Innovation Ecosystem/Opinion

What is public health in 2024?

The opening of a new state public health lab raises questions about how the community can participate in developing an action plan focused on place-based outcomes

Photo by Richard Asinof

The vision we have for our future is often defined by the paths we need to journey across wide expanses of water and sky.

By Richard Asinof
Posted 4/1/24
As Rhode Island moves forward in its effort to rebalance the delivery of health care for its residents, there needs to be a clearer definition of what public health means and development of an action plan on how to get there.
Will the Commonwealth of Massachusetts block the sale of physician practices owned by Steward Health Care to Optum? How will the state of Rhode Island determine the budgetary requirements for bidders in the next iteration of the Medicaid Managed Care Organization contract, said to be worth some $7 billion? What role will Health Equity Zones play in the future determination of investments in health care delivery in Rhode Island? Will the General Assembly ban third-party authorization as an insurance practice in Rhode Island?
How we talk about violence against women, domestic violence, and gun violence remains an uncomfortable conversation in Rhode Island, it seems. In the mid-1970s, a woman whom I knew found herself being robbed at gunpoint, and in order to save her own life, ended up shooting her attacker and killing him, resulting in a drawn-out legal case. That kind of fierce self-preservation and how we tell such stories often gets lost in the rhetoric of our times. The events occurred 50 years ago in Somerville, Mass., and it is one of those stories that I have never quite figured out how to retell the story, giving it justice.
During a time when women’s rights to choose their own health care and make their own decisions about their reproductive choices are under attack, men need to step up to the plate and become active voices, not just bystanders.

LITTLE COMPTON – The seascape from the beach in Little Compton offers a tabula rasa, a clean slate upon which to project our dreams and hopes for our lives and the lives of our families, friends and neighbors.

We are free to inhale the salty sea breezes and listen to the seemingly endless drumming of the waves from the Atlantic Ocean, the horizon filled with the clarity of an uninterrupted vista on a hazy afternoon, where turquoise blue of the sky appears to collide with the bluish-green of the ocean. Squint at the horizon and perhaps you can see the British Isles.

With the power of our dreams, any destination seems possible to travel toward, without getting stuck in rush-hour traffic across broken-down bridges and the delusion of lies told by those covering up apparent decades of engineering mistakes.

In the past, on a spring afternoon, the pathway between a freshwater pond and stream separating the Town Beach and Goosewing Beach would often serve as the haunt of hungry gulls, awaiting the return of the herring to spawn, a veritable “happy hour” of our natural world.

Like the return of the osprey to Narragansett Bay, it is a ritual of springtime that often goes unnoticed by the humans always in a rush to get somewhere. But to where?

As I write this, recalling numerous journeys of the past where my family would venture to the shoreline, my emotions are darkened by the knowledge that such adventures are now lost in the past and are unlikely to occur again, except in memories.

What is public health?  
This past week, dignitaries gathered in downtown Providence to celebrate the topping off ceremony for the new state public health laboratory building. Many of the Rhode Island poobahs were there – the Governor, members of the Congressional delegation, state bureaucrats from the health and commerce agencies, the Senate President and the Speaker of the House, along with representatives of the new $45 million R.I. Life Science Hub – all to offer their words for posterity, much like the signatures on the steel girder being hoisted into place atop 150 Richmond St, labeled as “the future home of innovation,” which will also serve as the home of a commercial enterprise, “The PVD Labs.”

I had contemplated attending the event, if only to get the dignitaries on the record in their answer to the question, in their own words: “What is public health?”

It is not an easy question to answer; it cannot be dispensed with by a glib turn of phrase. As we enter the fifth year of the COVID pandemic, with a population at increasing risk of succumbing to what is known as “long COVID,” with our health care delivery system in shambles, the question, “What is public health?” keeps taking on more significance in our lives.

To be honest, I was not expecting to get illuminating answers from the dignitaries in attendance, but no matter. I felt it was my responsibility as a reporter covering the health care landscape in Rhode Island to try to capture, in their own words, what our political and bureaucratic leaders believed to be the essence of “public health.”

I have to admit that I no longer possess a clear vision of what public health is anymore. What I have become a witness to as a reporter – and a participant in as a patient – is the disruption, breakdown, and total collapse of our health care delivery system.

