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By Richard Asinof, ConvergenceRI, health contributor
Photo: Womazetta Jones, Secretary of RI EOHHS, and Neil Steinberg, president/CEO of the Rhode Island Foundation in August of 2019.
An immediate challenge: the need to have an “uncomfortable conversation” about how racism may be embedded in the analytics software algorithms used by Optum, according to findings in new investigative report by STAT
On Monday, Oct. 19, the Rhode Island Foundation announced that it is launching a major new program focused on racial equity in Rhode Island, investing an initial $8.5 million over three years to create the Equity Leadership Initiative and to make additional investments.The new effort will be led by Angela Bannerman Ankoma, who will serve as a vice president at the Rhode Island Foundation and executive director of the Initiative, with a focus on investments in diversity, racial equity and inclusion.[The work of Ankoma has been featured in numerous stories by ConvergenceRI; see links below to: “Recognizing the good work of public health heroes in RI”; “An impromptu tour of the West End, the cultural mecca of Providence”; “Beautiful beginnings, happy endings”; “Success at Sankofa”; and “Sankofa builds health community oasis in diverse West End.”]“To achieve a better future for all Rhode Islanders, we must provide opportunities to eliminate disparities and close achievement gaps,” said Neil Steinberg, president and CEO of the Rhode Island Foundation, in a news release accompanying the launch.In explaining the rationale behind the focused new investment, Steinberg said: “Addressing the underlying causes of inequity and working to eliminate disparities is one of our core organizational values, and has been an important part of our work for years. It’s a lens that we use to make decisions about how we allocate discretionary funding and civic leadership resources. Now is the time to commit to listening more, and doing more, and to hold ourselves accountable to this focus.”The lens of racial and health equity has emerged as a critical component in a number of statewide initiatives, including health equity zones and the development of long-term state strategies for health and education.Indeed, when Womazetta Jones was introduced as the new Secretary of the R.I. Executive Office of Health and Human Services on Aug. 22, 2019, at a reception at the Rhode Island Foundation, she said: “We have to get comfortable with having uncomfortable conversations about racial equity.”
[See link below to ConvergenceRI story, “It is time to have some uncomfortable conversations.”]The killings of George Floyd in Minneapolis and Breonna Taylor in Louisville at the hands of police resulted in widespread national protests under the rallying banner of “Black Lives Matter” – as well as a heightened awareness of racial equity issues across numerous segments of Rhode Island’s government and economic sectors, including health care. [See link below to ConvergenceRI story, “Black moms matter.”][It has also crystallized the forces of reaction against the concept of Black Lives Matter, magnified by the opposition from President Donald Trump.]Most recently, a “race equity lens” was declared as a central, core value in the state’s Health IT Strategic Roadmap.In the executive summary of the Rhode Island Health IT Strategic Roadmap, published on July 24, 2020, it said: “Three overarching core values surfaced and are imbued throughout the Roadmap and Implementation Plan.” These include: Health information technology is an enabler of broader health transformation effort; a race equity lens must be applied to efforts in order to reduce health disparities [emphasis added]; and patients are key and must be considered with all initiatives.” [See link below to ConvergenceRI story, “Some stakeholders remained in the dark about final IT strategic plan.”]A very uncomfortable conversationOne of the very first challenges that the new Equity Leadership Initiative at the Rhode Island Foundation may need to engage in, confront, and respond to are findings from the recent investigative reporting by STAT about how racism may be embedded in the algorithms of software analytics used by Optum and others.Call it an “uncomfortable conversation about racial equity” in the management of health care by algorithm.In the investigative story by STAT, published on Oct. 13 by reporter Casey Ross, entitled, “From a small town in North Carolina to big-city hospitals, how software infuses racism into U.S. health care,” the reporting details how a recent study of software built by Optum offered a rare look under the hood of how algorithms used to assess patients’ needs churn in the back offices of health systems nationwide, out of view of patients who are not privy to their predictions and how they are being applied. [See link below to STAT story, “How software infuses racism into U.S. health care.”]The findings appear to have significant relevance and resonance here in Rhode Island to the way that health care services are delivered, because Optum, a corporate division of UnitedHealthcare, has an apparent contractual “lock” on managing more than 95 percent of Medicaid managed care population in Rhode Island.A private contractor, Optum is currently employed by both Neighborhood Health Plan of Rhode Island and UnitedHealthcare of New England, the two principal care management organizations, or CMOs, for Medicaid members, according to the director of a large community agency providing behavioral health and mental health services in the state.