Delivery of Care/Opinion

The human equation

Why RI’s future prosperity hinges on increasing Medicaid rates

Photo courtesy of Richard Asinof

Two giant pandas cavorting at the National Zoo in Washington D.C.

By Richard Asinof
Posted 10/2/23
The details of how the General Assembly and the state agencies respond to the recommendations made by OHIC to increase the rates for Medicaid providers by some $45 million and how they are included in next year’s state budget will shape the state’s future economic prosperity.
What are the pressure points to push the General Assembly to increase Medicaid rates for providers? What role will hospitals play in lobbying to increase the Medicaid rates for providers? Was Richard Rothstein correct in his analysis in his book, The Color of Law, “We have created a caste system in this country, with African Americans kept exploited and geographically separate by racially explicit government policies.” Is House Speaker Joseph Shekarchi considering challenging Gov. Dan McKee in the 2026 election for Governor?
The level of misinformation flooding our information channels keeps growing, making it difficult to stay engaged on social media. The same is true for the TV broadcast news in Rhode Island. The recent interview conducted by WPRI with John Fernandez, the president and CEO at Lifespan, seemed to ignore or miss some of the biggest questions facing the state’s largest health care system. Why were there no questions about the reasons why Dr. Alan Kurose, the founder of Coastal Medical and an executive vice president at Lifespan, left his position at the end of July? And why were there no questions about the ongoing struggle at Coastal Medical to convert the operation to Epic software, leading to angry outbursts on Facebook about the transition? Further, why were there no questions about how the crisis in primary care is driving up the volume in Lifespan’s emergency departments?
Also missing was any questions about the connection between research around endocrine disruptors, plastics production, and the incidence of cancer in the region, even as Lifespan attempts to position itself as a new center of cancer research and treatment. There was a story about microplastics in Narragansett Bay, but what about the potential connection to endocrine disruption and cancer?

PROVIDENCE – The giant pandas are leaving the U.S. To celebrate 51 years of alleged détente between China and the U.S., which led to the arrival of Ling-Ling, a female, and Hsing-Hsing, a male, in 1972. In response to the departure of giant pandas, the National Zoo is staging a “Pandapalooza.”

For sure, using a 1975 photograph taken by an official zoo photographer of those two giant pandas in captivity at the National Zoo in Washington, D.C., caught in a centerfold pose worthy of Vogue, is click bait. It is tempting you to read a story about the efforts to increase Medicaid rates in Rhode Island. Consider it much like the throwaway from the late comedian Robin Williams: “Made you look!”

It should have been enough to say that Rhode Island’s future prosperity depends on the state’s ability to increase the Medicaid reimbursement rates paid to health care providers. But no… to quote the late comedian John Belushi.

Outside of ConvergenceRI, there has been a paucity of news coverage about the recent Office of Health Insurance Commissioner’s report, issued on Friday, Sept. 1, calling for an increase of $45 million in reimbursement rates in the next fiscal year. Why is that?

Some very good reporters have danced around the issue: Kathy Gregg at The Providence Journal detailed how the Department of Human Services has failed to spend the money budgeted for the operations of its agency – and detailed the long wait time for consumers trying to access services on the phone.

“Unacceptable.” That was the response [on Thursday, Sept. 21] from Senate Finance Committee Chairman Louis DiPalma to the explanations so far for why millions of budgeted dollars went unspent – and 100 jobs remain empty – while the average call wait time for people trying to get help from the state agency that handles cash assistance, child-care subsidies and Medicaid is close to an hour.

Gregg’s story continued, quoting Sen. DiPalma: “I say this respectfully: it’s not anything new. It should have been addressed much before now ... We still have people on hold 45 minutes, 50 minutes, an hour ... That’s unacceptable. It just is,” said DiPalma, following the release of an end-of-year report reflecting more than $1 billion in budgeted, but unspent, dollars overall, including $16.9 million at the state’s Department of Human Services.

The failure of the McKee administration to hire DHS workers, leaving nearly $17 million unspent on positions that had been already approved left some DHS employees “disgusted,” according to Gregg’s terrific reporting.