For starters, the new building that will house the state public health laboratory, to be owned and operated by the R.I. Department of Health, is merely an important toolbox with state-of-the-art tools. But it is not an action plan that will produce better health outcomes for Rhode Island’s residents. Nor is it an investment in the people who are needed to run the agency and direct its activities.

[Editor’s Note: Like the ongoing brouhaha surrounding the need to tear down and rebuild the Washington Bridge, what was missing was a mission – a vision and an action plan about how the flow of traffic would restore connectivity. Translated, what Rhode Islanders desperately needed were answers to the question: What is public transportation?]

From just across the border of Rhode Island, where the Area Code of 401 falls off the cliff, the health care delivery system in Massachusetts is on the verge of collapse. Steward Health Care, the for-profit hospital system, is now in debt to Medical Properties Trust, its for-profit, private equity landlord. The state of Massachusetts is attempting to perform an emergency resuscitation – but there is no easy way to deliver a financial dose of Narcan to keep the delivery system from overdosing from greed.

Steward Health Care last week announced that it plans to sell off some of the most valuable parts of its enterprise, its physician practices, to Optum, a for-profit division of United Healthcare. Optum is one of the largest owners of physician practices in Massachusetts. No sales price was revealed.

Optum and Rhode Island, in bed together  
Optum also has an intimate relationship with Rhode Island and many of its residents. Optum manages some 95 percent of all behavioral health claims for patients served by Medicaid Managed Care Organizations in Rhode Island. By the numbers, that amounts to roughly 300,000 Rhode Island residents – about one-third of the entire state’s population.

They have that job because they are the “chosen” vendor by both UnitedHealthcare of New England and Neighborhood Health Plan of Rhode Island, two of the three private insurance firms hired by the state of Rhode Island to manage the Medicaid health care population. [The third, Tufts Health Plan, has less than a 5 percent share of the Medicaid membership.]

Why haven’t you heard more about Optum before? It is not for lack of reporting efforts  by ConvergenceRI. In November of 2020, as part of the story announcing the $8.5 million investment by the Rhode Island Foundation to create the Equity Leadership Initiative, ConvergenceRI wrote extensively about an investigation by STAT, reporting on the problematic use of an algorithm that seemed to promote racial inequities in health care.

[See link below to ConvergenceRI story, “RI Foundation launches $8.5M Equity Leadership Initiative to tackle racial disparities: quote here.” The subhead to the story posed an immediate challenge: “The need to have an ‘uncomfortable conversation’ about how racism may be embedded in the analytics software algorithms used by Optum, according to findings in the new investigative report by STAT.”]

It is worth sharing a long excerpt from that story to provide the context around Optum and its relationship with Rhode Islanders.

The excerpt begins: ONE of the very first challenges that the new Equity Leadership Initiative at the Rhode Island Foundation may need to engage in, confront, and respond to are findings from the recent investigative reporting by STAT about how racism may be embedded in the algorithms of software analytics used by Optum and others.

Call it an “uncomfortable conversation about racial equity” in the management of health care by algorithm.

In the investigative story by STAT, published on Oct. 13, 2020, by reporter Casey Ross, entitled, “From a small town in North Carolina to big-city hospitals, how software infuses racism into U.S. health care,” the reporting details how a recent study of software built by Optum offered a rare look under the hood of how algorithms used to assess patients’ needs churn in the back offices of health systems nationwide, out of view of patients who are not privy to their predictions and how they are being applied. [See link below to STAT story, “How software infuses racism into U.S. health care.”]

The findings appear to have significant relevance and resonance here in Rhode Island to the way that health care services are delivered, because Optum, a [for-profit] corporate division of UnitedHealthcare, has an apparent contractual “lock” on managing more than 95 percent of the Medicaid managed care population in Rhode Island.

A private contractor, Optum is currently employed by both Neighborhood Health Plan of Rhode Island and UnitedHealthcare of New England, the two principal care management organizations, or CMOs, for Medicaid members, according to the director of a large community agency providing behavioral health and mental health services in the state.

[Tufts Health Plan manages its own members, but its share of the Medicaid managed care market in Rhode Island is miniscule, according to the agency director.]

How big an issue is this? As of June 2020, Rhode Island had enrolled approximately 305,208 individuals in Medicaid and CHIP, who were eligible for the health insurance program because of having met low-income eligibility guidelines and metrics, according to R.I. EOHHS data reports.

