PART One

PROVIDENCE – On Monday morning, Feb. 28, there will be no marching bands playing oom-pah oom-pah oom-pah songs – nor will there be an enthusiastic Providence College student cheering section singing Taylor Swift’s “You Belong with Me” – to celebrate the opening of a new health care facility in Olneyville.

But there will be, no doubt, plenty of political hoopla associated with the ribbon-cutting for the opening of a new $15 million facility built by Providence Community Health Centers [PCHC] in the heart of Olneyville, at 31 Atwood St., at the site of a former Providence Boys & Girls Club, where patients are scheduled to be seen the very next day, on March 1. It is 2022, an election year, after all.

On hand to celebrate and give speeches will be Sen. Jack Reed, Gov. Dan McKee, Lt. Gov. Sabina Matos, and Providence Mayor Jorge Elorza, among others. Also speaking will be PCHC President and CEO Merrill Thomas and Dr. Karen Ng, who had been caring for patients at the other health center site in Olneyville for more than two decades, according to the news release.

The Feb. 28 ribbon-cutting ceremony will feature many of the same speakers who were on hand for the staged groundbreaking ceremony for the facility, which took place on Jan. 8, 2021, 14 months ago. [See link below to ConvergenceRI story, “This is what reporting looks like.”]

At that time, 14 months ago, Rhode Island was in the midst of being overwhelmed by a surge in the coronavirus pandemic, and Olneyville had earned the “bragging” rights of being one of the hardest-hit communities in the state, competing, if that is the right word, with Central Falls, for the honor.

As ConvergenceRI had reported: “The people who call Olneyville home face some of the greatest barriers to health care in New England,” Thomas said, in his remarks. “Central Falls may have the most cases of COVID per capita, but Olneyville has had thousands of more cases overall.” Thomas continued: “The infection rates in this neighborhood have been nearly 10 times higher than the state average.”

The ConvergenceRI story continued: The new health care facility, when it is completed in 11 months, with the capacity to serve 14,000 additional new patients beyond the 60,000 currently being served by Providence Community Health Centers as well as creating 50 full-time “sustainable living wage jobs,” promises to serve “the families of Olneyville that have more poor health outcomes than any other neighborhood in the city,” Thomas said.

For Thomas, even more alarming, the ConvergenceRI story continued: was the fact that when you looked at the same health data by race and ethnicity, the outcomes for “Black and Latinx communities” were even worse, often by 25-30 percent.

This year, on the cusp of state mask mandates being lifted and new state vaccine mandates being loosened, Gov. McKee appears poised to try to claim credit for the current pause in the COVID pandemic, claiming that he has righted a listing ship left to him by former Gov. Raimondo – a posture he chose to assume when he officially announced his election campaign for Governor on Feb. 22, at a plastics factory in East Providence, surrounded by a bevy of adoring mayors, in what Boston Globe columnist Dan McGowan labeled as the Governor “speaking mayor.”

But, as the Grateful Dead once warned: “Trouble ahead, trouble behind, and you know that notion just crossed my mind.”

Across the great divide – between the haves and have-nots
While there is much to celebrate whenever the state’s health care delivery system opens a new community health center facility to serve one of the more neglected communities in Rhode Island, the underlying issues around race, ethnicity, the lack of affordable housing, and poverty – what has become known in the vernacular as the social determinants of health, the disliked reality is that the current budget policies under Gov. Dan McKee [and the current leadership of the R.I. General Assembly] have exacerbated the problems by the continued refusal to raise the extremely low reimbursement rates for Medicaid providers.

R.I. Attorney General Peter Neronha got it right when, in the midst of his Feb. 17 news conference explaining the reasons why he had decided to reject the merger application by Care New England and Lifespan, because of the antitrust problems raised by a new entity that would control 80 percent of the market share in the state, he said: “Potential changes in Medicaid reimbursement, which, by the way, is an issue that we need to address, but not in the context of a proposed merger. This notion of whether or not Rhode Island reimburses Medicaid at the right level,” Attorney General Neronha continued, “is a question and a concern and a problem.” [See link below to ConvergenceRI story, “Promises, promises.”]

