.I. EOHHS, with Rep. Patricia Serpa serving as the facilitator.

“It would be wise to listen to us,” Burke urged, in a calm voice. “We know what we’re doing. We should be at the table.”

Burke told the story about how she had recently offered a potential solution to Patrick Tigue, the new director of the R.I. Medicaid, about how best to deal with overwhelming backlog in determinations of eligibility for long-term care services under Medicaid, many which stretched beyond 90 days, with millions of dollars owed.

The current process for expedited payments, described as one that responded to asks made by nursing facilities, has resulted in more than $25 million in such payments being made in the last few months. But the payments were being made without direct attribution to particular patient cases, requiring nursing facilities to keep a second set of books. Payments are being made based upon averages of patient payments, making it even more difficult to reconcile the payments to actual patients.

Instead of the current, convoluted process, Burke recommended that nursing facilities be allowed to submit applications on paper, as they had done pre-UHIP.

Tigue, to his credit, according to Burke, “heard what we had to say.” He has not yet given an answer. Larry Ross, who serves underneath Tigue, had told Burke no, that the average payment program was better, according to Burke.

No contingency plan
Sheahan testified about the inability for her voice to be heard and listened to throughout the entire UHIP process, despite her efforts to warn state officials about the impending disaster.

Since Sept. 9, four days before, Sheahan said, she not has received a single referral from the R.I. Department of Human Services.

Without referrals, the ability to provide services through her agency has been diminished, and many of the CNAs she once hired have left the profession.

Without being able to access home health care services through the Medicaid program, many of the potential people seeking services are instead ending up in hospital emergency rooms or nursing homes, at a much greater cost, Sheahan said.

Eight months later, Sheahan contended, there is still no contingency plan in place to deal with the failure of UHIP, other than workarounds.

Sheahan also complained about the position that she has been put in, forced to chase down co-payments and patient shares owed for services to the insurance company managing the Medicaid program. “I’m not a loan shark; I’m a nurse,” she said.

Serpa, in her role as facilitator, asked Sheahan what the legislators could do to help the situation.

“You could impeach the governor,” Sheahan bluntly answered, leaving the legislators momentarily speechless.

The lack of information flow
Oliver, in his written testimony, lambasted the lack of information being shared with providers to date, and recommended that a workgroup be established specific to Medicaid-contracted home care providers. Oliver also called for a suspension of all patient shares and co-pays, because the Deloitte system is still “incapable of calculating accurate patient shares and co-pays for home care services.”

Echoing Sheahan’s concerns about being a nurse and not a loan shark, Oliver said the Medicaid program should be responsible for collect the patient shares.

Penalty, penalty, what penalty?
The saga of the $805,197 penalty dates back to Feb. 10, 2016, when the Food and Nutrition Service office in Boston, a division of U.S. Department of Agriculture, sent then director Affigne a letter concerning the fact that contract amendments executed between the R.I. Executive Office of Health and Human Services and Deloitte Consulting, without prior approval from FNS, were in violation of federal regulations.

“All contract amendments must be submitted to FNS,” the letter said. “Unless specifically exempted by FNS, the State agency shall obtain prior written approval form FNS of any contract amendments which cumulatively exceed 20 percent of the base contract costs before being signed by the State agency.”

It gets worse: a letter was then sent to R.I. EOHHS on Nov. 3, 2016, notifying the agency of the decision by the FNS oversight committee to disallow a percentage of SNAP funds. But no response was ever received by FNS to its Nov. 3 letter.

As a result, a Bill of Collection was sent to Affigne on Jan. 6, 2017, in the amount of $805,197.

No one, however, bothered to inform members of the House Committee on Oversight of the outstanding penalty and potential added interest in fines.

Dennis Hoyle, the R.I. Auditor General, in a response to a question from House legislative policy staff, wrote in an April 19, 2017, email:

“This was Eric [Beane’s] response when I forwarded [the Jan. 5 certified letter with the $805,197 bill] to him to inquire and to make sure he was aware:

“Thanks, Dennis. After I came on board, we filed an appeal of this penalty and I asked FNS to issue a stay in that appeal process so we could discuss an alternative to the penalty that allows the State to reinvest those resources in our recovery plan. Those conversations are ongoing.”

When questioned repeatedly about why he had not shared the letter with members of the House Committee on Oversight, Beane initially replied that he had not been asked for the document.

“This is not small potatoes!” Serpa resonded, her voice rising in anger.

[Note to investigators at the U.S. Attorney’s Office in Providence: Don’t forget to ask the state auditor general for documents in your ongoing investigation.]

The narrative not taken
On the day of the hearing, the Raimondo communications team put out a news release, the headline announcing that the Governor had secured a $27 million credit to cover continuing costs of the UHIP rollout.

The credit from Deloitte was said to cover extra personnel costs and contracted services costs in FY 2017 and expected contracted services costs through the first quarter of FY 2018.

Translated, the credit will go to help pay for the additional 115 workers who have been hired to date to help resolve the glitches and snafus with the Deloitte software system.

The news release became the basis of the online story reported in advance of the House Committee on Oversight hearing, in both The Providence Journal and The Providence Business News.

The day before the hearing, in an April 26 news release, the R.I. Department of Human Services shared the latest UHIP Progess Update submitted to Raimondo by Beane, which, according to the news release, showed a downward trend in pending applications and the lowest lobby wait times since the go-live date of Sept. 13, 2016.

The report read, in part: “Although overall customer service at field offices has not yet returned to acceptable levels, measures do show significant improvement in certain areas. Total pending applications have stabilized and are now steadily trending downward, having declined from over 13,600 at the end of March to 10,579 as of April 26.”

Rep. Patricia Morgan chastised Beane about the update: We should not be “celebrating” the fact that we have a backlog of some 11,000 cases seven months after the launch of UHIP.

Editor's Note: The hearing as "therapy session" proved succesful in having the R.I. Medicaid office agree to adopt the policy change recommended by Virginia Burke, president and CEO of the R.I. Health Care Association, which had been previously rejected. Burke wrote to ConvergenceRI that Patick Tigue, the state Medicaid director, notified her in the evening on May 1  that the state will permit facilities "to use the payment methodology we suggested at last Thursday's UHIP hearing, as an alternative to the 'average daily payment' that had been favored by Larry Ross. This is good news!"

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