[Editor’s Note: As of March of 2023, that number had grown to approximately 365,000, according to the state’s Medicaid office, before the state began to re-determine eligibility in the program.]

Translated, nearly one-third of the entire population of Rhode Island, capturing many of the state’s most vulnerable residents as well as a large number of children and families of color, may have been subjected to a different kind of racial equity lens because of how IT algorithms deployed by Optum were being applied by health insurers to manage costs.

Here are some extended excerpts from the 2020 ConvergenceRI story:

  • “A STAT investigation found that a common method of using analytics software to target medical services to patients who need them most is infusing racial bias into decision-making about who should receive stepped-up care. While a study published last year [had] documented bias in the use of an algorithm in one health system, STAT found the problems arise from multiple algorithms used in hospitals across the country. The bias is not intentional, but it reinforces deeply rooted inequities in the American health care system, effectively walling off low-income Black and Hispanic patients from services that less sick white patients routinely receive.”
  • “These algorithms are running in the background of most Americans’ interaction with the health care system. They sift data on patients’ medical problems, prior health costs, medication use, lab results, and other information to predict how much their care will cost in the future and inform decisions such as whether they should get extra doctor visits or other support to manage their illnesses at home. The trouble is, these data reflect long-standing racial disparities in access to care, insurance coverage, and use of services, leading the algorithms to systematically overlook the needs of people of color in ways that insurers and providers may fail to recognize.”
  • “Nobody says, ‘Hey, understand that Blacks have historically used health care in different patterns, in different ways than whites, and therefore are much less likely to be identified by our algorithm,” said Christine Vogeli, director of population health evaluation and research at Mass General Brigham Healthcare in Massachusetts, and co-author of the study that found racial bias in the use of an algorithm developed by health services giant Optum.”
  • “There are at least a half dozen other commonly used analytic products that predict costs in a similar way as Optum’s does.The bias results from the use of this entire generation of cost-prediction software to guide decisions about which patients with chronic illnesses should get extra help to keep them out of the hospital. Data on medical spending is used as a proxy for health need – ignoring the fact that people of color who have heart failure or diabetes tend to get fewer checkups and tests to manage their conditions, causing their costs to be a poor indicator of their health status.”
  • “Optum executives also said they do not plan to make any changes to the product, because they believe the 1,700 measures embedded in it provide enough information to eliminate bias that arises from isolated use of the cost-prediction algorithm.”
  • “The study was conducted based on the use of Impact Pro by Mass General Brigham, a health system affiliated with Harvard University. The health system was using the tool to help identify patients who would benefit from referral to programs designed to avert costly medical episodes by delivering more proactive care.”
  • “Optum advertises the product’s use for that purpose. A prospectus posted on its website says the software can ‘flag individuals for intervention using Impact Pro’s predictive modeling technology … and identify individuals with upcoming evidence-based medicine gaps in care for proactive engagement.’”
  • “In the years following passage of the Affordable Care Act in 2010, their pitches found a newly receptive audience. The law prevented insurers from using data on costs to deny coverage to people with pre-existing conditions. But it created incentives for health providers to identify and intervene in the care of high-cost patients, through new arrangements that shared financial responsibility for runaway medical expenses between insurers and hospitals.”

    • “By 2019, these algorithms were being used in the care of more than 200 million Americans — essentially applying an actuarial concept of risk to decisions about who might benefit from additional doctor visits or outreach to help manage their blood pressure or depression.”

The excerpt from the 2020 ConvergenceRI story continues:  How do you argue with, or talk back to, an algorithm?

“Systemic racism is a root cause of the challenges and barriers experienced by people and communities of color,” Larry Warner told members of the Cranston City Council, when the council recently enacted a resolution declaring that “racism is a public health crisis.”

“Algorithms are incredibly flawed, no matter what,” said Neil Sarkar, president and CEO of the Rhode Island Quality Institute. “There is always a bias. I think that is especially true when you are looking at things through the lens of race or ethnicity.”

Sarkar said that he expected that some of the algorithmic disparities would be even more acute in Rhode Island's population, “because we have diversity, but our diversity is actually very concentrated and very focused in particular parts of our state, and we need to be cognizant of that, especially when it comes to decisions that are going to be made [about health care].” That is why, Sarkar continued, having full transparency of data is really important.

