PROVIDENCE – Benjamin Shaffer, the director of the R.I. Medicaid office, has his finger on the pulse on a huge share of medical spending in Rhode Island. He is responsible for managing the flow of money that represents approximately one-third of the entire state budget.

In performing that role, Shaffer currently oversees an ambitious program to transform health care from a fee-for-service payment model to a value-based payment model, focused on the Reinvention of Medicaid – enacted into law as a signature program during the first term of former Gov. Gina Raimondo.

The initiative was funded in 2016 with nearly $130 over five years in federal funds by the Centers of Medicare and Medicaid Services. The project is now in its third year, with the fourth year of the program postponed because of the public health emergency from the coronavirus pandemic.

In addition, Shaffer has been drawn into the controversy regarding the way that Medicaid funds have been spent – or not spent – on the care of patients at Eleanor Slater Hospital.

ConvergenceRI recently spoke with Shaffer, who was appointed in 2020, to get an overview of where things stand moving forward with the efforts to implement a new payment model for health care in Rhode Island.

ConvergenceRI: What are the biggest challenges you are facing in your job?
SHAFFER: The greatest challenge that we all face, but certainly anyone in health and human services, is how to think about recovery from the pandemic and the public health emergency. And, to borrow a phrase [from President Biden], how to “build back better.”

I think there are a few reasons to start there. Rhode Island’s vaccines have largely gone into arms, but there are plenty of folks we still need to reach, and obviously, plenty of kids. But that doesn’t mean that the public health emergency is over.

It is not over for kids who may need, or have missed, childhood vaccination, or wellness checkups, or lead screening. It’s not over for kids who may have been otherwise screened or referred for early intervention services, but because they were home during the pandemic, didn’t get screened.

It’s certainly not over for anyone who may have delayed health care for chronic condition treatments.

And, certainly, it is not over the long-term care system, which is primarily Medicaid funded.

So, we are really looking hard at ways to one, identify those shifts and changes and impacts on the public health emergency, but also to think more structurally about how we need to improve the system in the long run, based on what we’ve learned over the last year and three months.

ConvergenceRI: Clearly, you are in an interesting position in an interesting time. Sometimes, it seems, many of your roles may be in conflict, in that you are trying to control Medicaid expenses, at the same time that demands on the system that you oversee keep increasing. How do you balance those goals?
SHAFFER: I don’t necessarily think that they are in conflict. We spend a lot of money as a country in health care and don’t get particularly good results.

So, a lot of what we try and do, I think, is two things: One, identify from a public health perspective, where we are spending too much, and conversely, where we are spending too little, based on the best research available, into what actually keeps people healthy.

And, to try and either shift, or make more investments, in those areas that really contribute to health. And that could be primary care, or social determinants, community health workers, housing stabilization. Most of which I just mentioned are included in the Governor’s recommended budget.

And then, we look at changing the care models, which you obviously have written about as well, which is our fee-for-service [payment] system, [which] doesn’t do well to improve health; it forces doctors and their practices and their nurses and people who work with them to treat patients like they are on a hamster wheel or a conveyor belt, just seeing one after another after another, and not really building the kind of trusted and connected relationship that you need to improve health, particularly in the Medicaid population.

And, as you know, ultimately, we want to make sure that we’re paying for outcomes, which is really another important part of what people call value-based payment.

So, paying for the procedure, or paying to see a patient, that’s great, but how can we incentivize the outcomes that we really care about,

That is very challenging; it doesn’t happen in one budget cycle, or in one Medicaid director’s tenure, or in one Secretary’s tenure. But it’s what I think we try and do to “square that circle” that you’re pointing out.

ConvergenceRI: One of the things that have come under scrutiny is the fact that there are a number of private contractors who are doing work under Medicaid in Rhode Island. And, as you try and find out how, excuse the cliché, to get the most bang for your buck, have you ever conducted an internal review of how the money is being spent – and what the outcomes are, for those private contractors?
In the past, there have been some questions raised about the patient transportation services, for example.
I have covered what used to be known as Rhody Health Options – and now it’s called the Integrated Health Initiative. I was wondering sometimes if it seems that the overarching mission of what you want to accomplish is perhaps rooted in great emotional content, such as, “We’re going to get people out of nursing homes and perhaps back into the community,” rather than the reality of what it takes to do that.
SHAFFER: Yes, and certainly, the reality of what it takes to do that, to build up a stronger primary care system, to move to value-based payments and sustainable Medicaid accountable entities, supporting and advancing home community-based services in long-term care, it is challenging. It is often easier to set the goal than it is to work towards it. But that is not terribly different than anything in public service.

It takes incremental change and incremental steps, and working not just in Medicaid but across the EOHHS agencies, across government, and with all sorts of different stakeholders.

I think that in health, in health care, in policy-making in general, it is something we want to focus on as best we can in those concentrated areas that we think can make a difference.

ConvergenceRI: Just to get back to the first part of my question, do you have  an internal review of performance metrics of those private contractors and how they are doing?
SHAFFER: Yes, I think we do. I’m not entirely sure what contracts you are referring to, but generally speaking, yes, we do all manner of contract reviews, audits of performance.

MTM has been well covered, we do significant contract reviews, damages assessments, weekly reporting on trips and calls and complaints, the team does monthly meetings, I do quarterly strategy reviews with MTM, where we talk about things like, “How do we make sure that transportation is available to get people to primary care appointments or screening appointments,” or what have you.

That’s been well covered. The initial roll out and transition was difficult, but the fact of the matter is that service is now incredibly strong to Medicaid beneficiaries through that contract.

I’m not sure what other contracts – you were a little vague about which other contracts. Obviously, there are continued questions about managed care contracts, in which we have extensive contract management, quality audits, and financial reviews on the managed care organizations. The finances are public – through R.I. Department of Business Regulation, through quarterly reports and annual reports. This is not a place where we lack oversight.

