Delivery of Care

When it comes to UHIP, money talks, the needy walk

Despite what the Governor said in explaining her decision to renew the Deloitte contract, after three years of flawed operations, there are still apparently ongoing, pervasive, unresolved glitches with the UHIP software system that require major fixes

Photo by Richard Asinof

Gov. Gina Raimondo and her team explain the reasons behind the decision to renew the contract with Deloitte at a March 15 news conference.

By Richard Asinof
Posted 3/18/19
The contract renewal with Deloitte means that Rhode Island will be wedded to the firm, for better or for worse, for the foreseeable future, despite a very rocky first five years of marriage. The decision to stay together and not sue for divorce was predicated on the concern that starting over and bringing in a new firm would be too expensive and cause too much disruption.
Why is Gov. Raimondo apparently afraid to be interviewed by ConvergenceRI? Beyond the promise by Courtney Hawkins to write a book, is there a need to conduct a case study of what went wrong with UHIP, from the poor initial contracting to the denial of problems before the launch in 2016 to the continuing glitches in the software built by Deloitte? What are the economic calculations of the human cost caused by the UHIP boondoggle? Why is the Raimondo administration still trying to change the name of UHIP to RI Bridges? What would happen if the CEO of Deloitte had to stand in line for hours to try and revolve mistakes made about his health plan coverage?
Despite mounting evidence to the contrary, there is still a persistent belief that health IT data systems, in the form of electronic health records, can improve patient care and outcomes; there is still a persistent belief that complex data systems creating an online portal for benefits can reduce the costs of delivering services to the most vulnerable; and there is still a persistent belief that state governments have the resources, talent and expertise to manage complex data systems.
We have already moved far, far beyond basic concerns about who controls the data. Big Data firms such as Facebook, Google, Amazon, Microsoft and Apple have created sophisticated algorithms to mine the data and predict and manipulate the choices we make in what we buy and even how we vote.
In her new book, Shoshanna Zuboff defines surveillance capitalism as: “a new economic order that claims human experience as a free raw material for hidden commercial practices of extraction, prediction, and sales”; “a parasitic economic logic in which the production of goods and services is subordinated to a new global architecture of behavioral modification”; and as “a rogue mutation of capitalism marked by concentrations of wealth, knowledge and power unprecedented in human history.”
There appears to be much more involved in the contract renewal with Deloitte than meets the eye.








PROVIDENCE – On a steep grading curve, Gov. Gina Raimondo and her team might be rated as “improving” in the management of complex IT data systems and contracts that cost Rhode Island taxpayers hundreds of millions of dollars in order to deliver services and benefits to the most vulnerable Rhode Islanders.

But they would no doubt be rated “excellent” in how they manage messaging and manipulating the flow of news.

Take, for instance, the press conference to announce the decision to renew the contract with Deloitte Consulting and its work on the Unified Health Infrastructure Project, or UHIP, on Friday afternoon, March 15, which was scheduled for 1 p.m.

The decision to renew the contract with Deloitte, which had been scheduled to expire at the end of March, was not really a surprise to anyone. It was not a secret to those involved in the decision-making on either side of the negotiations; rather, it was more a question of choosing what Friday afternoon to announce the decision publicly.

The contract renewal was fully cooked; it was a done deal. It had been shared with, and reviewed by, the Centers for Medicare and Medicaid Services Administrator Seema Verma a few weeks before the news conference.

For better or for worse, the decision means, instead of suing for a divorce, that Rhode Island will be wedded to Deloitte for the foreseeable future. The contract renewal could be seen as a kind of post-nuptial agreement, following a rocky first five years of marriage, with Deloitte vowing to meet strict new performance standards, or else. What happens if Deloitte fails to live up to its end of the bargain was not part of the conversation. [See link below to ConvergenceRI story, “To renew contract with Deloitte, or not, that is the question.”]

The contract renewal was pitched at the news conference as an “unprecedented” victory for the taxpayers of Rhode Island, because the state said it had been able to recoup a $50 million cash payment as well as some $162 million in reduced fees from Deloitte as part of the new contract. [How much, if any, the feds will claw back of that $50 million in cash destined for the general revenue fund is still a matter of negotiation, according to the Governor.]

Accountability?
Some would argue that the citizens of Rhode Island deserve a full, public, transparent accounting of what went wrong, and why. However, that is unlikely to happen, so the soap opera saga about UHIP will remain, much like 38 Studios, an untold story for now, with little accountability for what actually happened.

At the news conference announcing the contract renewal, ConvergenceRI asked: “In terms of what you have learned, is there any potential to do a case study about what went wrong, so the mistakes do not get repeated in the future? You have garnered a lot of knowledge, but I’m not sure whether it has been made transparent or whether it has been shared publicly.”