The question is: How do you argue with – or talk back to – an algorithm that is deciding what kinds of investments are to be made in “rationing” health care by the health insurer,

Another critical question: If there are flaws that can be identified in the Optum software used for Rhode Island’s managed Medicaid population around issues of racial equity, then how does that require changes in the way that health care investments are managed and delivered by UnitedHealthcare and Neighborhood Health Plan of Rhode Island?

A third question: When it comes to the delivery of two of the highest-cost services of health care – women’s health and mental health and behavioral health care, according to presentations to the Senate Commission on Health Insurance Reimbursements, how can such apparent racial biases in the software algorithms be identified and remedied?

A fourth question: Is there a connection between the racial equity biases identified by the STAT investigative report in the algorithms deployed by Optum and the very low reimbursement rates paid for behavioral health and mental health services in Rhode Island?

A fifth question: If you are a board member of Neighborhood Health Plan of Rhode Island, which employs Optum to manage delivery of health services for Medicaid patients, do you need recuse yourself from participation and discussions around racial equity as part of the new Equity Leadership Initiative by the Rhode Island Foundation? 

Translated, if you want to address racial equity in Rhode Island, will it require removing those who may be directly profiting from the practice of racial health disparities from being decision-makers?

In the third part of the excerpt from the 2020 story, ConvergenceRI attempted to connect the dots around accountability: Who will be held accountable? The apparent racial bias embedded in the algorithms deployed by Optum is not the only alleged problem that has been identified with the way that Optum has behaved in its management of the delivery of health services. Frequently, payments by Optum to providers have been delayed, forcing the providers to have to borrow money from the state to stay in business, according to executives of a leading community agency involved in mental health and substance use services.

In a ConvergenceRI interview published on Feb. 17, 2020, with Susan Storti and John Tassoni of the Substance Use and Mental Health Leadership Council of Rhode Island, Storti and Tassoni revealed that delays in timely payments from Managed Care Organizations such as Optum had forced their member agencies to borrow money from the state in order to be able to stay in business.

As ConvergenceRI reported in the story: “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.”

Further, ConvergenceRI reported: 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 [because of delays in payments], 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."

The reporting on Optum continued  
Two and half years later, in December of 2022, ConvergenceRI continued its reporting on Optum, featuring a story written by Lisa Peterson, the chief operating officer at VICTA, “The state’s codependence upon Optum is not optimal.” [See link below to ConvergenceRI story.]

Here is an extended excerpt from that story: Right now, over a third of Rhode Islanders qualify for health insurance under the Medicaid program. In 2014, the state opted to expand Medicaid benefits under the Affordable Care Act, with the goal of ensuring access to the right care at the right time for anyone who needs it.

Although this expansion significantly reduced the number of uninsured individuals, and despite the fact that Medicaid spending accounts for nearly a quarter of the State’s budget, essential services remain out of reach for far too many. Rhode Island outspends more than 40 other states on health care, yet our behavioral health system is teetering on the verge of collapse.

Why is there such a disconnect between our stated goals, our substantial investment, and our actual health care system? Much of this quagmire can be explained by the decision to spend more “managing” access to care than to providing it. Over the last few decades, Rhode Island moved away from the state-led, traditional fee-for-service payment model, through which a provider delivers care, submits a claim, and is reimbursed accordingly.

In an attempt to improve quality outcomes and contain costs, Rhode Island moved Medicaid benefits under the purview of private health insurers known as Managed Care Organizations [MCOs]. The MCO model is designed to manage costs and quality by contracting with certain providers for discounted fees. Three health insurance corporations are currently approved by the R.I. Executive Office of Health and Human Services [EOHHS] to “manage” the state’s Medicaid spending: UnitedHealthcare, Neighborhood Health Plan of Rhode Island, and Tufts Health Plan [now known as Point32 Health, following Tufts’ merger with Harvard Pilgrim Health Plan].

As a result, more than 90 percent of Rhode Islanders with Medicaid coverage are currently enrolled in an MCO.

The excerpt continued, detailing how the benefits often remained in silos: Behavioral health is a critical component of overall wellness, and integrated care models providing both physical and behavioral health services produce the best results. Yet benefits under Managed Care plans remain “siloed,” in most cases. Oversight of behavioral health care services is even subcontracted by some Managed Care Organizations.

