Delivery of Care

What we have here is a failure to communicate

Neighborhood Health Plan of RI’s president and CEO sent letters to the House and Senate Finance committees opposing a telemedicine budget article, but apparently kept his board of directors in the dark about the content

Photo by Richard Asinof from PDF of letter submitted

A portion of the letter sent by Peter Marino, president and CEO of Neighborhood Health Plan of Rhode Island, opposing the proposed budget article on telemedicine, which was apparently sent without the contents being shared with the insurer's board of directors.

By Richard Asinof
Posted 7/26/20
Neighborhood Health Plan of Rhode Island submitted letters written by its president and CEO, Peter Marino, to the House and Senate Finance committees, in opposition to the proposed Telemedicine budget article as written. The contents of the letters, however, were apparently not shared or discussed with members of Neighborhood’s board of directors.
Will the board members of Neighborhood Health Plan of Rhode Island demand greater accountability from the insurer’s president and CEO? What are the best metrics to measure the success of telehealth platforms moving forward in terms of outcomes? Can the digital platforms created by Healthcentric Advisors be adapted to serve the populations of teachers, parents, students and workers to create a feedback mechanism in real time about coronavirus testing and treatments? When will the work of Sen. Josh Miller’s commission on insurance reimbursement resume again? In the age of growing consolidation between health systems, insurers and pharmacies, how do regulators and legislators discern corporate responsibility for poor decision-making?
Neighborhood Health Plan of Rhode Island maintains a strong philanthropic presence in Rhode Island, supporting important work such as the Issue Brief on “Maternal Depression: Two Generations at Risk,” produced by Rhode Island Kids Count in January of 2018.
The question arises, however, given the recent position taken by Neighborhood Health Plan of Rhode Island President and CEO Peter Marino, opposing the budget article on telemedicine and questioning the authority of OHIC, how children’s advocacy groups such as Rhode Island Kids Count can make their voices heard – whether in public or in private – about their potential concerns with Neighborhood’s stated legislative positions. How do you bite the hand that is feeding you?
It is a problem not unlike the uncomfortable position being faced by many corporate executives and business leaders today about whether to remain silent in the face of the extreme positions of the Trump administration about testing, wearing a mask, and social distancing policies, as the numbers of cases of coronavirus in the pandemic keep escalating at an exponential rate across the nation.
Where do businesses draw the line? At what point do businesses “just say no.” What would it take for a business advocacy group such as the Greater Providence Chamber of Commerce to speak out?

PROVIDENCE – For the last several months, ConvergenceRI has been diligently reporting on how numerous community health agencies, primary care providers and health systems in Rhode Island have quickly adapted to deploying telehealth platforms as a critical tool of patient engagement during the coronavirus pandemic.

Some have emerged as passionate advocates of telehealth platforms, particularly for providing mental health and behavioral health services, such as Margaret Howard, Ph.D., the executive director of Women’s Behavioral Health at Care New England, the division director of Women’s Behavioral Health at Women & Infants Hospital, and Professor of Psychiatry and Human Behavior and Medicine at the Warren Alpert Medical School of Brown University.

Howard is the psychologist who had helped to create the “Day Hospital” for mothers at Women & Infants, which offers intensive mental health services for pregnant women and women with young children. In an interview published on May 4, Howard detailed the importance of continuing the telehealth platform on a more permanent basis. [See link below to ConvergenceRI story, “We are human, battling an inhuman disease.”]

When asked what question she would ask of Gov. Gina Raimondo if she could attend one of the Governor’s news briefings, she responded: What is the state going to do to ensure that everyone has access to mental health services?

“Here in this division, Richard, we worked very quickly to adopt virtual visits for our patients, in fact we are running the whole Day Hospital program virtually now,” Howard said. “We felt we were on a burning platform: our patients could not have a disruption of care. We were fortunate in that we didn’t have to shut down, but that meant we had to be very nimble, and we had to learn quickly how to hold Zoom group therapy sessions, how to hold zoom psychotherapy sessions [emphasis added].”

Howard continued: “And it’s worked well; it’s hard, it’s worked well.” Her biggest fear, Howard explained, “is that when things die down, the Office of the Health Insurance Commissioner is going to say: OK, it’s back to business as usual [and remove the emergency waivers authorizing payments for virtual visits].”

