PROVIDENCE – The timing of the news release was curious indeed. The announcement that the R.I. Executive Office of Health and Human Services had signed a three way contract with Neighborhood Health Plan of Rhode Island and the federal Centers for Medicare and Medicaid Services to move forward with the second phase of what is known as the Integrated Care Initiative occurred at the exact same moment that Elizabeth Roberts, secretary of R.I. EOHHS, was testifying before the R.I. Senate Finance Committee about the FY2016 supplemental budget and the proposed FY2017 budget.

The news release headline hailed the “innovative new partnership” with Neighborhood Health Plan, which was slightly misleading.

The first phase of the Integrated Care Initiative, known as Rhody Health Options, had been launched two and a half years ago in October 2013, under then R.I. EOHHS Secretary Steven Costantino, as an initial partnership between Neighborhood Health Plan and the state’s Medicaid office as a way to provide managed care to the dually eligible population for both Medicaid and Medicare.

The expectation was the two-legged stool, featuring the state and Neighborhood Health Plan, would soon become more balanced as a three-legged stool that included Medicare. However, the signing of the contract, preceded by a Memo of Understanding, took more than two years to be completed. Why did it take that long? The problem, according to numerous sources, was negotiating how much money Medicare would take off the top on the contract.

While no one disputes the overarching good intentions behind the desire to rebalance the system of care for some of our state’s most vulnerable and frail population – and, at the same time, hopefully driving down the costs of care paid for by the state – the methodology and effectiveness of Rhody Health Options has been criticized from the start.

At the time of the launch, the state projected that savings were to be achieved by the projected transition of some 3,000 patients currently in nursing homes back into the community.

It was wishful thinking; those transitions never materialized. In 2015, the total number of transitions achieved under the direct auspices of Neighborhood Health Plan [and not under other pre-existing programs] was 36, according to the state’s public records. The total number of transitions from nursing facilities back to the community had actually been reduced, when transition numbers were compared with previous programs underway before Neighborhood Health Plan became involved, according to state’s public records.

There were also other questions raised:

• The size of the administration fee paid to Neighborhood Health Plan for its work, given that the touted skilled managed care capability of Neighborhood Health Plan was going to be limited in its use once a determination of care was made – because many of the residents of nursing facilities were not candidates to move back into the community.

• The confusing manner in which dually eligible nursing facility residents were enrolled, which enrolled them in Rhody Health Options unless they chose to opt out.

• The reality of the demographics of Rhode Island – the state leads the nation in the number of “old old,” people who are 85 years and older. And, the fact that the frailer, older residents of Rhode Island are much more susceptible to the ravages of Alzheimer’s, Parkinson’s, dementia and the full flowering of chronic diseases such diabetes and heart disease, requiring constant 24/7 care.

Since its inaugural issue in September of 2013, ConvergenceRI has frequently covered the controversial roll out of Rhody Health Options. [See link to ConvergenceRI stories below.] For its part, the rest of the news media has been strangely quiescent.

The path ahead
With the signing of the new three-way contract with Medicare, the path ahead was painted in colors of an optimistic landscape by Peter Marino, president and CEO of Neighborhood Health Plan. “Neighborhood has a long and successful record of working with the state, the community health centers and others to improve member access to high-quality services at a price taxpayers can afford,” Marino said in the news release. “This new work to integrate Medicaid and Medicare benefits and help some of Rhode Island’s most vulnerable people represents out biggest opportunity to date.”

We believe, he continued, “We will be able to make a major difference by getting these new members the right care at the right time and controlling the corresponding costs.”

The problem with Marino’s pledge about “the right care at the right time” is that, to date, there has been no accounting or audit [at least one that has been made public or shared in a transparent manner] with Neighborhood’s performance during the first phase of Rhody Health Options.

Without that kind of analytics and measurement, to understand and account for the performance under the first phase of Rhody Health Options, how will the second phase be benchmarked?

Many advocates were diplomatically hopeful that the implementation of Phase Two of the Integrated Care Initiative would achieve its potential. “Phase Two of the Integrated Care Initiative holds real potential for decreasing costs without hurting quality of care,” Virginia Burke, the president and CEO of the Rhode Island Health Care Association, told ConvergenceRI. “It could even improve quality of care.”

Our only concern, Burke continued, “is that Phase One of this program has been so problematic. Neighborhood is working hard to fix the problems with Phase One, and we are confident that once this is accomplished, we can move forward into a productive Phase Two.”

Phase One has been “horrible”
However, Gail Sheahan, the owner and operator of the Consistent Care agency in Jamestown, who has run her business for more than 24 years and been a nurse for 32 years, did not hold back her harsh assessment of Phase One of Rhody Health Options and its failings when she testified before the Senate Finance Committee on April 28. [See link to testimony on link below, beginning at around 42:00.]

Sheahan said she was upset by Roberts’ testimony about how “great” Phase One was going.