As Gregg reported: Added Stacy Smith, who is both a DHS employee and head of the Council 94, AFSCME local that represents “eligibility technicians” at the agency: “I am flabbergasted, honestly, to know that there is $16.9 million on the table for positions that we have already had approved ... and they're sitting on this amount of money to get staff in the door and we don’t have them. And every day I have members coming to me stressed. They’re ready to quit their job. They’re going on a leave of absence because they're so mentally drained and physically drained.”

“It’s disgusting,” she said. “I’m disgusted.”

The perilous consequences of low Medicaid rates
Steph Machado at The Boston Globe wrote a detailed piece about the failure by the state of Rhode Island to invest in funding Early Intervention – and the perilous consequences.

In her piece, Machado interviewed John Kelly, president and CEO of Meeting Street School, about the inadequacies of Medicaid funding. Machado quoted Kelly:“So the federal government and the state have said (early intervention) is a mandated entitlement, we’re just not going to pay for it all,” Kelly said. “I think it’s outrageous. ... If you think it’s that important, pay for it.” Meeting Street solicits private donations to supplement the money it gets from the government and health insurers.

The response, however, from other members of the press corps has been disappointing and myopic, in ConvergenceRI’s opinion. The Boston Globe’s Dan McGowan and WPRI’s Ted Nesi complained about the failure to provide a spokesperson from EOHHS, to appear on air, for the Machado report, which was done in collaboration with RI PBS.

To borrow a phrase from WPRO’s hard-working reporter, Steve Klamkin, “Really?”

As if the decisions about media TV availability are being made at the agency level – and not by the McKee administration. Please do not forget that the McKee administration brought in Chris Raia from Duffy and Shanley to manage the media relations of former Housing Secretary Josh Saal before they fired him. The provisions of that contract – and how much Duffy and Shanley had been paid – have yet to be revealed.

If they can get you to keep asking the wrong questions…
One might think that there was some kind of conspiracy of silence, to not talk about the high stakes that are involved in the efforts to raise Medicaid rates.

ConvergenceRI has reported at length in detail in the last two editions about the OHIC report.[See links below to ConvergenceRI stories, “New OHIC report recommends $45 million increase in Medicaid provider rates,” and “Gaining traction.”]

The numbers are clear: Even with the current winnowing taking place of the Medicaid rolls after a three-year pause in eligibility reviews precipitated by the federal emergency rules adopted during the COVID-19 pandemic, some 330,000 Rhode Islanders will end up being dependent on Medicaid for their health care in 2024. That is roughly one-third of the state’s entire population.

Further, given the aging population in Rhode Island, with its high percentage of old-old residents [people who are 85 or older], the reality is that the future residents of nursing homes in Rhode Island will largely be funded by Medicaid, once any other sources of income have been exhausted.

Translated, health care, as some would argue, is a human right. But it is also the admission ticket to survival in our disrupted economic world, where urgent climate threats are now the rule, not the exception, and a extreme group of right-wing Republicans can threaten to shut down the government.

On the road to find out
Ever diligent, ConvergenceRI trudged to the Department of Administration building on Friday morning, Sept. 22, where a public hearing was held about the report. The first floor of the building had recently been buffed, making the tile extra slippery and dangerous for ConvergenceRI, forcing him to use his trekking poles to tap out a safe pathway so as not to slip and fall.

No other reporters appeared to be in attendance in the hearing room, but there were plenty of the usual suspects – dedicated legislators and agency executives bearing witness to the need to increase the low Medicaid reimbursement rates. There were Rep. Teresa Tanzi, Sen. Josh Miller, and Rep. Tina Spears, among others, including John Tassoni Jr.. president and CEO of the Substance Use and Mental Health Leadership Council of Rhode Island, and Jamie Lehane, president and CEO of Newport Mental Health.

For those Rhode Islanders having problems with their circadian rhythms after three days of rain and the change of seasons, you can go to the OHIC website and view the presentation, which may help restore your sleeping balance. [See link below to the recording of the Sept. 22 OHIC hearing.]