Howard argued persuasively about the importance of continuing the telehealth platform on a more permanent basis. “I think it is so important for our patients to be able to continue, if they choose, to have virtual visits versus coming into the office. And, it sets up a conflict if the insurance company is saying, well, we are only going to pay 85 percent of the fee for a virtual visit, versus a 100 percent of the fee for a face-to-face [session]. I am hoping and praying that the Governor and the Health Insurance Commissioner will find a way to use this as a platform for true parity and reimbursement, whether it is virtual or in person.”

Praising the rapid introduction of telehealth
Howard was not alone in praising the results achieved in the swift adaptation of telehealth platforms as a critical component in patient engagement. In an interview with ConvergenceRI published on April 13, CEO Merrill Thomas, MBA, and Chief Medical Officer Dr. Andrew Saal at The Providence Community Health Centers spoke about the leverage that telehealth provided their efforts to deliver primary care services to the at-risk populations they serve. [See link below to story, “Connecting primary care to emergency care in a pandemic.”]

“Yet despite the chaos, there are moments of hope and genuine innovation,” they wrote. “Despite our inability to provide a face-to-face visit with a worried patient, we call our patients and are humbled to hear, ‘Thanks for calling, doc. It’s good to know I’m not alone in all of this and that I can still get help.’

Thomas and Saal continued: “Right now, most of the primary care system is reeling from the abrupt inability to provide traditional office visits. PCHC has had to significantly limit office visits for most, while preserving direct care for special populations such as pregnant women and infants.”

As they explained, “Preventative services for healthy adults have been significantly restricted in order to see our patients safely. The health center’s large dental program is now limited to only a handful of emergencies per day. Likewise the optometry and podiatry programs have been greatly restricted. The immediate impact of these shutdowns [in care] is a financial shortfall of about $1 million per month. The health center leadership has chosen to not lay anyone off for the time being, and has been carrying all of the salaries for the past month.”

How important was telehealth as a tool? Thomas and Saal made it very clear about the crucial role telehealth was playing: “The most dramatic and possibly enduring impact of the pandemic has been the rapid introduction of telehealth services [emphasis added]. Though PCHC had been piloting telemedicine video capacity, we abruptly had to mobilize and scale up the technology to serve 70 care teams and 60,000 patients.”

Thomas and Saal acknowledged that it required a lot of effort on the providers’ end to make it work. “In order to provide high-quality health care to our existing patients as well as the new patients seeking care, our stellar staff had to quickly re-design clinic workflows and safety protocols. With telehealth services now becoming widely accepted by patients and staff, we are witnessing a rapid evolution of primary care [emphasis added].”

From a novelty to a necessity
Nowhere has the coronavirus tested the limits of the current health care delivery system then with the way that patients stay in contact with providers, particularly patients with symptoms of the virus. In response, Healthcentric Advisors introduced a new digital texting software platform, one that has been adopted by Coastal Medical, one of the state’s largest physician group practices, and also by Integra, the accountable care organization managed by Care New England. [See link below to ConvergenceRI story, “From a novelty to a necessity.”]

In the story, published on April 6, Lauren Capizzo, the director of Practice Transformation at Healthcentric Advisors, discussed the ways that the new innovative technology was helping to facilitate patient interaction with providers during a time a pandemic.

The need to practice social distancing, Capizzo explained, has created a pressing need to outreach remotely instead of in-person care. 
“Texting is a direct communication channel using a device almost everyone has within six feet of themselves. It allows for timely outreach to an increasing number of patients in a particular population like COVID-19,” she said. “Alerting care teams of the priority patients who need their help in real-time allows providers to operate efficiently and effectively.”

Capizzo captured the rapid transformation in telehealth underway in response to the coronavirus pandemic. “Telehealth has moved from novelty to a necessity in a matter of days [emphasis added]. Healthcentric Advisors has always been focused on advancing health quality and empowering people. We support patients and providers outside of the brief, 15-minute office visit.”

The work of Healthcentric Advisors, Capizzo continued, is focused on a continuum of care. “As we strive to increase patient activation and improve clinical and social health needs, we are driven to reduce clinician burden and fragmented communication within health care. The digital solutions we build address these needs in real time [emphasis added].”

Resilient patients
The most recent ConvergenceRI story, published on July 20, in an interview with Linda Hurley, the president and CEO of CODAC Behavioral Healthcare, the largest nonprofit outpatient provider for opioid treatment in Rhode Island, detailed how her agency has been able to maintain access to care during the COVID-19 crisis, with the primary goal to mitigate exposure to the virus.

