PART THREE

PROVIDENCE – The basic format of the R.I. Senate Special Legislative Commission To Study the Impact of Insurer Payments on Access to Health Care hearings is straightforward: There are presentations; the members ask questions; and at the end, public comment is encouraged. The news media, if anyone is present, is there to serve as the recorder and translator, a passive role, interpreting what is said [and what is not said], attempting to share the information and data within the regular flow of news.

The overall goal of the Commission is to shape the anecdotal and data evidence collected into potential legislative health remedies, addressing the way that inequities in rates of insurance reimbursements for both commercial and government health plans have hindered the delivery of health care.

The first two hearings, held in November and December of 2019, were not covered by any other news media, save for ConvergenceRI. [See links below to ConvergenceRI stories, “Open wider,” and “Will anecdotal and data evidence converge in legislative health care remedies?”] Two more hearings are tentatively scheduled, one in January and another in February.

In PART ONE of the story, I detailed the content of the presentations, focused on gaps in dental reimbursement rates for commercial and government insurance plans and on disparities in rates for mental health and behavioral health services.

In PART TWO of the story, I detailed the consequences of the lack of media coverage of the Commission hearings as well as the difference in narratives around health care. I also shared a conversation with Sen. Josh Miller, chair of the Commission, exploring the possibilities of a journalist making a presentation to the Commission, and efforts to recruit a fellow health care reporter to collaborate on such a presentation.

In PART THREE of the story, with the goal of transparency, I am sharing details of what might be contained in a presentation that ConvergenceRI would be prepared to make to the R.I. Senate Special Legislative Commission To Study the Impact of Insurer Payments on Access to Health Care, if invited.

It seeks to connect ongoing reporting by ConvergenceRI to the ways in which disparities in reimbursement rates are reflective of health and wealth disparities, information that has not yet become part of the Commission’s agenda. It also seeks to break down the well-defended silos in most news reporting around health care issues.

• Who is accountable? Three years after the botched launch of UHIP on Sept. 11, 2016, there were 1,228 Medicaid applications for long-term services and supports pending for longer than 90 days, in apparent contravention of state law, as of Aug. 28, 2019. That total amounted to a small decrease in the number of such pending applications, which totaled 1,315 on June 26, 2019.

Despite the promise that an online portal created by Deloitte would speed eligibility processing, no such portal exists today.

The consequences of failure to process Medicaid eligibility applications, which led to a series of interim payments of tens of millions of dollars made by R.I. Executive Office of Health and Human Services, beginning in late 2016, to keep many skilled nursing homes afloat financially, are still reverberating. Those payments are still in the process of being reconciled with the federal Centers for Medicare and Medicaid services, according to Scott Fraser, president and CEO of the Rhode Island Health Care Association.

The bigger problem continues to be the big lag in processing applications “going in the door,” according to Fraser, even after the Governor inked a new contract with Deloitte in March of 2019. [See link below to ConvergenceRI story, “The issue is still UHIP.”

“What if it takes another 90 days or more?” Fraser said he asked government officials. “We were told: ‘Well, you can always apply for more interim payments.’ Which doesn’t sound to me like it is solving the problem.”

As Fraser explained, even if the overall numbers of Medicaid applications pending longer than 90 days are going down, “If your nursing home has even 10 of those thousand claims [outstanding for more than 90 days], you’ve got a [financial] problem, and you’re going to be chasing problems. It is still a matter that needs to be addressed.”



The issue, Fraser said, “is still UHIP; that is what I’m hearing from our members.”


Translated, if you can’t get paid on time, having to care for patients for three months and longer without being able to receive compensation, it can put a real crimp in your operating budget, regardless of how high or low the rates are, limiting what you can pay employees.

• Who is not being held accountable? Overall, the costs for Medicaid in the state budget account for about $2.7 billion annually, roughly one-third of the entire state budget, including both state and federal funds. The majority of that $2.7 billion goes to pay for long-term services and supports.

Despite the new Reinvention of Medicaid law enacted by the R.I. General Assembly in 2015, which mandated the creation of accountable entities for managed Medicaid populations, there is currently no accountable entity for long-term care for supports and services, according to Patrick Tigue, director of the R.I. Medicaid office.

Translated, the impetus behind the Reinvention of Medicaid law, when it comes to the biggest cost driver of annual Medicaid spending, is not fully operational.

Further, the demand for long-term care supports and services under Medicaid is only going to grow in Rhode Island, given the demographic trends, in which the state has the highest percentage of “old old” residents, people 85 years and older, in the nation.

A further financial burden placed upon skilled nursing facilities is the failure of the R.I. General Assembly to allow facilities to receive the Medicaid Inflation Index, which is set by law. But for the last eight years, according to Fraser, the facilities have not received the inflation index, something, Fraser said, “Our members need just to try to cover the costs.”