The question is: What comes next? Will Gov. Dan McKee follow OHIC’s recommendation to increase Medicaid reimbursements by $45 million in his proposed budget for next year? It seems unlikely, given his often petulant behaviors around the funding of homelessness programs in the state. It is more likely that legislators will need to include the proposed increases in their own budget deliberations.

More in-depth coverage
In reporting on the OHIC report, ConvergenceRI sought to interview a number of stakeholders – including Acting OHIC Commissioner Cory King, Senate President Dominick Ruggerio, and House Speaker Joseph Shekarchi, as well as seeking responses from Blue Cross and Blue Shield of Rhode Island.

Here is a continuation of those interviews, first with Sen. Louis DiPalma, the chair of the Senate Finance Committee, followed by a response from the R.I. Executive Office of Health and Human Services, providing important context about the findings of the OHIC report and the next steps that will be taken to implement the recommendation that the Medicaid rates for providers be increased by $45 million.

The phone interview with Sen. DiPalma took place on Friday evening, Sept. 8. He spoke at length with ConvergenceRI, in his rapid-fire style of speaking, with many thoughts jammed together, often as sentence fragments, in a sing-song voice.

ConvergenceRI: The Senate President suggested that I talk with you about the OHIC report.
Sen. DiPALMA: Which I am excited about. Extremely excited about.

ConvergenceRI: Can you tell me why you are excited about the OHIC report?
Sen. DiPALMA: This emanated from [work done by] a large group of folks, a large group of advocates from all walks of health and human services, that were behind figuring out how to review health and human service rates.

It had never been done. Ever. We’d done sort of a – I’ll call it a reverse whack-a-mole kind of thing, based on looking at the situation we’re in.

Let me give you a personal example, not of me, but really what was the spearhead for this. I spoke about this, when the [legislation was first] brought before [the Senate], we had two bills. The core of them [can be found] in Article 12, Section 7 and Section 8, of the FY 2023 budget. Those are the two sections referenced in the OHIC report.

And so, this woman’s name is Mary. Mary called me from Newport. And Mary said, “Senator, do you have a couple of minutes. I need to tell you my story.” I said: Yes. She said, “I’m calling you because I am on Medicaid, currently living in Section 8 housing; I had to sell my car, I had a degree in Economics… I am authorized for services. They can’t find anybody because they can’t pay people enough.”

So, that situation is multiplied; you can say the same thing in the area of Early Intervention; you can say the same thing in the area of DD [Developmental Disabilities], I think we have addressed that now, really because of the courts, not because of [what] the state [did].

If you look at the area of behavioral health, we haven’t done it there [raised the rates]. So there are many, many many, many areas where we haven’t done it, and that is impacting the lives of folks, tens of hundreds of thousands of Rhode Islanders on Medicaid who are expecting to get all kinds of services, and they are not.

Because when you can’t find the people [to do the work], and you can’t find the people because we haven’t paid them enough, all the chickens have come home to roost.

I’m ecstatic we gave OHIC the work to do this. And, the first tranche of the work is looking at a few areas; the work is not done. Because the language in the bills that we had on the Senate side, every single Senator, all 38 of us, signed onto the bill.

It didn’t make a difference if you were Republican, Democrat, farthest left you can be, or farthest right you can be, all 38 of us signed onto both bills. In fact I have a copy at the State House of those signatures for both bills, because I said, “This is important to all of our constituents that we get this done.”

Other states do it. We will now do it, because the bill also indicates we have to do this rate review every two years moving forward.

ConvergenceRI: Do you think there is enough traction at the State House to get the $45 million that is recommended in rate increases for Medicaid providers done this year?
Sen. DiPALMA: I am hopeful. It is now my job and other legislators’ jobs to get it over the goal line. That is what we got elected to do.

But we couldn’t do this, Richard, until we had the facts. As an engineer, without facts, and without data, we can say, “Well, I don’t think we really are paying these people enough.” Where’s the evidence to say that? We now have it. The comparative analysis is done.