As ConvergenceRI reported: “Between April 1 and May 15, the organization provided nearly 160,000 doses of methadone to be self-administered outside the clinic [emphasis added].” Some 60 percent of the doses [would] not have been distributed outside the clinic before the pandemic, according to Hurley. Less than 1 percent of the medications [distributed] was found to be “not managed well,” with people losing it or taking too many doses, according to Hurley. [See link below to ConvergenceRI story, “A report from the front lines of telehealth.”]

While the majority within the health care industry are enthusiastic supporters of expanding telehealth, not everyone, apparently, is sold on the benefits of advancing the telehealth platform.

One of the prominent members of the small group of “naysayers” has been Neighborhood Health Plan of Rhode Island, whose president and CEO, Peter Marino, has authored and submitted letters opposing the proposed legislation to both the House and Senate Finance committees in the past two weeks, apparently without consulting with his board of directors. Therein lies a tale not yet told – until now.

The legislative push
Currently, the emergency rules that provide for the adaptation of telehealth platforms and the parity of insurance reimbursements for such services are being done by monthly executive orders by Gov. Gina Raimondo.

To remedy that situation, there is a legislative proposal before the R.I. General Assembly, entitled “Telemedicine Budget Article,” that was heard by the House Finance Committee on Wednesday, July 15, and by the Senate Finance Committee on Thursday, July 23.

As ConvergenceRI reported in its July 20 edition, under the proposed legislation: “One of the key provisions would be to continue providing full parity reimbursements from insurers for telehealth services, as well as the creation of a stakeholder group to be convened by the R.I. Office of the Health Insurance Commissioner to analyze the delivery of services under telemedicine.”

The story continued: At the hearing before the House Finance Committee, “There were some 98 written letters of testimony in support of the legislation and only five against. But one of the letters opposing the legislation, from Peter Marino, the president and CEO of Neighborhood Health Plan of Rhode Island, a managed care organization for the delivery of Medicaid services as well as a commercial health insurer, took many health care advocates by surprise.”

Further, the story reported: In the letter, Marino’s suggested that OHIC was overstepping its authority, that parity was not desired outcome, and that the emergency expansion of telehealth be sunset.

Translated, it was not OHIC, nor was it the Governor, who were opposed to expanding insurance reimbursement for telehealth platforms moving forward, as Margaret Howard had voiced worries about earlier. It was Neighborhood Health Plan of Rhode Island, or more particularly, its president and CEO, Peter Marino, who had apparently submitted the letter without any consultation with his board of directors.

What did the board know and when did they know it?
In the days following the publication of the story, “A report from the front lines of telehealth,” ConvergenceRI learned from a number of sources that members of the board of directors at Neighborhood Health Plan of Rhode Island had not been consulted about the letter.

Nor, it appears, were any board members shown an advance copy of it before the letter was submitted to the House Finance Committee, resulting in what was described as “grumbling” by board members about what was perceived as a lack of communication and unilateral actions being taken by Marino without consultation.

Context matters: Neighborhood Health Plan of Rhode Island was founded in December of 1993 as a partnership with Rhode Island’s Community Health Centers. Many of the current executive directors of community health centers in Rhode Island sit on the Neighborhood Health Plan of Rhode Island board of directors, including:

• Peter J. Bancroft, CPA, president and CEO, WellOne Primary Medical & Dental Care

• Merrill R. Thomas, president and CEO, Providence Community Health Centers

• Jeanne LaChance, president and CEO, Thundermist Health Center

• Raymond Lavoie, executive director, Blackstone Valley Community Health Care, Inc.

• In addition, Jane Hayward, president and CEO of the Rhode Island Health Center Association, serves as vice-chair of the Neighborhood Health Plan of Rhode Island board of directors.

Translated, the community health centers, whose very ability to maintain staffing and continue to serve at-risk populations because of insurance reimbursement parity under the emergency telehealth regulations, were seemingly being undercut by testimony offered by the president and CEO of Neighborhood Health Plan of Rhode Island.

The reasons for the “conflict” seemed like a good story to follow up on, in ConvergenceRI’s opinion. At least to begin to ask questions, even if the answers might not be forthcoming.

ConvergenceRI first reached out to Jane Hayward, who in addition to being a board member of Neighborhood Health Plan of Rhode Island and the leader of the association promoting the work of community health centers, also serves as vice-chair of the stakeholder group convened by the Rhode Island Foundation to develop a long-term plan for health care in the state.

