Delivery of Care

To have and have not

After 15 years, RI EOHHS is undergoing a legislative stress test, as a Senate commission seeks to ask and answer: How has agency consolidation worked?

Photo by Richard Asinof

Just before the start of the inaugural meeting on Wednesday, Oct. 27 of the Senate Legislative Commission to review and make recommendations regarding the efficient and effective administration of health and human services programs in the state of Rhode Island. From left: Michael DiBiase [seated], Marie Ganim, standing next to Sen. Lou Di Palma, Sen. Josh Miller [seated], Tina Spears, standing, talking to Elena Nicolella, seated.

Image courtesy of OMB press document from the agency website

The image from the budget proposal for FY 2022 by the McKee administration.

By Richard Asinof
Posted 11/1/21
A new Senate Commission is conducting an examination of R.I. Executive Office of Health and Human Services, exploring whether or not the umbrella agency has lived up to its promise of providing effective financial guidance in the delivery of services by government agencies tasked with keeping the safety net intact for vulnerable Rhode Islanders.
What is the earliest that the $1.1 billion unspent funds from the American Rescue Plan Act will be spent if the R.I. General Assembly does not convene until January of 2022? What were the outcomes of the $20 million State Innovation Model efforts funded by CMS? Will the attack by radio talk show host Dan Yorke on Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, with its racial overtones, prove detrimental to Gov. Dan McKee’s election prospects? How will the issues of childcare and paid parental leave galvanize voters in the 2022 elections?
During a conversation with a mainstream digital news competitor, the issue was raised whether or not ConvergenceRI should be considered as an advocacy platform, rather than a journalistic one. My response: I am an advocate for telling the truth, and calling out people when they lie and do not tell the truth.
When asked to explain, I pointed out the problems of the “he says this, she says that” model when it comes to things like Presidential lying. Did President Nixon lie about Watergate? Yes. Did President Johnson lie about Vietnam? Yes. Did President Bush lie about weapons of mass destruction? Yes.
The mainstream competitor laughed and admitted, with the former President, he lied all the time.
With climate change, the fossil fuel industry has not been telling the truth. With addictive painkillers, the pharmaceutical industry has not been telling the truth. No shockers there. The question moving forward is this: What value will readers place on having accurate sources of news that do not reprint news releases or shill for corporate or governmental entities?

PROVIDENCE – This is perhaps the most important story about the future of Rhode Island government that you will never read about – except here in ConvergenceRI, because there were no other news outlets covering it. Why was that?

At stake is merely the future of how health and human services in Rhode Island are being delivered – or not being delivered – for more than a third of the state’s residents, under the umbrella agency known as the R.I. Executive Office of Health and Human Services.

R.I. EOHHS was created in 2006 by the R.I. General Assembly but until now, 15 years later, the agency has never “gone under the knife” of any legislative analysis, examining whether or not it has ever lived up to its intended purpose.

That intent, as described in the Senate resolution that created the Commission, is a mouthful: “To be a consumer-centered system of publicly-financed, state-administered, health and human services that supports access to high-quality services, protects the safety of the state’s most vulnerable citizens, and ensures the efficient use of all available resources by the four departments responsible for the health and human services programs serving all of Rhode Islanders and providing direct assistance and support services for individuals and families.”

Translated, R.I. EOHHS is the parent agency for a group of fraying, safety net agencies for Rhode Islanders, responsible for spending nearly half the state’s budget in the FY 2021 budget, some $5.15 billion.

Those often overworked, sometimes dysfunctional agencies include: the R.I. Department of Children, Youth and Families [DCYF, $256 million, FY 2021 budget], the R.I Department of Health [HEALTH, $642 million, FY 2021 budget], the R.I. Department of Human Services [DHS $711 million, FY2021 budget], the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals [BHDDH $503 million, FY 2021 budget].

The R.I EOHHS FY 2021 budget for itself was $3.03 billion, which included $2.87 billion for Medicaid and other medical assistance, and $134 million for contracts for professional services.

The funds being spent are derived from state revenue and an increasing flow of federal sources.

Whether it is about following the money, or about following the trail of human pain and suffering – or understanding how entrenched state bureaucracies become so entrenched, the work of the Commission, to paraphrase President Joe Biden, is a big f***ing deal.

As competing groups – everyone from the Rhode Island Foundation to Gov. Dan McKee, from the R.I. AFL-CIO to Homes RI – lobby, spar, and debate how to spend some $1.1 billion in unspent federal funds from the American Rescue Plan Act, the work of the Senate Commission is occurring at a time of urgency. The work of the Commission will serve as a litmus test on how much the R.I. General Assembly is willing to tweak its current model of managing the flow of federal and state dollars into the delivery of services to vulnerable residents – or to maintain the status quo.