Later, in answering questions from reporters, Attorney General Neronha returned to the problem of low reimbursement rates for Medicaid: “There are a lot of things that are driving health care issues in Rhode Island. One of them is Medicaid reimbursements; they are really low here, they are really low.”

The low reimbursement rates for Medicaid will probably not be discussed by Gov. McKee at the staged ribbon-cutting for the new community health center facility in Olneyville, even though some three-quarters of the population served by Providence Community Health Centers’ new facility will be Medicaid members.

There are, however, several ongoing critical developments – bright warning signs of “trouble ahead” – regarding R.I. Medicaid spending shortfalls that warrant significant news reporting, even if they are being ignored by almost all of the state’s political pundits:

• The future status of whether or not the R.I. Medicaid office remains under the control of the R.I. Executive Office of Health and Human Services is one of the big topics of conversation now underway by the special legislative commission looking at the future organization of the statewide health and human services agency. The  official name of the commission is "The Special Legislative Commission To Review and Make Recommendations Regarding the Efficient and Effective Administration of Health and Human Services Programs in the State of Rhode Island." [See link below to ConvergenceRI story, “To have and have not.”]

As detailed in the story by ConvergenceRI: R.I. EOHHS is the parent agency for a group of fraying, safety net agencies for Rhode Islanders, responsible for spending nearly half the state’s budget in the FY 2021 budget, some $5.15 billion.

Those often overworked, sometimes dysfunctional agencies include: the R.I. Department of Children, Youth and Families [DCYF, $256 million, FY 2021 budget], the R.I Department of Health [HEALTH, $642 million, FY 2021 budget], the R.I. Department of Human Services [DHS $711 million, FY2021 budget], the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals [BHDDH $503 million, FY 2021 budget].

The R.I EOHHS FY 2021 budget for itself was $3.03 billion, which included $2.87 billion for Medicaid and other medical assistance, and $134 million for contracts for professional services.

The funds being spent are derived from state revenue and an increasing flow of federal sources. [Editor’s Note: A big issue that the Commission is also grappling with is the fact that the way the law is written, the Secretariat does not have statutory control over the directors at these agencies, including the R.I. Department of Health and R.I. BHDDH.]

Translated, about one-third of the proposed FY 2023 by Gov. Dan McKee involves Medicaid spending from state and federal sources, but nowhere in the budget are there any plans to increase the low Medicaid reimbursements that have resulted in major workforce crises and led to the shutdown of critical human services – such as Early Intervention services and behavior health treatment facilities for young women in Rhode Island. [Editor's Note: There is one change in Medicaid funding being proposed -- an increase in the amount of time – for 12 monhts –that a post-partum woman can receive benefits.]

The difficulties in getting the R.I. Medicaid office to endorse the need to increase reimbursement rates for providers was best illustrated in the dialogue between former R.I. Medicaid Director Ben Shaffer, who left his position to take a job as a principal at the Boston Consulting Group, and Sen. Josh Miller, chair of the Commission. [See link below to ConvergenceRI story, “When do low Medicaid rates create a break glass emergency.”

An extended excerpt of that dialogue between Sen. Miller and Shaffer was published by ConvergenceRI in the recent story, “Is there a news credibility gap in RI?” Here is that excerpt, again:

MILLER: To have a service that went out of business because the rates were too low, to have it exist again, would we consider raising the rates?

SHAFFER: Once again…

MILLER: [interrupting] Is closure a threshold that should be met?

SHAFFER: It depends on how many other providers are in that particular system, [whether] it is a “break glass” in terms of an emergency kind of situation.

MILLER: Zero services? Is that a threshold?

SHAFFER: Zero services is certainly a threshold. I am not sure what services you are referring to.

MILLER: There are no current providers for residential services for teenage girls in the state.

SHAFFER: I think the answer to that is that we are actively working on, in this particular case, we are [seeking] to add new services.

MILLER: I really tried to stay away from the 24-hour news cycle, but it was brought up to me that people are being inappropriately placed in hospital settings, children are being placed inappropriately in hospital settings, because there are not enough providers for the appropriate setting in outpatient care. Does that meet that threshold?