Courtney Hawkins, director of the R.I. Department of Human Services, responded by deflecting the question: “Will you buy my book?” which resulted in much laughter.

Still, ConvergenceRI persisted: “I will buy your book, if you actually write it and publish it.”

Raimondo then jumped in, saying: “I will let Courtney speak to her book, but I will say this: I did meet with the CMS administrator a few weeks ago in Washington to explain where we were [on the contract]. We are in constant contact with our federal partners on this. They tell us that this contract is now essentially best in class. With the key performance indicators in our new contract, essentially the standards to which Deloitte has to perform, [the performance indicators] are really among the best in America.”

Raimondo continued: “The contract we are signing with these new accountability metrics is available to every other state, and I hope that they use it. Because if you look around the country, in Kentucky, in South Carolina, in Massachusetts, in Maryland, every one of these systems is the same movie over and over again. So I hope people can learn from our story and take a look at this new contract, and copy it and use it, to make their systems better for their citizens.”

Later on in the news conference, Hawkins returned to the concept of her “book.” Every decision we make every day, she said, is about “the impact on my customers and my workforce, and ensuring that they have the tools that they need.” [Editor's note: In rereading the story, the grandiose use of "my" by Hawkins to describe apparent ownership of both the workforce and the "customers" jumps out.]

The effort to do so, Hawkins continued, “is the most complicated case study; my book will have multi-parts and be very long.”

ConvergenceRI asked: “Can I get an advance copy, please?”

To which Hawkins responded, with humor: “I’m going to dedicate it to you.” Not likely.

“It’s not sexy, it doesn’t get headlines,” Hawkins continued, describing the daily grind of the bureaucratic machine at work. “But it is about being able to put one foot in front of the other every day, to be better; that’s what has gotten us to this place.”

From ConvergenceRI’s perspective, the public deserves to know more than just what is contained in new contract metrics, to have a full discussion about what went wrong and why – and not just the way that the contract renewal with Deloitte was being shopped by the Raimondo communications team.

Yes, this particular story is long and involved, but like a hidden family history, it deserves to be seen in bright daylight, to cure the darkness and prevent future trauma.

The tactics of exclusion
When ConvergenceRI arrived 20 minutes early ahead of the scheduled time for the news conference, he discovered WPRI’s Ted Nesi already there, busy tapping away at his laptop keyboard, working on his story, because Nesi and other “select” members of the news media, including Katherine Gregg of The Providence Journal [she had left a paper sign on a chair in the room, saying, “Reserved for The Providence Journal], had received an unannounced, embargoed briefing from Courtney Hawkins, director of the R.I. Department of Human Services, on the contract renewal – before the news conference.

“I know that you’ve been briefed earlier as to the details by Courtney [Hawkins]  about the settlement with Deloitte,” Raimondo said, at the beginning of the news conference. “But, given that this is such an important and high-profile project, I wanted to take the opportunity to speak to it directly.” Raimondo might have added: for the benefit of the TV cameras and radio microphones. [At the news conference, reporters were presented with a blizzard of paper documents, detailing all the improved contract provisions.]

The problem was: not all of us reporters had received an invitation to be briefed. Translated, the Governor and her communications team have been carefully cultivating a private club of most-favored reporters to which special access had been granted – which means, of course, that these reporters were complicit in the hidden sharing of information as part of membership in an elite club granted privileged access.

Others, such as ConvergenceRI, had apparently been specifically excluded from the unannounced, embargoed briefing. Why was that? [More on that, later in the story.]

On the outside looking in
In many ways, the embargoed briefing for a select group of reporters provided an apt metaphor for the UHIP boondoggle: it mirrored a culture of arrogance reflected in the design of an expensive, flawed IT software system in order to make the process of delivering benefits to the most vulnerable Rhode Islanders allegedly more cost-efficient, from a top-down perspective. The human cost was never part of the equation, never calculated, never reimbursed.

Translated, in the age of surveillance capitalism, the “haves” designed the flawed computer systems, and the “have-nots” had to jump through the hoops to secure benefits that they depend on to survive.

As the popular advertising slogan goes: What’s in your wallet? For most reporters and top administrators in the room, it is not an EBT or a Medicaid membership card. They do not have to wait for two or three hours, on hold, on the phone, attempting to get answers from a customer service representative who never picks up. They do not have to wait in line for hours to try to resolve issues around their health care plans for themselves and their families, such as the unexplained cancellation of their Medicaid health coverage.

