WARWICK – Call it due diligence in health care. As impressive as the efforts have been by the Rhode Island Foundation to gather together stakeholders to develop a long-term statewide plan looking at health outcomes, with the vision of Rhode Island to become the healthiest state in the nation, where residents have the opportunity to be in optimal health, to live, work, learn and play in healthy communities, and to have access to high-quality and affordable health care, with an emphasis on investing in health equity [and a promise by the Rhode Island Foundation to invest $1 million in supporting those efforts], the nitty-gritty of how that will be achieved comes down to following the money: who gets paid, how much, and for what services.

That is where the ongoing work of Sen. Josh Miller’s special legislative commission studying reimbursement rates by insurers in Rhode Island comes into play. The fourth and final meeting will occur on Tuesday, Feb. 25, with the goal of coming up with potential legislative remedies to address the imbalances in reimbursement rates.

The testimony to date has revealed some significant gaps in reimbursement rates paid, including those paid to dental providers, where the rates have not been increased since 2008, according to Dr. Andrew Gazerro III, D.M.D., chair of the Council on Dental Benefits for the Rhode Island Dental Association. [See link to ConvergenceRI story below, “Open wider.”]

ConvergenceRI recently sat down to talk with Susan Storti, Ph.D., RN, the president and CEO of The Substance Use and Mental Health Leadership Council of Rhode Island, along with her colleague, John Tassoni, Jr., the director of Operations at the agency.

Storti is both a member of the stakeholder group brought together by the Rhode Island Foundation to develop the long-term plan as well as a member of the study commission on reimbursement rates. As such, she has a unique perspective to talk about how the low reimbursement rates paid to providers of mental health and substance use services have disrupted and crippled attempts to provide a continuum of care.

Storti was also able to put into context what she called the absence of a structure in Rhode Island that can determine what it actually costs to deliver the best evidence-based practice in mental health and behavioral health care.

“We consistently talk about research and evidence-based practices,” Storti explained, “where the providers in the state [would be] held to that standard. Yet they are not being compensated for that level of care – delivered by specifically trained professionals. If you are not being reimbursed at an appropriate level, how do you even hire individuals to be able to deliver that type of care?”

The reimbursement rates paid, according to Tassoni, have not changed for nearly 20 years.

Much like the skilled nursing facilities that found themselves confronting cash flow problems as a result of backlogs created by UHIP in processing Medicaid eligibility applications for long-term support services, which resulted in the R.I. Executive Office of Health and Human Services making tens of millions of dollars in interim payments, the interview with Storti and Tassoni revealed that a similar situation had recently occurred with mental health and substance use providers, caused by delays in timely payments from Managed Care Organizations, forcing agencies to borrow money from the state to be able to stay in business.

“We have so many of our providers which belong to this agency that are on the cusp of going out of business, who have sold property, who have given paychecks to individuals and told them not to cash them until a week later, because they are not getting reimbursed by the MCOs in a timely manner,” Tassoni said, the anger rising in his voice. “That’s horrible.”

The MCOs, Tassoni continued, get a huge lump sum check from the state, usually between the first and the seventh of every month. “They get this huge sum of money to provide third-party services to pay our people,” he said. “We had people who had to sell a condo in Newport in order to make payroll.”

Is the problem that the MCOs are not distributing the money in a timely fashion? ConvergenceRI asked.

“Correct,” said Tassoni.

“It waxes and wanes,” Storti said. “Sometimes, they are very good, and there are other times, if there is a glitch in the system….” payments can go awry.

While efforts have been made to rectify the billing situation, Storti continued, “The members will tell you: it’s good until it’s not good, because when it goes bad, it goes really bad.”

And, at one point, when individual agencies could not meet payroll, the only option that they had was to go to the state and borrow money from the general fund, through the offices of Medicaid and R.I. EOHHS, according to Storti. “And now, they are in the process of paying the money back.”

“Even though they are now receiving payments on a regular basis,” Storti said, “I can’t call it timely, but certainly on a regular basis, any of the slim margin that they would have been able to put aside, to be able to capital investments in their property, is now being shifted to paying back the state because of untimely [payments].”

