Delivery of Care

Meet the woman in charge of Medicaid in RI

Kristin Sousa, the new director of the RI Medicaid office, is, in many ways, the antithesis of the former director, Ben Shaffer

Photo courtesy of RI EOHHS

Kristin Sousa, director of the R.I. Medicaid office.

By Richard Asinof
Posted 4/25/22
An in-depth interview with Kristin Sousa, the new director of the R.I. Medicaid office, and the challenges she faces in managing the delivery of healthy care for more than one-third of all Rhode Islanders.
When will the special Senate legislative commission looking at the organization of RI EOHHS offer its recommendations? How will the re-certification of eligibility for Medicaid members disrupt the continuity of health care coverage for the poorest, most vulnerable Rhode Islanders? As we move into budget enactment season at the R.I. General Assembly, will there be a revolt against the Governor’s proposed budget to increase the low, low Medicaid rates for reimbursement? How will the chronic conditions linked to long COVID – such as increased incidence of diabetes, liver diseases in children such as hepatitis, and dementia in elderly patients – be tracked?
When it comes to data constructs about health care delivery, sometimes it is not the lack of data but the lack of correlation and integration of data, it seems. Last week, pediatricians and hospitals affiliated with Lifespan declared an emergency crisis in the delivery of services for children with mental health conditions. The emergency should not be a “new” news story – it is what the data has shown us for months if not years: long before the COVID emergency. All the data and analyses have pointed to a growing gap of unmet needs when it came to children’s mental health and the difficulty in accessing care. ConvergenceRI published two separate stories, a month before the declaration, reporting on two initiatives to find solutions to the crisis – a texting service for parents and a provider network for providers treating pregnant and post-partum women.
It is no “hush, hush big secret” that the problem has been directly linked to Medicaid – and the program’s obscenely low rates of reimbursement for providers.
Nor is it a “hush, hush big secret” that homelessness has been linked to chronic mental health issues. The ongoing scandal at Eleanor Slater Hospital has been directly linked to the state’s unwillingness – by both the R.I. General Assembly and Gov. Dan McKee – to invest the millions needed in increased Medicaid rates to address the lack of access to mental health care at the community level. If you starve the community mental health providers, and keep the wages of community health workers artificially low, what did legislators and the Governor think would be the result?
There is a tendency by some to view the homeless – the un-housed – as being somehow unworthy of investment of tax dollars – the ultimate stigma, that their lives are not worth enough.
But the numbers for those on Medicaid in Rhode Islander today – 347,977 residents as of March 31, 2022 – paints a true picture of “prosperity” in Rhode Island. Translated, 38 percent of all Rhode Island residents are living at or below 120 percent of the federal poverty level.
Politicians running for office are betting that those whose health care benefits come from Medicaid do not vote – but that might not be a smart wager to make.

PROVIDENCE –There are many “hot potatoes” being passed around in Gov. Dan McKee’s administration these days, with the kind of “mission impossible” assignments that appear to be without any easy answers – and with tasks that will not self-erase.

One of the more thankless tasks was recently handed to Kristin Sousa, appointed to be the new director of the R.I. Medicaid office. She is now in charge of managing the delivery of health care services for more than one-third of all residents of Rhode Island – 347,977 as of March 31, 2022, to be precise, using the numbers provided by Sousa herself in a recent interview with ConvergenceRI.

Sousa is a veteran of working in the state Medicaid office, having worked there for more than a decade. In many ways, she is the apparent antithesis of the former director, Ben Shaffer, who left his job in state government to return to the world of the Boston Consulting Group, a high-priced consulting firm, as a principal.

If Shaffer – at least as personified in his testimony before the Senate special legislative commission looking at the future organization of the R.I. .Executive Office of Health and Human Services – took on the demeanor of being a smug, arrogant, know-it-all, Sousa’s tone of voice during a recent interview was one of patience, with an ability to listen to questions, with the qualities of being competent, smart and humble. [See link below to ConvergenceRI story, “Will Medicaid remain a part of RI EOHHS?”]

The political and economic future of Rhode Island will be linked at the hip, so to speak, to the skills of how well Sousa accomplishes her “mission impossible” task.

• The actual numbers of Rhode Islanders on Medicaid is about to shrink – perhaps by as much as 50,000 – if and when the federal government ends its COVID emergency declaration, which put a stop to certification requirements for those on Medicaid. The “disruption in the force” will be handled by the R.I. Department of Human Services – dependent upon the software, hardware and expert advice delivered by Deloitte.