Translated, the Raimondo administrative team, her communications staff, and the news media often seem to behave as privileged members of the luxury class on the cruise ship of life, while the rest of us toil away in steerage, leading lives of increasing desperation to make ends meet.

There was a telling moment during the news conference, when the Governor explained her efforts to get to the bottom of the problematic, flawed software system designed by Deloitte, beginning in January of 2017.

For the last two years, Raimondo said, “I have met nearly weekly or bi-weekly with the Deloitte CEO and their senior leadership team, to make it crystal clear that they had to deliver, that they had to deliver a system that works, and that they had to do right by the taxpayers of Rhode Island.” And, she continued, “I have apologized in the past to the people who have gone through difficulty on account of this, but at this point in time, we have a system that is working.”

Perhaps there was no better description of a top-down approach to solving problems.

The bottom line calculation
The bottom line: the flawed UHIP system could be seen, in many ways, as a way to take the human out of health and human services, in order to streamline labor costs and to make the system more efficient and cost-effective. The projections were that UHIP would be able to pay for itself in a few years because of all the cost savings.

That was the mission statement for UHIP, as articulated by former R.I. EOHHS Secretary Elizabeth Roberts and R.I. Department of Administration Director Michael DiBiase, in advance of the launch in 2016. [Of course, at the time of the UHIP launch on Sept. 13, 2016, it was apparently common knowledge that DiBiase and Roberts were allegedly involved in a personal relationship, clearly a potential conflict of interest, a situation never reported on by the news media or explored by the House Committee on Oversight.]

Selective memory
Toward the end of the news conference, WPRI’s Ted Nesi asked a question of the Governor: Were there questions that reporters could have raised as potential red flags in advance of the launch, which could have helped to prevent the disastrous turn of events?

“As you can imagine, I have wracked my brains, what more could I have asked?” Raimondo answered. “How could I have known this?”

She continued: “I sat down with the Deloitte people and with the technology team – you rely on technologists, [and asked]: Do you promise it’s ready? Have we done enough testing? Tell me about the testing. You just had a problem in Kentucky; what is going to be different here. [I asked] every question you could think of, and all the technology people had seemingly good answers.”

Her direct answer to Nesi was: “I don’t know; I don’t know if you could have. Maybe a technology-focused reporter could have asked more incisive questions.”

However, ConvergenceRI, if asked, would have answered Nesi’s question much differently. The warning signs and red flags had already been identified and reported on. The problem was the information had been ignored or shunted aside.

The flaws in the software system built by Deloitte had been identified and documented in 2014 by HealthSourceRI, detailing nearly $10 million in cost overruns as result of such glitches. That information had been presented to newly elected Gov. Raimondo – but ignored. The problem with the glitches had been featured in a story published by ConvergenceRI in 2015.

Instead of holding Deloitte accountable for the flaws identified in 2014 in its defective software system, or, in the words spoken by Raimondo at the March 15, 2018, news conference, “to hold Deloitte’s feet to the fire,” the firm was rewarded by being “hired” to facilitate the final sessions of the Working Group to Reinvent Medicaid, on a pro bono basis. [Once again, this was reported by ConvergenceRI in 2015 – but not covered by other media outlets.]

In the spring and summer of 2016, in advance of the UHIP launch, first scheduled for July and then postponed to September, there were strenuous objections being raised internally by high-level staff at R.I. EOHHS about potential flaws with Deloitte’s UHIP system. Such concerns were ignored or swept under the rug by the Raimondo team. Were these concerns shared with Raimondo? Why not?

Also in the spring and summer of 2016, the nursing home industry in Rhode Island, who were experiencing longer than the usual delays in the state processing applications to determine Medicaid eligibility, with the backlog for many such applications approaching six months, attempted to share their concerns with state officials. In response, state officials told them that the backlog would be resolved once the UHIP system went live, with its new online portal to process such applications more speedily. However, the online portal never worked.

How could Raimondo and her team not have known all this? And, how could the news media have been so oblivious?

What is still not working and what needs to be fixed
At the news conference, ConvergenceRI asked specific questions about continuing problems with the UHIP system that have apparently not been fixed. They were deep-in-the-weeds questions, given the nature of ConvergenceRI’s in-depth reporting.

The first question concerned the ongoing backlog in certifying applications for Medicaid for long-term care services, and the status of reconciliation of interim payments made to skilled nursing facilities to alleviate the financial crunch caused by the backlog.

Some background: Because of the backlog in processing eligibility claims caused by the UHIP snafu, nursing homes and skilled nursing facilities found themselves in a severe cash flow crunch. To alleviate that pressure and to keep the facilities from going bankrupt, R.I. EOHHS began making interims payments in late 2016 and throughout 2017, amounting to an estimated $150 million by 2018, according to R.I. EOHHS officials. Many of those initial interim payments, however, were made as bulk payments, not tied directly to specific individual claims. As a result, the interim payments had to be reconciled with the federal government, within two years of the payment.