Will it recommend the break-up of R.I. EOHHS? Will it seek to limit the growing role of private contractors and business consultants in the delivery of services? In an election year, will the work of the Commission find champions in candidates who seek to upset the political status quo? Stay tuned.

The first commission meeting
The first meeting of “The Special Legislative Commission To Review and Make Recommendations Regarding the Efficient and Effective Administration of Health and Human Services Programs in the State of Rhode Island” was convened on Wednesday afternoon, Oct. 27, in the Senate Lounge at the State House.

The Commission currently has 10 members – three senators, Sen. Lou DiPalma, Sen. Josh Miller, and Sen. Jessica de la Cruz – and seven others: Tina Spears, executive director of the Community Provider Network of Rhode Island, Elena Nicolella, executive director of the New England States Consortium Systems Organization; Susan Storti, Ph.D., president and CEO of Substance Use and Mental Health Leadership Council of RI; Michael DiBiase, president and CEO of the Rhode Island Public Expenditure Council [and before that, director the R.I. Department of Administration; Matthew Gunnip, president of SEIU 580 [who is also a caseworker for DCYF]. Marie Ganim, Ph.D., former R.I. Health Insurance Commissioner [and before that, R.I. Senate Policy Director]; and Tania Kubas-Meyer, executive director of the Rhode Island Coalition for Children and Families.

An apparent 11th member of the Commission is Jennifer Wood, who told ConvergenceRI she was serving as an unpaid, volunteer advisor to Sen. Josh Miller. Wood is currently the executive director of the nonprofit Rhode Island Center for Justice [and who before served as chief of staff for former Lt. Gov. Elizabeth Roberts and then as the top lawyer for the R.I. EOHHS when Roberts served as Secretary].

If you add up the total combined number of years of public service by the members of the Commission, it comes to roughly 200 years, by ConvergenceRI’s count. And, in Sen. DiPalma and Sen. Miller, the Senate Commission’s leadership has two of the more diligent and effective elected officials when it comes to parsing complex state health policy.

Translated, the members of the Commission have oodles and oodles of expertise and experience. The only folks missing from the table at the beginning of the legislative journey are the individuals and families who have an intimate knowledge of what happens when bureaucratic systems break down and the dream of an integrated care delivery system becomes a nightmare, despite all the good intentions.

Opening remarks
Sen. Josh Miller opened the inaugural Commission meeting by suggesting that the focus of the commission should not be on the effectiveness of a particular director, but rather on the overall effectiveness of the agency.

To set the stage for the Commission’s work, Sen. Miller began with two presentations: the first, a written document by Jane Hayward, the president and CEO of the Rhode Island Health Center Association, “History of Health and Human Service Organization in the Rhode Island State Government. [Hayward has announced her pending retirement.]

In her succinct historical presentation, Hayward labeled the intent of the creation of R.I. EOHHS as establishing a “business approach to government,” promoting “fiscal fitness.” It had been created by an executive order by former Gov. Donald Carcieri on Dec. 1, 2005, and then codified as a statute in 2006 by the R.I General Assembly.

The Rhode Island umbrella structure, however, exists as something of a hybrid model, containing some deliberate authority “loopholes” in its design. While it centralized a single state agency to have authority for Medicaid, it also provided for limited statutory authority over departments, such as the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals. That apparent lack of oversight has been revealed as problematic during the continuing scandal that has enveloped the Eleanor Slater Hospital around the delivery of care to patients.

Further, the directors of departments were appointed by the Governor with advice and consent of the R.I. Senate, which has meant that the effectiveness of R.I. EOHHS was dependent on the engagement and commitment of the Governor to support the structure, according to Hayward’s analysis.

The other major limitation to the model, according to Hayward, was that it was “vulnerable to resistance to change and the efforts and energy employed to retain the status quo.”

The second presentation by Emily Blanford, who is the program principal at the National Conference of State Legislatures, was presented remotely. Blanford outlined the differences between the “umbrella” and “standalone” agencies around the U.S.

Then, each of the Commission members had an opportunity to weigh in with their own observations.

What was said
Both Sens. Miller and DiPalma, along with Dr. Storti, noted that it was no longer 2006 anymore, and the world around the delivery of behavioral health care, in particular, had been forever transformed by the ongoing opioid epidemic that has ravaged the state.

Storti and Nicolella spoke about the need to hear from the clients’ perspective; Sen. Miller said that he would include an extra session of the Commission in order to do so.

Sen. DiPalma raised the issue of accountability related to the recurring problem of “interim” directors at the numerous agencies under the umbrella of R.I. EOHHS.

The future proposed meeting topics for the Commission include:

• The role of RI EOHHS and centralized services, focused on data, accountability, and other centralized service.