• The state is in the midst of a re-procurement process for those private health insurance firms being chosen to “manage” the health care delivery of approximately 90 percent of all Medicaid members as Managed Care Organizations, or MCOs.

Currently, there are three – Neighborhood Health Plan of Rhode Island, UnitedHealthcare, and Tufts Health Plan. Tufts Health Plan has apparently been “disqualified” from participating in the procurement process because of a late application. [See link below to ConvergenceRI story, “The big disconnect.”]

Two new potential applicants who have entered the pool are Blue Cross and Blue Shield of Rhode Island, and Molina Healthcare, with corporate headquarters in Long Beach, Calif.

• As of May 1, Secretary Womazetta Jones is departing her job as Secretary of the R.I. Executive Office of Health and Human Services, which means that Sousa will be working without an “official” boss for the next few months.

• The special Senate legislative commission looking into the future organization of R.I. Executive Office of Health and Human Services, chaired by State Sen. Josh Miller, has apparently completed its hearings and is expected to be offering its suggestions sometime later this year – which may include separating out the R.I. Medicaid office from the auspices for R.I. EOHHS.

All of the ongoing crises in the delivery of health care services in Rhode Island have been linked to the low reimbursement rates paid by Medicaid to providers – from behavioral health care to the shut down of Early Intervention, from children’s mental health crises to homelessness, from the health care workforce crisis to the unsustainable business model for hospitals, from the failure to better manage the COVID public health crisis to ongoing surge in opioid deaths – all are intimately tied to the unwillingness to invest in Medicaid by increasing rates.

Here is the ConvergenceRi interview with Kristin Sousa, who will have more to say about the future prosperity of Rhode Island, perhaps, than any politician running for office – or any political reporter busy reading the tea leaves of polling. Are you listening, Rhode Island?

ConvergenceRI: How does it feel to be handed the hot potato?
SOUSA: [laughter] Well, how about if I start by telling you a little bit about myself and how I got here?

I have actually been in Medicaid for between 10 and 13 years, in various capacities. I am pretty familiar with it. I am humbled to be have been offered the opportunity to lead the program.

And, although there are challenges to face, I think we do try our best to serve the population, as best as we can.

ConvergenceRI: I still think that you have been handed a hot potato, if that’s OK to say.
SOUSA: Sure. I think that Medicaid is challenging across the country. It serves a vulnerable population. And, it always faces project challenges and tough decisions. The work – and the beneficiaries – will remain my focus.

ConvergenceRI: With that, let me jump right in and ask you: What is the current number of Rhode Islanders enrolled as members of Medicaid? The latest figure, which I got from Sen. Di Palma, is 352,000. Is that accurate? He said that number was as of February 2022.
SOUSA: I am just pulling up the numbers so that I can give you an accurate number. The number I had as of March 31, 2022, is 347,977.

ConvergenceRI: Thank you. It appears that the number is only down a little bit from February. Do you think that the number will shrink if and when the federal government declares that the national emergency from COVID is over, and the state begins to review eligibility? Do you have any “guesstimate” of how much that number may shrink by?
SOUSA: I do think the number will be reduced. And, we are working on those figures as we speak, diligently, to try to figure out how much. As you know, we have not done any re-certifications in over two years.

And, therefore, we would anticipate that individuals [will] fall off of Medicaid, for hopefully very good reasons, like employment and new opportunities for them.

There will be, in my estimation, some level of reduction. At this time, we are still working those numbers. It is difficult to know.

ConvergenceRI: In terms of those re-certifications, will that [process] be handled by HealthSouceRI? Are they the people who will be used to verify eligibility?
SOUSA: No. Eligibility is done through the R.I. Department of Human Services.

ConvergenceRI: And will they be using the Deloitte technology and software to do that?
SOUSA: Correct.

ConvergenceRI: Have there been any models [developed] in other states that are considering how to do this work? Are you in consultation with them about what the best way to do this is?
SOUSA: We are. We have a full team here at the Medicaid program. Our partners from DHS and EOHHS are involved. And, we have associations that help us in critical contacts with other states.

Mainly, we talk with our partners and friends in our neighboring states about their plans. There has been a lot of work done internally to try to prepare for the unwinding [emphasis added].