The questions asked included:

• As Vice-Chair of the Neighborhood Health Plan of RI Board of Directors, did you see a copy of the letter before it was submitted?

• Do you believe that Marino's letter accurately represents and reflects the policies and mission of the Neighborhood Health Plan of RI Board of Directors?

• As the head of the Rhode Island Health Center Association, do you believe that Marino's letter accurately reflects the policies and mission of community health centers?

• As the co-chair of the Rhode Island long-term health planning stakeholder group, how does the content of Marino's letter square with the mission of that group?

ConvergenceRI has not yet received any response from Hayward to the questions asked. What was telling, however, was the letter that Hayward submitted to the Senate Finance Committee for its July 23 hearing, dated July 21, which offered her full support as president and CEO of the Rhode Island Health Center Association, without qualifications, for the budget article to extend emergency telemedicine provisions.

Hayward wrote: “Telemedicine has also been a financial lifeline to health centers during the pandemic. It’s allowed practices to maintain the supportive required infrastructure needed to provide clinical services to the community [emphasis added]. While the trajectory of COVID-19’s impact is unclear, the demand for safe, primary, behavioral, and oral health remains.”

The proposed telemedicine budget article, Hayward continued, “will allow [federally qualified health centers], and the larger provider community, the ability to put plans and procedures in place for the next nine months assuring their capacity to care for patients as work is done to evaluate long-term telemedicine policies.”

Translated, in her professional capacity, Hayward supported the budget article, contradicting the opinions in the letter sent by Marino, allegedly on her behalf, as a board member of Neighborhood Health Plan of Rhode Island.

In addition, ConvergenceRI had reached out to Dr. Pablo Rodriguez, also a member of the Neighborhood Health Plan of Rhode Island board of directors, asking about Marino’s letter.

Rodriguez responded as follows:

“Yes I am on the board of directors and will bring your concerns to the board. As you must know, as an individual board member I can’t comment on board deliberations, and frankly can’t speak for the board. This is for the Chair or a delegate to respond. I hope this is useful.

Stay safe,

In a separate postscript, apparently mistakenly attached to the response by Rodriguez sent to ConvergenceRI, which was apparently also sent to unidentified members of the leadership team at Neighborhood Health Plan of Rhode Island, Rodriguez wrote:

“FYI. This means Richard is preparing an article. May be helpful to brief the board since he will follow up with others after me. Zoom you later.”

Translated, the irony, of course, is that Neighborhood Health Plan’s board and leadership are apparently engaged in frequent conversation via Zoom during these perilous times of the coronavirus pandemic. But the organization, in a letter authored by its president and CEO, voiced opposition to making parity insurance reimbursements for telehealth a part of the state budget.

For the record, no official response from Neighborhood Health Plan of RI has yet been received by ConvergenceRI.

Two bites at the apple?
One more fascinating tidbit emerged in reviewing the letters sent to the House Finance Committee hearing on July 15 and to the Senate Finance Committee for its July 23 hearing.

For the Senate Finance Committee hearing on July 23, numerous health care industry organizations, representing an impressively broad swath of the health care interests, sent letters voicing their strong support of the budget article, including, among others: the Hospital Association of Rhode Island; Lifespan; the Rhode Island Health Center Association; the Rhode Island Public Health Institute; Brown Physicians Inc.; the Rhode Island Medical Society; The Providence Center; the Mental Health Association of Rhode Island; the chair of the Aging in Community Subcommittee of the Long Term Care Coordinating Council; Planned Parenthood of Southern New England; the Rhode Island Parent Information Network; the Community Care Alliance; Thundermist Health Center; the Rhode Island Psychological Association, and psychotherapy researchers at Butler Hospital. [Finding common ground and consensus among these diverse entities is a rare occurrence, in ConvergenceRI’s experience.]

Once again, Neighborhood Health Plan of Rhode Island had submitted a letter to the Senate Finance Committee opposing the budget article on telemedicine.

One of the letters unearthed by researchers was a letter sent by the Northern Rhode Island Chamber of Commerce, from Elizabeth Calucci, the organization’s president and CEO, to the House Finance Committee. The letter appeared to parrot concerns voiced by Marino in his letter raised about the authority of the R.I. Office of the Health Insurance Commissioner. It turned out that Marino is listed on the letterhead as the Chair Elect of the 2020 Executive Committee of the Northern Rhode Island Chamber of Commerce.

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