UnitedHealthcare, a national for-profit insurer, delegates these services to its for-profit subsidiary, Optum. Since its creation in 2011, Optum has grown into a behemoth, creating billions of dollars in profits for the parent company. Optum’s revenue per covered individual increased by more than 30 percent from the first quarter of 2021, compared to the same time period this year 2022.

In 2019, Neighborhood Health Plan of RI terminated its long-term relationship with another behavioral health benefits management company in favor of subcontracting these benefits to Optum. Combined with the existing United/Optum relationship, this has led to a near-monopoly in Rhode Island: nearly 95 percent of Medicaid-covered individuals are now enrolled with a plan that uses Optum for behavioral health contracting, credentialing, and claims.

As Rhode Island has moved toward the privatization of Medicaid, and United/Optum revenues have continued to balloon, provider reimbursement rates have remained stagnant. As a result, providers experience de facto cuts to revenue while attempting to adapt to the surge in costs, need, and complexity of services being delivered. With more than 60 percent of Medicaid dollars going to the “management” of care, little is left for those who provide it.

The next excerpt provided insights by Peterson from her position as sitting in a front-row-seat: Even without this data, it is clear that what we are doing is not working. For nearly four years, I have had a front-row seat to this unfolding disaster. Obstacles with Optum’s contracting and credentialing caused VICTA to push back its opening by at least six months. Because Optum has such a large market-share, it was not feasible for a new provider like ours to start delivering desperately needed services without them.

Once we were finally able to open our doors to the community, we encountered multiple issues with appropriate medical contracting to ensure that we were set up to deliver truly integrated care; to date, claims are still being denied because they don’t fit neatly into “medical” or “behavioral” categories – a separation that by its nature impedes integration. It took a recent escalation to R.I. EOHHS to begin to generate some movement towards a solution.

Optum’s domination of the Medicaid market affects new providers as well as long-established organizations. For anyone who delivers home- and community-based care, it is an unfortunate part of the routine to navigate these types of issues, even as they distract from or delay our real work of improving the lives of those we serve.

Experiences such as long hold times, being transferred from department to department, repeating the same information with each new representative, and receiving conflicting information are the norm when seeking authorization for a service that the care team and member know is needed.

While most payers have moved away from cumbersome “prior authorization” requirements for services, such as “Intensive Outpatient” programming, Optum’s Utilization Management process remains in place.

With nearly 70 percent of our client population covered by an Optum plan, the unpaid time spent on these authorizations is significant. The impact of a single MCO having such a disproportionate share in the Rhode Island Medicaid market is clear, and it is not positive.

  • Providers of critical, life-saving services throughout our community are at risk of financial crisis each time a process is changed or a ‘glitch’ occurs.
  • Delayed payments from a payer with a footprint as large as Optum creates devastating effects for providers and service recipients alike.
  • Our workforce has been decimated because already razor-thin budgets cannot support wages that adequately reflect the qualifications and value of our providers. 

Rhode Island’s behavioral health system cannot continue to address the surging demand for mental health and substance use care without significant changes. If we are staying true to our collective goal of ensuring that anyone who needs help gets it, we cannot accept the current status quo.

The future of public health in Rhode Island.  
In 2020, ConvergenceRI wrote: “All health care is personal; all health care is complex; all health care is expensive. Further, the crises in affordable housing, in health care, in the economy, and in the environment are all intimately connected. The links between racial equity and health outcomes have been made more transparent by the coronavirus pandemic still raging in our midst.”

In 2020, Jennifer Hawkins, president and CEO of ONE Neighborhood Builders, tweeted out: “The impact of COVID tracks the pre-existing [and unconscionable] health disparities faced in low-income/majority BIPOC [Black, Indigenous, and people of color] neighborhoods.”

In 2024, Angela Ankoma, vice president and director of the Equity Leadership Initiative, told ConvergenceRI that the “outcomes of the pandemic, in terms of racial equality and social justice, showed us that we need to lean into this work, moving forward.”

The increasing demands for mental health and behavioral health services in Rhode Island have created huge gaps in the provision of care. Will the General Assembly step up to the plate and make the investment recommended by OHIC for a $45 million increase in payments for Medicaid providers in FY 2025? What kinds of regulation will be imposed on the for-profit Optum in how it handles behavioral health management of services? Stay tuned.

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