Could there always be more oversight? Of course. The Governor’s recommended budget includes more funding for R.I. EOHHS to perform those oversight responsibilities. And I am certainly hoping that it will pass, in recognition of how much funding passes through these organizations, and how many Rhode Islanders rely on it.

We are proud of our managed care program; we have actually had very highly ranked plans. But, as I said, it doesn’t mean that we don’t’ try and push the envelope, to try and do better, to try and do better on quality, try and do better on access, and work with the managed care organizations on those broader goals that I talked about at the beginning of our conversation.

ConvergenceRI: As I was scanning my Twitter feed today, there was legislation now pending in the Senate to increase the length of Medicaid coverage for new mothers beyond the current 60-day limit. Do you support that legislation?
SHAFFER: I certainly think it is something in concept that we are already interested in making sure that we look at newly available opportunities to provide access.

The opportunity came up through the American Rescue Plan following the Governor’s budget, but certainly if the R.I. General Assembly enacts it in this session, we will, of course, implement it.

And I think, if it is something that doesn’t happen, that we’ll be interested in taking a closer look at through the next Governor’s budget cycle moving forward.

But certainly, as a general matter, we want to promote as much access as possible to any health insurance coverage, but particularly for Medicaid for pregnant women, mothers and kids.

ConvergenceRI: I heard that Medicaid was not reimbursing physical therapy or occupational therapy visits of Medicaid members. Is this accurate? My sources tell me that the providers billed for such services, but that they never got paid, with the physical therapy practices having to eat the costs.
SHAFFER: I am not aware of anything related to that. We cover PT and OT; I’ve seen data recently about how much [of those services] were able to be provided through telehealth, where there were claims being paid. I believe more on the PT side than the OT side. So, I’m not familiar with any difficulties there, at this time.

ConvergenceRI: Well, let me be the first to say that is apparently on that front and you may want to investigate it, because I’ve heard directly from a provider about it.
SHAFFER: I think it is important to differentiate between individual provider billing issues which happen, and systemic issues about Medicaid not covering something, or not paying for something.

ConvergenceRI: This is not just an individual provider; this is one of the largest health providers in the state, where the information is coming from. I cannot reveal my sources.
SHAFFER: I look forward to learning more about it, from the provider or from the provider groups, should there be an issue.

ConvergenceRI: You have talked about value-based payments. I was wondering what you see as the current status of the accountable entity program as part of the Reinvention of Medicaid? What are the metrics for measuring its success? And, what will happen when the initial federal money, I believe it was about $120 million in 2016, runs out?
SHAFFER: We’re quite proud of the accountable entity program. We’re about to finish up Project Year Three through the HSTP [the Health Systems Transformation Program] and the funding that you mentioned and enter Project Year Four.

So, I think, that is an area that we continue to make improvements, not just on the AE side, but also focus heavily on things around the AE program that relate to broader health [outcomes] as we talked about.

We recently announced the procurement, through the AE program, with HSTP funds, of a community resource platform that will help connect AEs and primary care with community-based organizations, which is something that came out very strongly in stakeholder sessions in our public social determinants of health plan.

I think, broadly speaking, some of this funding has been used quite well on the projects that we ultimately fund to improve health.

And, upcoming in Project Year Four, will be the first time that we are asking some of the AEs, the non- health center AEs, to take on downside risk. So, that’s a big shift. We intended to do that originally in Project Year Three, but because of the public health emergency, decided to delay that. Which I think is an important part of the story, to be moving ahead on that ability to take on risk, at least for those non-health center providers, and particularly when you look at providers that are a bit larger, that are hospital based, that’s something we are very committed to pursuing.

You talked about sustainability. We have a couple more years of funding through this, so we are really starting now to think about sustainability. A lot of the work of sustainability is finding out what is currently being paid for by HSTP and seeing what other funding streams we might have. I think that the Governor’s budget initiative to cover community health workers as a Medicaid-reimbursable service is a really good example of that.

We are certainly hopeful that that will pass the General Assembly this year and become [part of our] core sustainability plan.

That sustainability plan is due to CMS [Centers for Medicare and Medicaid Services] by mid-December of this year. It will go through a public comment period and the like.

But, we see this as an area of real promise, both as core practices in the transformation [care] and in improving quality and building those kinds of connections in the community and with patients that I talked about previously.

ConvergenceRI: You may have seen – I suspect that you did see – my long piece about the results that OHIC published regarding the cost trends related to Medicaid and the fact that there was a great disparity between the lowest providers and accountable entities, the top two were 0.2 percent and 0.3 percent for increases in costs, from 2018 to 2019, while the highest cost provider saw a 14 percent increase, which is a difference 700 percent.
The providers were not named under the accountable entities; OHIC said that I should talk to you about that.
I understand from my sources that there was problem with data from Neighborhood Health Plan of RI initially presented that had to be corrected.
From your standpoint, is there an opportunity to get a ranking of the different cost trends for those accountable entities. Is that something you can do?
SHAFFER: I don’t have the specific cost trends data in front of me at the moment. But I would be happy to follow up on what we have and what we can provide.

I will say that one of the things that we are looking at as part of the AE program and this should be public at the end of this month is if you look at how much AEs have earned in reductions in total costs of care.

Those calculations I should mention are pegged to whether or not they maintain or exceed accepted quality benchmarks as well, to make sure that they are not skimping on quality to cut costs. So that will be available at the end of this month, we will be sharing it with AEs as well.

So I think that’s another data point for the AE program that will be certainly looking at, and continuing to look at as EOHHS specifically takes on those total cost calculations in Project Year Three and moving forward.