The ripple effect has been a mass exodus of employees, according to Tassoni. “If you get a letter in the mail with your paycheck, with a note that says, don’t cash the check until next week, what are you going to think? ‘Geez, I got to get out of here, because they must be in serious [financial] trouble.’ And the agencies have to start all over again hiring new individuals.”

Here is the ConvergenceRI interview with Susan Storti, president and CEO of The Substance Use and Mental Health Leadership Council of Rhode Island, along with her colleague, John Tassoni, Jr., the director of Operations at the agency, revealing the existing shortcomings in reimbursement rates and the lack of a sustainable model of care in Rhode Island, based upon evidence determining what the costs of providing services actually are.

ConvergenceRI: Did you attend the stakeholder session on Monday held by the Rhode Island Foundation on the long-term health plan?
STORTI: I was actually scheduled to be there but unfortunately, I had a family situation come up so I wasn’t able to join the group.

[Working as a member of the stakeholder group] was an absolutely wonderful experience, to have the leadership from so many facets of the community come together, to think about where the state of health care in general needs to go, moving forward.

There are so many moving parts right now, both at the federal and state level; we have to develop creative and innovative partnerships and opportunities to truly be able to address the needs of individuals in the community differently than we have in the past.

There were a number of great minds that consistently met over a period of time to be able to develop that document.

The document, for me, is a guide. Hopefully, individuals will read it and use it in a way that will help to drive whatever activities they are involved in to become more encompassing of some of the ideas and recommendations that were outlined within the document.

ConvergenceRI: Given your participation in both the stakeholder group and in the study commission on reimbursement rates, from a 30,000-foot view, what is the future direction of health and health care delivery in Rhode Island?
STORTI: [Let me share] my perspective, from a behavioral health and medical component – my background is in nursing. I worked in a hospital setting and in a community treatment provider setting for a number of years.

When I think about health in general, it’s always been a struggle, because there has always been the great divide of mental health, substance use disorders and primary health care.

In my years of working in an emergency room setting, that’s often very hard to tease out.

For me, while most people would think about health care on a continuum, I think of it as circular. Let me explain that.

When someone comes into the emergency room complaining of chest pain, the first thing you are going to do is to evaluate whether or not that individual is having some sort of cardiac event, and if they are, you are going to take the appropriate steps to stop it, so it doesn’t get worse. Then, once that happens, that person usually gets hospitalized – or they used to.

And, then there is someone that goes and talks to [the patient] about how they really need to make some significant lifestyle changes, and if not, they’re going to end back here again, maybe with a worse situation.

When I think about that, I say: how do you draw the line between prevention, intervention, treatment and recovery?

And, if I take that lens and I apply it to behavioral health, and the delivery services within primary care, and health care in general, I say the behavioral health, the mind, and the body, go hand in hand. I can’t separate those out.

Thus, all of the efforts made to do an integration of behavioral health care and primary health care.

Yet, when you look at the variety of models that we have in Rhode Island, they are kind of all over the place. If indeed, that is the intent of the state to move into an accountable entity kind of framework, that’s one thing.

But nobody has been able to give me when I’ve asked the question, what is the vision? What does that look like going forward? I don’t think we have a clear vision yet in this state.

ConvergenceRI: Linda Hurley of CODAC raised the issue of low Medicaid rates at a Governor’s Task Force on Overdose Prevention and Intervention meeting last summer, saying that providers were unable to find a provider because of the rates, making it difficult to provide for a continuum of care. Is that still the case?
TASSONI: In the aftermath of the recent shooting in Westerly, Sen. Dennis Algiere asked us to help in getting services in Westerly, where there are very limited services. I told him that you’re not going to get anybody to go down there because the rates are so bad. The rates haven’t been changed in close to 20 years.

ConvergenceRI: So, it’s even worse than what’s going on with dental rates, which haven’t been increased for providers since 2008?
TASSONI: Absolutely, absolutely. We have so many of our providers who belong to this agency which are on the cusp of going out of business.

STORTI: When Beacon left as a Managed Care Organization, and the contract was moved over to Optum, I said at the time, to Patrick Tigue, [the former director of the R.I. Medicaid office], “How could you have allowed that to happen? You’ve given the lion’s share of behavioral health to Optum, and that’s the one with which we were having the most difficulty in terms of reimbursements Why would you do that? Why would you allow that to happen?

And all I got in response was: it is part of contracting. Well, change the damn contract. That’s not an answer.