As an engineer, I am focused on when you want to get something done, you need three things: “What needs to be done”; “who needs to do it”; and, the most important thing is, “By when.”

So, in the language in the budget, and in the bills, we specified. We were very specific about saying we need this by this, this by this, this by this, this by this, and this by this. And, we want something by Sept. 1, very directly, so that it can inform EOHHS and the Medicaid office, and other offices, to submit to the Governor a budget that reflects the recommendations of the work that we did.

Commissioner King and his team did a phenomenal job. And we need to ensure that he [King] becomes our OHIC Commissioner.

ConvergenceRI: The focus in the OHIC report was on fee for service rates…
Sen. DiPALMA: Correct.

ConvergenceRI: Left out of the equation is what is happening with the Medicaid MCOs [Managed Care Organizations]. In my opinion, there has not been a good, comprehensive audit of the way that the MCOs are spending money. Does the Legislature need to mandate such an audit?
Sen. DiPALMA: I’m not certain. I would say to folks: We need to articulate why something needs to get done. An audit could be the way, that is. I am not certain that necessarily the way it gets done, the way and the means to understand it.

We clearly do need more transparency. Categorically and absolutely, we need more transparency with regards to how the billions of dollars we are spending via the MCOs are being spent.

I suspect we are going to see from EOHHS/Medicaid their recommendations about what has to happen. You are spot on. [The OHIC report] is only one-half of the equation; the other half of the equation is managed care.

ConvergenceRI: Do you have any idea if the Governor is on board with any of this?
Sen. DiPALMA: No. I think it is the case where his agencies need to inform him on that. The Governor is involved with lots of things. I’d like to think he knows about this, given the magnitude of the number of people that it impacts in the state. We’re talking about the state’s most vulnerable people – children, adults, seniors, folks with behavioral conditions that need to be addressed.

They are expecting all of us to get it right for them. Because we don’t see them at the State House. The woman [who called me], Mary, she had no way to get around anymore. She called me, so I needed to become her mouthpiece.

I don’t know what is happening with the Governor. I am cautiously optimistic that the Governor …first it needs to come from the agencies. I am cautiously optimistic that EOHHS Secretary Charest and Medicaid Director Sousa will have read this [OHIC] report, digested it, and figured out how to put forth the budget that has this included in it.

The view from EOHHS
In response to a series of questions that ConvergenceRI sent to EOHHS, Kerri White, the agency’s director of communications, sent the following response to the OHIC report.

“OHIC has released a comprehensive review and set of recommendations for the programs and services under the current scope of their work,” White wrote. “The product of the review is a critical tool for Medicaid and policymakers as the state fiscal year 2025 budget process begins.”

White continued: “EOHHS communicated regularly with OHIC throughout the process and is completing a detailed review of the impact of the recommendations on the Medicaid budget. This includes looking at broader impact beyond fee-for-service only, to Managed Care Organization (MCO) rates, to the extent that MCO reimbursement rates are functionally related to the Medicaid Program fee schedule.”

In addition, White said that the agency would address the recommendation to increase the rates for Medicaid providers by some $45 million as part its budget recommendations. She wrote: “EOHHS is assessing the impact of the recommendations on the overall Medicaid budget, including on Managed Care rates, particularly in a constrained budget environment. Our Medicaid program budget submission will address the recommendations outlined in the report, and as required by law, describe any variation between our budget recommendations and the OHIC recommendations.”

White concluded her response by quoting Commissioner Cory King’s cover letter to the report, identifying the need to integrate the OHIC recommendations into broader health policy context, in a “financially sustainable manner.”

“In his cover letter, Commissioner King wrote, ‘The recommendations were developed and are offered in isolation of fiscal considerations, public health priorities that may inform the allocation of resources, or program specific considerations that link reimbursement to measurable outcomes.’

White continued: EOHHS’s budget submission will seek to integrate the OHIC recommendations, and the feedback our staff heard at the public hearing on 9/22, into broader health policy goals to improve the health of Rhode Islanders in a financially sustainable manner.

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