ConvergenceRI: Have you hired any consultants to assist you in that work?
SOUSA: No. We have not hired any consultants. Let me just say, obviously, Deloitte is managing and helps us work our eligibility system. So, there are vendors that we are currently contracted with that will be working on the project. But there have not been any additional technical assistance consultants hired for the project.

ConvergencRI: I know that you cannot talk about it in specifics, but is the re-procurement of the Managed Care Organizations proceeding on schedule? Is that an OK question to ask?
SOUSA: It is an active procurement [process], and that is as comfortable as I am in responding. So, it is going through its process.

ConvergenceRI: Any idea of when it might be completed?
SOUSA: The new contract will be effective July 1, 2023.

ConvergenceRI: Has there been any movement – is Tufts Health Plan still out? Any further developments?
SOUSA: Well, I would love to be able to talk to you about it, but that really has to do with the R.I. Department of Administration.

ConvergenceRI: Do you believe the Medicaid rates for reimbursements for mental health and behavioral health care services need to be increased? I recently heard that the rates in some cases have not been increased for 14 years. Is that accurate?
SOUSA: There have been various reviews, and I do believe there is a move to do rate reviews in particular around behavioral health to determine the accuracy of the rates and what level of increase is needed.

ConvergenceRI: When will that review be completed?
SOUSA: At this time, we manage to a budget. And so, the reviews are really part of our budget process. And so, for Fiscal Year 2024, the budget process really kicks off in July.

ConvergenceRI: Recently, a bill was passed in the Senate – S 2079A -- that supported the creation of a pilot program to test the effectiveness of using Medicaid waiver funds to treat chronic homelessness for those Rhode Islanders who are un-housed. Do you support that legislation?
SOUSA: I believe that we [have] a homelessness problem, not just in Rhode Island, but nationally. If there are opportunities within the Medicaid program, and authority that if we can reach out to federal partners to assist in that problem, that we should do so.

ConvergenceRI: Is that a qualified yes?
SOUSA: It is a qualified yes, because I have not read the legislation in totality. And, so long as there is in Medicaid an opportunity within Waiver authority to assist in homelessness, we should be active partners in that.

It is very important. One of my focuses is certainly to bring social determinants of health in any capacity that is appropriate to the Medicaid program [which] are not already there.

ConvergenceRI: I just read in a press release that work is underway on what I believe will be the fourth edition, of the survey that Blue Cross and Blue Shield of RI is doing in conjunction with the School of Public Health at Brown, looking at what they call the “Rhode Island Life Index.” Are you familiar with the R.I. Life Index, and what its findings have been?
SOUSA: I am not.

ConvergenceRI: They take an annual snapshot of where people in Rhode Island think they are in terms of some 50 categories. It might make for interesting reading, I am sure that I could probably send you a copy, if you are interested, of what they came up with last year. Siena College is doing the actual work on the survey.
SOUSA: Of course, I am interested in learning more.

ConvergenceRI: Yesterday, there was a group of pediatricians that declared that there was an emergency crisis in mental health and behavioral health services for children in Rhode Island. What do you think is the role and responsibility of the Medcaid office in Rhode Island to help alleviate this crisis?
SOUSA: There are various things that Medicaid can contribute to assist. I will start by saying that the public health emergency has certainly had a burden on both children and adults, in particular, in behavioral health.

And, so, in partnerships with sister agencies, BHDDH and DCYF, our community partners, the pediatricians themselves, and certainly our members, I think we have to pull together to try to build a system of care that begins to focus on the recovery from the public health emergency.

And, the area of focus should be on the things we know that are critical; obviously, children are paramount to all of us.

I think that with our partnerships, and with an understanding where we can build in efficiencies to make it easier for our providers and our beneficiaries, and where we can ask our federal partners for assistance, et cetera, in trying to curb the crisis news we are hearing across the state.

ConvergenceRI: Never let a good crisis go to waste, as they say.
SOUSA: [laughter[

ConvergenceRI: One of the questions that got raised, I have tried to cover the Senate commission looking at EOHHS, and the various meetings that they have had. They have not officially come up with any recommendations but one of the questions that got raised during the hearings was whether it was proper for both Neighborhood Health Plan of Rhode Island and UnitedHealthcare to be using Optum, which is a wholly-owned subsidiary of UnitedHealth, as the benefits manager for both of those MCOs. The question was repeatedly raised: Was that a conflict of interest?