“I sat here and heard about Phase One, and how great Phase One was going, that [there] had been a few bumps in the road in Phase One,” Sheahan testified.

And now, Sheahan continued, the state is going to flip the switch and think that everything’s going to work great under Phase Two.

“It’s not going to happen. Phase One is so messed up, you cannot believe it; it’s a nightmare,” describing the lack of coordination of care between agencies, the state and Neighborhood Health Plan. “The right hand doesn’t know what the left hand is doing.”

I have no idea, she testified, “why they are going to roll out Phase Two when Phase One was horrible.”

Further, she warned the members of the Senate Finance Committee: “They are selling you a bad bill of goods, people.”

What went wrong and ways to fix it
ConvergenceRI reached out to Sheahan about her testimony, asking here to describe, in more detail, the problems her agency had encountered with Phase One of the Integrated Care Initiative. known as Rhody Health Options.

“Some of the major issues with Phase One was poor planning and lack of training, right from the start,” Sheahan explained. “The state, Neighborhood [Health Plan], case managers, agencies, primary care MD’s, discharge planner's from hospitals/nursing homes – nobody knew what was going on, and no one could answer questions regarding level of care, or about changing supply companies.”

Confusion reigned, according to Sheehan. “We were hearing one thing from Department of Human Services caseworkers, and a totally different answer from Neighborhood [Health Plan].

As a result, one patient, Sheahan continued, had to wait for three months for supplies. “Case management workers had no idea of their role, and frankly, they added another layer of bureaucracy.”

In terms of remedying the situation, Sheahan said that the state needed to get its act together. “They all need to be put in a room and listen to the workers [at the agencies].”

Major changes in policy were being made regarding client eligibility and payments, she explained, but there was a disconnect with the people who were actually doing the work in the field.

“Many of these issues could have been prevented if the policy makers got educated on the project they were charged with implementing,” Sheahan said.

Supply and demand
One of the principles in rebalancing care for Rhode Island’s poor and frail elderly is the be able to keep them out of nursing homes by increasing community-based services.

But without a major increase in pay by the state for CNAs working in home health care, Deb Driscoll, president and CEO of Ocean State Nursing, testified at the Senate Finance Committee hearing on April 28, there will be a continuing crisis in the shortage of workers.

Driscoll and her fellow home health agencies are asking to increase the rate of reimbursement for CNAs by 40 percent, in order to make their pay equal to what it is in Massachusetts and Connecticut. The Raimondo administration has proposed a 7 percent increase, but Driscoll called it unacceptable.

She explained that many of the CNAs who work at her agency are working mothers, and they value the flexibility in the work schedule that allows them to be home with their children.

The situation has gotten so bad that Driscoll said her agency has had to invoke the emergency preparedness plan for her agency, to put it on an emergency footing, rationing care, not because of a hurricane or a snowstorm but because of the ongoing crisis in the shortage of care.

“I have never seen it this bad,” Driscoll told the senators. “We cannot accept the 7 percent raise offered.” While Driscoll said she agreed with the desire to rebalance the system and increase home care services, the problem was: “We have no staff.”

Driscoll acknowledged that Roberts had reached out to her and invited her to sit down and try to work things out, but the prospect “petrified” her. Because every year, she continued, on the day that the budget gets signed, “We’re not in it.”

Driscoll told the legislators that Ocean State, beginning three or four weeks ago, had to implement its emergency preparedness plan. “We’re not using it because of weather; we’re using that because [of a shortage of] staffing.”

Sophie O’Connell, spokeswoman for the R.I. EOHHS, responded to questions about the testimony at the Senate Finance Committee hearing by saying that home care workers had not received a raise since 2008, and the Governor’s budget included $4 million “to provide these workers with their first wage increase since the middle of the Carcieri administration.”

O’Connell called the $4 million “a step toward better wages” and one that the administration hoped to build upon in the years ahead.

She acknowledged that at 7 percent increase for home care workers was only a small increase, but said: “The current fiscal situation dos not allow us to increase home care reimbursement rates by 40 percent, as the industry has requested.”

O’Connell added that Roberts and her team were open to amendments to improve the Governor’s budget proposal.

Translated, there is an emergency shortage in home health care workers, forcing agencies onto emergency preparedness footing, but there isn’t enough money in the budget to pay for raising wages of the CNAs doing the work, who haven’t had a raise from the state in almost a decade. The question is: how can you rebalance the system in the hope of keeping people at home longer and not in nursing facilities if you are not willing to invest in pay wages that are the equal of Massachusetts and Connecticut?

In terms of economic development and real jobs, wouldn’t it make sense to invest in higher wages for home health care workers?

Name changes
In case you missed it, at the hearing, Roberts announced two name changes: the process of “reinventing Medicaid” will now be referred to as just Medicaid, and the health IT infrastructure build out, previously known as the Unified Health Infrastructure Project, the biggest-ever IT project in the state’s history, will now be known as RIBridges.