• Who should be held accountable? The state of Rhode Island wasted five years and tens of millions of dollars in administrative fees on a poorly designed program, launched in 2013, called Rhody Health Options, with the goal of enabling older residents to move from skilled nursing facilities back to the community, projecting that some 3,000 nursing home residents who were dually eligible, receiving both Medicaid and Medicare, would return back to the community under the program.

To do so, the state hired Neighborhood Health Plan of Rhode Island as a private contractor, the sole bidder, to administer the initiative. The results were beyond poor; only a small number of such dually eligible patients ever returned to the community. Finally, in 2018, the R.I. General Assembly turned off the spigot. The problem was that for most residents of skilled nursing facilities, once the determination of care was made, they were not candidates to move back into the community – many were afflicted with debilitating chronic diseases such as Alzheimer’s, Parkinson’s and dementia, requiring 24/7 care. Many others had no place to go back home to.

The same beguiling narrative about UHIP offered by government officials – that changes in technology would pay for themselves because of improved efficiencies – seemed to have infected Rhody Health Options, too. Perhaps the best way for the R.I. Senate to proceed would be to request that an audit be conducted of all private contractors and consultants and the fees being charged for work under Medicaid.

• Who is providing the care? Not only are there serious difficulties in meeting the increasing demand for services of Rhode Island’s aging population, given delays in eligibility certification and refusal to add in the annual inflation index to reimbursement rates, there are also worries about how to sustain a workforce to deliver care for all.

Translated, the workforce hired by skilled nursing facilities is often underpaid and overworked, with a high churn rate. Two years ago, the percentage of licensed CNAs in Rhode Island who were working in health care was about 50 percent, according to one nursing professor, reflective of the low hourly wages.

• Who gets access to services? One of the continuing complaints heard during the public comments before the Governor’s Task Force on Overdose Prevention and Intervention is the way in which the low reimbursement rates for Medicaid services for mental health and behavioral health services prevent patients from being able to access care. A member of the recovery community, in undiplomatic language, called the low Medicaid rates and the resultant difficulty in accessing care a “shit storm,” because of the low rate of reimbursement paid to providers, including peer recovery specialists, the difficulty in accessing treatment and housing services for those in recovery, and burnout. [And, of course, stigma, even when advocating for yourself: one recovery advocate requested two weeks off – and was approved – as a way to deal with burnout. Upon the advocate’s return, the person was terminated from their job.]

Another problem, identified by the chief medical officer of the R.I. Department of Behavioral Health Care, Developmental Disabilities, and Hospitals, found that in the treatment of mental and behavioral health care needs and substance use disorders, only 6 percent of patients were treated holistically for both conditions.

Was this a direct consequence of low Medicaid rates? Good question.

• What are the metrics being measured? The number of people who die from accidental drug overdoses in Rhode Island is on track to reach more than 300 for the fourth consecutive year in 2019. [Although final confirmation of the numbers who died will not be confirmed until March or April, the current data through August has the death count six individuals higher than in 2018.]

While enormous resources and effort has gone into addressing what is called the “opioid epidemic” in Rhode Island, which has become a model for many other states for its collaborative approach, and different data points have been developed, looking at access to Naloxone, access to peer recovery coaches, visits to emergency rooms, and a breakdown of such data by community, there remains a big elephant in the room: the lack of data coordination around the deaths of despair in Rhode Island, including alcohol, suicide, and drugs, tied to economic conditions.

Alcoholism, according to a number of recovery professionals, is a co-morbidity present in more than 75 percent of all overdoses. Yet the only alcohol diversion program operating in the state was closed down two years ago. Alcohol intoxication remains one of the top “indications” for emergency medical services transports at most hospital emergency departments in Rhode Island.

A long and winding road
Clearly, there is too much detail, too much information, in this first draft of a potential presentation. It should be considered as a starting point.

From the 20,000-foot view, what one sees is a kind of Rube Goldberg construction of a complex machine that eats itself.

Some in the R.I. General Assembly, which reconvenes on Tuesday, Jan. 7, seek to maintain the illusion of not needing to find additional revenue sources to pay for the higher demand for Medicaid patients for skilled nursing facilities, for mental health and behavioral health services, and for dental services – not to mention affordable housing, public education and services provided by DCYF. The idea of taxing the wealthy more has been declared a non-starter.

As a result, there are often budget contortions performed around the state’s Medicaid budget each year. They include:

• Not providing the legally mandated Medicaid Inflation Index increases for the past eight years to skilled nursing facilities.

• Failure to properly manage and audit corporate contractors, including Deloitte, when it comes to the backlog of Medicaid eligibility claims for long-term supports and services, with more than 1,000 older than 90 days, in apparent contravention of state law.

• Failure to provide proper oversight for the state Medicaid office in its inability to create an accountable entity for long-term support services.

On Tuesday, Jan. 14, Gov. Gina Raimondo will deliver her state address. Two days later, on Thursday, Jan. 16, the Governor will submit her version of the state budget for the next fiscal year. Stay tuned.