• Medicaid.

• Behavioral health, children and adults.

• Hospitals.

• Reflections discussion.

• Wrap-up and recommendations.

It isn’t necessarily so
The nuance and context for the Commission’s deliberation is that it is occurring during an ongoing public health crisis caused by the continued contagion of the COVID pandemic, where all of health care delivery and essential human services have been disrupted. All of the social, racial and health disparities in Rhode Island have become magnified during the pandemic, which, as the current R.I. EOHHS Secretary, Womazetta Jones, requires Rhode Island to have some uncomfortable conversations about racial equity. [See links below to ConvergenceRI stories, "A change is going to come," "Listening to our authentic voices," and "It is time for some uncomfortable conversations."]

The dire lack of staffing, particularly of nurses and CNAs, at nursing homes and hospitals in Rhode Island, has escalated into a crisis situation. To some degree, it has been exacerbated by the mandate of state-licensed health facilities to have all employees vaccinated. In response, almost all the health care facilities in Rhode Island, including nursing homes, have complied. The major outlier, it turns out, as documented by reporter Katherine Gregg at The Providence Journal, is the state-run Eleanor Slater Hospital system, run by R.I. BHDDH. A private firm employed by the state to recruit out-of-state nurses has apparently been unable to find vaccinated nursing staff to replace unvaccinated workers at Eleanor Slater. Under the current agency structure, neither the R.I. Department of Health nor R.I. EOHHS can “mandate” a solution. The question is: Will Gov. McKee decide to hold R.I. BHDDH Director Richard Charest accountable for the unvaccinated workforce shortfalls?

The two major hospital systems, Care New England and Lifespan, have proposed merging with Brown University into a consolidated academic medical enterprise, one that will control roughly 80 percent of the market, despite continued questions about the sustainability of the current business model for hospitals. The Rhode Island Foundation is preparing to share its report on community input about the merger to the R.I. Business Group on Health meeting on Nov. 19, even though the application for the proposed merger has not yet been deemed “complete” by the R.I. Attorney General’s office. Is that putting the cart in front of the horse?

With the approval of Gov. Dan McKee, R.I. EOHHS is sending out a new procurement to entice competition in the private managed care organization market, which currently has three private MCOs – Neighborhood Health Plan of RI, Tufts Health Plan, and UnitedHealthcare – providing services to Medicaid members in Rhode Island. At the same time, the plans to establish accountable entities under the Reinvention of Medicaid as the backbone of alternative payment methods are now entering the fifth year, faced with the fiscal reality no future funding source has yet been identified to achieve the “reinvention” of Medicaid.

More than vendors
The work of the Commission in examining whether R.I. EOHHS, in its 15-year history, has proven to be effective in achieving its mission, will need to wrestle with some larger philosophical questions in its deliberations. What should be the proper role of private consulting firms and contractors as the experts in deciding state policy? How will the increased role of private philanthropy supplant state government as the way that services are funded? And, what are the ways that data analytics and algorithms should be regulated when used to make decisions around what health care services to provide?

An equally important question: How will the relationship between community agencies and nonprofits providing services for R.I. EOHHS be redefined?

“For too long, the state has viewed nonprofits simply as vendors or as altruistic volunteers,” as a recent op-ed in The Boston Globe, written by four nonprofit executives, defined the problem.

Written by Mario Bueno, executive director of Progreso Latino. Anthony Hubbard, CEO of YouthBuild Preparatory Academy, Cortney Nicolato, president and CEO, United Way of Rhode Island, and Daniel Schliefer, executive director of New Urban Arts, the op-ed claimed that the state “has not fully recognized the sector’s vital, central role in providing emergency relief, social services, community building, and economic development.”

“Even though 17 percent of Rhode Island’s workforce is employed by nonprofit organizations, the state has not invested in nonprofit staff properly, especially since these are highly trained professionals who have been a cornerstone of the state’s work.”

The op-ed continued: “Nonprofit staff are exhausted and burnt out. They’re also increasingly leaving the sector for good, which should be an alarm for all of us who call the Ocean State home. They have shouldered much of the burden of the state’s relief efforts with persistence and empathy, but the need and stress are unrelenting.”

The complaint about being viewed as “vendors” and not “partners” mirrored the complaint by members of the recovery community at the Sept. 8 meeting of the Governor’s Task Force, when they demanded that more than $2 million in cuts by R.I. BHDDH in recovery programs be rescinded, before they staged a walkout. The recovery community won, and the cuts were restored.

In addressing the future structure of R.I. EOHHS, the Commission members would do well to consider what the relationship is between the state agency and the nonprofit providers who are doing the work, providing services to clients.

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