Is that something that the R.I. Medicaid office should be involved with in determining whether there is such a conflict of interest?
SOUSA: What I would say is, my contract with both Neighborhood Health and United do allow for subcontracts.

There is language in those contracts that purposely [looks at] how they contract with their downstream vendors. I know that Neighborhood has to do a full procurement for their behavioral health vendor.

So, I would be of mind to say that in our oversight of our managed care organizations,we do look at whether or not they are following proper protocols in contracting with their vendors.

ConvergenceRI: I raise the question because OHIC recently fined UnitedHealthcare because of violations in parity for commercial health insurance. According to OHIC, the vendor at UnitedHealthcare was making this determination that were found to be in violation was Optum. I was wondering if that might mean that there were some increased scrutiny in terms of vendors and what they are doing in terms of parity, when it comes to MCOs.
SOUSA: Correct. So, we do, on a regular basis, review for parity. We continue to do that on an annual basis, and I am aware of Commissioner Tigue’s report and findings. And, we will be doing some additional discovery on parity with our MCOs as an outcome of that report.

ConvergenceRI: Big broad question. What do you see as your biggest challenges moving forward in the job as director of the Medicaid office?
SOUSA: I think immediately, moving into the endemic phase of the public health emergency [for COVID], we do have to do our re-certifications of the Medicaid population. And that will be a tremendous lift for our office, as well as for our partners, and so that is a very big focus. Trying to prevent [any disruption] to our beneficiaries’ continuity of care is paramount as we move forward.

We are moving into a year where we will have to renew our 1115 waiver, a very important piece to our Medicaid program. [Editor’s Note: The waiver to Section 1115 of the Social Security Act gives authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and Children’s Health Insurance Program, or CHIP, in order to give states additional flexibility to design and improve their Medicaid programs.]

It is another priority and focus of our program, so that we can ensure we have the authority to continue to provide care to our population.

Those two items are top of mind right now. And then, obviously, maintaining the continuity of the program, while trying to do two major lifts.

ConvergenceRI: You’ve said that you have been with Medicaiid for more than a decade. One of the key components of the Reinvention of Medicaid was the development of accountable entities. I have not been able to determine whether there is an accountable entity established for long-term services and supports for Medicaid. Is that accurate? Has there been such an accountable entity established?
SOUSA: There is currently not an accountable entity for that population.

ConvergenceRI: And how much of the Medicaid population do they represent?
SOUSA: So, the accountable entities program, part of its authority, is that it has to run through our Managed Care [Organization] program.

Currently, we only have a managed care program for that population for those who are dually eligible [for Medicaid and Medicare]. It is a CMS dual demonstration project, and there were approximately13,000 individuals enrolled in that.

ConvergenceRI: The recent health cost trends analysis conducted by Bailit Health for OHIC was that the spending on the dually eligible population, which is handled by Neighborhood Health Plan of RI, was very high. [See link below to ConvergenceRI story, “The bigger disconnect.”] I was wondering whether you are going to be looking at their spending trends moving forward.
SOUSA: The spending for that population tends to be the highest. They are long-term population. It is a demonstration, which indicates that it is new. I believe it is in its sixth year, I do believe that that trend is improving. And so, we do look at that on a regular basis. There are discussions ongoing about the demonstration project with CMS and its value, and if it will be continued.

ConvergenceRI: I ask at the end of every interview: What questions haven’t I asked, should I have asked, that you would like to talk about?
SOUSA: I think you did not ask me about equity. And race equity. And efforts that we are trying to push forward to bring equity to our programs.

I think that is another area that is extremely important to me and to the Medicaid program. And we have brought some efforts forward. Maybe the next time we speak, we can highlight some of that work for you.

ConvergencedRI: I would be glad to so.
SOUSA: I think it is a really important piece of work.

ConvergenceRI: Is there anything in particular that you have done around equity? Is there an effort to tabulate the equity according to data? Are you creating new data constructs to do that?
SOUSA: We are working on that. It is funny that you asked the question, because data is the first thing that came to mind to me. We are working internally to try to improve our data in that capacity. I think that is a challenging thing to do for many reasons. But it is critically important for us to understand our gaps. And so, we will continue to work with that as we go forward.

ConvergenceRI: Is there a report or anything that we can look forward to, that you can share at some appropriate point, as you develop the new data construct?
SOUSA: I think we are building toward that. And so, yes, as soon as something is available, that we feel would be valuable, we are open to sharing that.

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