SHAFFER: I...[long pause]

MILLER: It is also a budget item; it is multiple times more expensive [to place patients] in hospitals, rather than if the Medicaid reimbursement rates supported [outpatient] providers.

MILLER: [continuing] Early Intervention is closed. One of the reasons is because they cannot function or operate, they cannot hire for the services; they cannot fund the services under the current Medicaid-funded reimbursement rates.

Therefore, they are closed, and therefore, Medicaid is paying for hospitalization at triple the current Medicaid reimbursement rate, and for whatever reason, the reimbursement rate is not being re-evaluated to maybe go up to 50 percent compared to hospitalization, so that the provider could survive.

And, inversely, those of us who are trying to legislate around the procurement over managed care organizations, their reimbursement takes over 90 days for a vulnerable provider to get reimbursed for services. Because there are so many examples, during and post-COVID, where those services are falling apart. [The example of] the lack of accessibility of residential care for teenage girls has been used a lot by this Commission.

How long do we have to hear from providers, or to hear from patients, that they don’t have access to services because the Medicaid rate is too low?

It even applies to commercial insurance rates, because the same payer is basing their rate on Medicaid rates, and therefore, [the system of reimbursement] is broken not only though Medicaid, but through commercial insurance rates, because the Medicaid rate is reflected in commercial rates.

More evidence
In the same story, there was also a detailed analysis published about the ways in which the Governor’s proposed budget for FY 2023 had failed to include any increases in Medicaid reimbursements for key programs supporting children and families in Rhode Island, as documented by Rhode Island Kids Count.

• Early Intervention: The proposed FY2023 budget does not include funds to support a Medicaid rate increase [emphasis added] for Early Intervention.

• Family Home Visiting: The proposed FY 2023 budget does not include funds to increase Medicaid rates [emphasis added] for the First Connections home visiting program [which acts as the state’s Child Find for Early Intervention] or for evidence-based Family Home Visiting Programs [Healthy Families, Nurse-Family Partnership, and Parents as Teachers] that provide comprehensive, long-term services to pregnant and parenting families with infants and young children.

• RI Pre-K: The proposed FY 2023 budget maintains $14.9 million in state general revenues to support operation of existing RI Pre-K classrooms. No funds are included in the budget to expand RI Pre-K for 2022-2023 [emphasis added]. The state will need to identify $7.6 million in FY 2024, when some key federal grants expire, to maintain existing RI Pre-K classrooms and additional funding for further expansion.

Translated, in Rhode Island, kids don’t seem to count. Medicaid reimbursements for the community service providers for Early Intervention and Family Home Visiting will continue to be frozen under Gov. McKee’s proposed budget. Further, even in a time of great surplus and abundance of federal funds, Gov. McKee’s proposed budget offers no additional support for existing Rhode Island Pre-K classrooms, and worse, fails to identify a source for $7.6 million needed next year when key federal grants expire just to maintain the existing number of Pre-K classrooms.

On the hopeful side of the equation, there is rate-setting legislation being proposed by Sen. Lou DiPalma to address the need to raise low Medicaid reimbursement rates. What chances of success it has in the R.I. General Assembly remains anyone’s best guess.

Despite a rash of stories by Rhode Island reporters detailing the problems with low Medicaid reimbursement rates and the depletion of the underpaid and overworked human services workforce, illuminating the ongoing crisis, there exists, as Jamie Lehane, president and CEO of Newport Mental Health, put it: “No political will or interest to address these problems,” which Lehane labeled “a human crisis,” in a recent story by G. Wayne Miller in The Providence Journal, published last week on Feb. 21.

One long-time community agency executive echoed Lehane’s lament, saying that she had come to the conclusion that the down-and-out populations were simply not a priority for the Governor’s office.

[Editor’s Note: One recent addition to the membership of the Commission has been Joseph Polisena, Jr., deputy counsel to Gov. McKee, and son of Johnston Mayor Joseph Polisena.]

In PART Two, ConvergenceRI details the problems related to the state’s re-procurement of Managed Care Organizations and, in particular, the questionable way in which Optum, a wholly owned subsidiary of UnitedHealth, is currently being deployed by two of the current MCOS, Neighborhood Health Plan of RI and UnitedHealthcare.