We worked with Neighborhood Optum for a year. We hosted meetings here, trying to make it a smooth transition. Efforts have been made to rectify the billing situation. But [our] members will tell you: it’s good until it’s not good.

ConvergenceRI: In Linda Hurley’s recent presentation to the study commission on reimbursement rates, she had a slide that documented the high staff turnover rates. What happens to the continuum of care?
TASSONI: The relationships between patients and therapists, or social workers, goes off track.

STORTI: The individual who is seeking treatment today, whether it is mental health and substance use, regardless of the setting, because at this point, behavioral health care is being delivered in settings we never thought we would see.

In a way, that’s a good thing, because there is that subset of individuals who can go to their primary care doc, be assessed, and maybe they have a generalized anxiety disorder that can be appropriately addressed by a primary care doc. But, there is a group of individuals, at the other end of the continuum, that need much more structured care.

As far as individuals who have a substance use disorder, with a mental health disorder, who also may have some sort of physical health issue going on, that is often whom we are seeing today. Which is very different than the individuals who would have showed up on your door 20 years ago, or 10 years ago.

At the same time, we have significant changes happening at the federal level, we have significant changes happening at the state level, we have significant changes in terms of what is showing up in terms of health care needs, and we have this desire to integrate primary care and behavioral health in a way that meets all of the needs of the person sitting in front of you. It’s a tall challenge, an incredibly tall challenge.

To me, the only way that gets addressed is that you have to look at the system as a whole, you need to identify where the gaps are, and you need to identify where are the success stories, and you need to start to move forward with creating a system of care that looks at those gaps, and looks at those success stories, to see if there is some way those two things can be merged to be able truly address what is happening in the field.

To be able to support that type of infrastructure, there needs to be a better reimbursement rate, because it’s not going to happen without that.

ConvergenceRI: How does that play out in terms of sustainability?
STORTI: We have seen this emergence of innovative ideas, which I have to say, I think we have some very creative people in this state; we’re able to secure an enormous amount of federal funding. One of the things we don’t do very well is succession planning or sustainability planning.

You have these wildly successful programs, and then after the funding ends, how do you sustain it. We can’t keep going back to Medicaid or Medicare to always be answer to sustaining successful programs.

It tells me that we need to do things differently than we have done, up to this point.

ConvergenceRI: What is it that you like to see come out as a potential legislative fix from the study commission on reimbursement rates?
STORTI: It probably would be two-fold. I could be wrong, I am unaware at this moment in time of a structure that actually looks how to deliver an evidence-based practice and what the actual cost is for that within the state of Rhode Island.

We consistently talk about research and evidence-based practices, with [the goal of] providers in the state being held to that standard. Yet they are not compensated for that level of care. When I say, that level of care, what I mean is that there are some practices that can only be delivered by specifically trained professionals.

If you are not being reimbursed at an appropriate level, how do you even hire individuals to be able to deliver that type of care?

I would love to see a review body, for lack of a better word, that can look at the literature. We have the expertise in the state, god knows, we just don’t use it as much as we should, to come together and actually lay out a plan to cost out the actual delivery of a particular type of service. What does that look like?

From a very brief literature review, I came up with probably 10 or 11 different types of models to look at reimbursement. And I’m not saying that any of them are the right model for Rhode Island. But, we need to start somewhere. So, is there some way we can collectively develop a brain trust that would look at this comprehensively, to come up with an actual reimbursement rate that would allow the system to be able to provide the level of care that patients need or consumers need, so they are actually able to live a productive life within the community and participate within the community at all levels.

I don’t know, from a legislative standpoint, what Sen. Miller will be able to propose that is not going to sound like a mandate – other than a Medicaid review process maybe every two years, or maybe every five years. That might be something that would be beneficial.

Once we get to that place, when we know what the actual cost of health care delivery is, we are able then to review it and make the appropriate changes as time goes on.

Once you develop that good infrastructure for health care, you need to figure out a way to sustain it. The hope is, going back to the Rhode Island Foundation [long-term plan], is if we can design a system that not only looks at the physical and behavioral health components, but also [includes] all of those other wrap-around services such as housing, because housing cuts across everything, quite honestly.

Those are things we need to focus our attention on and continue to fund. I don’t think we’ve done that yet.