ConvergenceRI: What is the status of the reconciliation with interim payments to skilled nursing facilities? What is the projection date for that reconciliation process being completed? A third question: What are the number of outstanding applications to determine Medicaid eligibility that are still pending with long-term care services?
HAWKINS:
I don’t have the specific long-term care backlog number, but I think we can get that for you.

[As Hawkins was answering the question, DHS’s communications person, Alisha Pina emailed the latest status report, which included the latest data as of February 2019: there were currently 916 overdue long term support services applications pending state action, the largest backlog of any of the 16 programs that were wrapped into UHIP. But no information was given about how long the applications for Medicaid eligibility have been pending.

In fiscal year 2019, the report said that the state had paid out some $16,315,493 in interim payments to facilities. In total, the state has paid out some $130,001,000 in interim payments, according to the report. Of that dollar amount, the state has collected $15,619,794 in reconciliation payments so far.]

HAWKINS: We have, over the past six months, escalated our work to process eligibility for overdue long-term care applications and to reconcile the interim payments.

Part of this deal actually includes additional services from Deloitte to the state to help us continue to expedite that work, and the work we’ve done to improve that processing. We are seeing an escalation of return interim payments over time. But we have more work to do there, and we expect it is going to take six to 12 months for us to continue to recoup the money.

In the early part of the project, there were larger payments made to nursing homes, but that has since stopped, and there is a pretty robust procedure around that now.

LISA VURA-WEISS [the new acting secretary for the R.I. Executive Office of Health and Human Service]: I would just say that we have been working with the nursing homes to help sort out the claims from previously [made interim payments] where there had been individuals with delayed eligibility determinations. It’s an ongoing process. And, as Director Hawkins said, we expect another six to 12 months going through that.

Online portal glitches
Just one week before the news conference, ConvergenceRI had met with a woman, a mother, who described her frustration at trying to navigate her way through the online portal to determine eligibility for health benefits, and been unable to do so.

She could be considered an expert in terms of her knowledge and understanding about how to navigate the state health care bureaucracy. But she admitted that she had been stumped repeatedly in her attempts to interface with the Deloitte-built online portal, which kept rejecting her answers to the online data entry questions. She tried calling the help line, only to be kept on hold for two hours, without anyone answering.

She said that she had met with a representative from the state health and human services team, walking that person through all the problems with the online portal. The representative kept snapping photos of the screen, agreeing with the mother that there were significant problems, and promising to share them with Deloitte team.

Was that a description of a fully functioning system that was working well?

HAWKINS: The customer portal is one of the areas where we have a lot of work to do. Actually, the release that we have scheduled for June [of 2019] targets the customer portal. I am really excited about a number of improvements that will [result].

I think it will change the user experience for customers and navigators.

Another part of the new contract that is important is that Deloitte will be responsible to fix all of the things are broken. Our teams have worked hard over the past years to log what we call defects that are problems in the system. Part of the new contract provides for the fact that all of this has to be fixed, and that they have to continue to introduce new technology that we have been asking for, which would include the improvements to the customer portal.

What we have here is a failure to communicate
The apparent purposeful exclusion of ConvergenceRI from the unannounced, embargoed briefing touched a raw nerve. It stung; it seemed deliberate.

First, with more than 45 years of professional experience, both in news biz and in the communications biz, ConvergenceRI is well versed in embargoes and how they are supposed to work.

The back story is that for the last four years, despite dozens of requests, including two, in-person, eye-to-eye requests, sealed with a handshake, where the Governor had agreed to do an interview, no interview has ever been granted to ConvergenceRI. Does that mean Gov. Raimondo is not a person who keeps her word? Or, does it mean that the Governor is “afraid” to sit down and talk with ConvergenceRI?

During that time, ConvergenceRI has interviewed any number of key members of the Raimondo administration, without difficulty.

Since January of 2019, when Jennifer Bogdan took over for Mike Raia as the Governor’s communications director, ConvergenceRI had made several renewed requests for an in-person interview with Raimondo, coordinating the ask through Bogdan.

The most recent conversation with Bogdan had occurred on Wednesday afternoon, March 13, two days before the news conference, when Bogdan told ConvergenceRI that she had not yet found the time discuss my request with the governor. Really?

Dear Gov. Raimondo: Can we talk? If and when you read this, here’s the ask: let’s find a time to sit down to talk, in person, face-to-face, for a 20 minute interview. Thanks for your prompt consideration.

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