[Tufts Health Plan manages its own members, but its share of the Medicaid managed care market in Rhode Island is miniscule, according to the agency director.]How big an issue is this? As of June 2020, Rhode Island had enrolled approximately 305,208 individuals in Medicaid and CHIP, who were eligible for the health insurance program because of having met low-income eligibility guidelines and metrics, according to R.I. EOHHS data reports.Translated, nearly one-third of the entire population of Rhode Island, capturing many of the state’s most vulnerable residents as well as a large number of children and families of color, may have been subjected to a different kind of racial equity lens because of how IT algorithms deployed by Optum were being applied by health insurers to manage costs.Here are some excerpts from the STAT story:• “A STAT investigation found that a common method of using analytics software to target medical services to patients who need them most is infusing racial bias into decision-making about who should receive stepped-up care. While a study published last year [had] documented bias in the use of an algorithm in one health system, STAT found the problems arise from multiple algorithms used in hospitals across the country. The bias is not intentional, but it reinforces deeply rooted inequities in the American health care system, effectively walling off low-income Black and Hispanic patients from services that less sick white patients routinely receive.”• “These algorithms are running in the background of most Americans’ interaction with the health care system. They sift data on patients’ medical problems, prior health costs, medication use, lab results, and other information to predict how much their care will cost in the future and inform decisions such as whether they should get extra doctor visits or other support to manage their illnesses at home. The trouble is, these data reflect long-standing racial disparities in access to care, insurance coverage, and use of services, leading the algorithms to systematically overlook the needs of people of color in ways that insurers and providers may fail to recognize.”• “Nobody says, ‘Hey, understand that Blacks have historically used health care in different patterns, in different ways than whites, and therefore are much less likely to be identified by our algorithm,” said Christine Vogeli, director of population health evaluation and research at Mass General Brigham Healthcare in Massachusetts, and co-author of the study that found racial bias in the use of an algorithm developed by health services giant Optum.”• “There are at least a half dozen other commonly used analytic products that predict costs in a similar way as Optum’s does. The bias results from the use of this entire generation of cost-prediction software to guide decisions about which patients with chronic illnesses should get extra help to keep them out of the hospital. Data on medical spending is used as a proxy for health need – ignoring the fact that people of color who have heart failure or diabetes tend to get fewer checkups and tests to manage their conditions, causing their costs to be a poor indicator of their health status.”• “Optum executives also said they do not plan to make any changes to the product, because they believe the 1,700 measures embedded in it provide enough information to eliminate bias that arises from isolated use of the cost-prediction algorithm.”• “The study was conducted based on the use of Impact Pro by Mass General Brigham, a health system affiliated with Harvard University. The health system was using the tool to help identify patients who would benefit from referral to programs designed to avert costly medical episodes by delivering more proactive care.”• “Optum advertises the product’s use for that purpose. A prospectus posted on its website says the software can ‘flag individuals for intervention using Impact Pro’s predictive modeling technology … and identify individuals with upcoming evidence-based medicine gaps in care for proactive engagement.’”• “In the years following passage of the Affordable Care Act in 2010, their pitches found a newly receptive audience. The law prevented insurers from using data on costs to deny coverage to people with pre-existing conditions. But it created incentives for health providers to identify and intervene in the care of high-cost patients, through new arrangements that shared financial responsibility for runaway medical expenses between insurers and hospitals.”• “By 2019, these algorithms were being used in the care of more than 200 million Americans — essentially applying an actuarial concept of risk to decisions about who might benefit from additional doctor visits or outreach to help manage their blood pressure or depression.”How do you argue with, or talk back to, an algorithm?“Systemic racism is a root cause of the challenges and barriers experienced by people and communities of color,” Larry Warner told members of the Cranston City Council when the council recently enacted a resolution declaring that “racism is a public health crisis.
“Algorithms are incredibly flawed, no matter what,” said Neil Sarkar, president and CEO of the Rhode Island Quality Institute. “There is always a bias. I think that especially true when you are looking at things through the lens of race or ethnicity.”
Sarkar said that he expected that some of the algorithmic disparities would be even more acute in Rhode Island’s population, “because we have diversity, but our diversity is actually very concentrated and very focused in particular parts of our state, and we need to be cognizant of that, especially when it comes to decisions that are going to be made [about health care].” That is why, Sarkar continued, having full transparency of data is really important.
The question is: How do you argue with – or talk back to – an algorithm that is deciding what kinds of investments are to be made in “rationing” health care by health insurers?Another critical question: If there are flaws that can be identified in the Optum software used for Rhode Island’s managed Medicaid population around issues of racial equity, then how does that require changes in the way that health care investments are managed and delivered by UnitedHealthcare and Neighborhood Health Plan of Rhode Island?A third question: When it comes to the delivery of two of the highest-cost services of health care – women’s health and mental health and behavioral health care, according to presentations to the Senate Commission on Health Insurance Reimbursements, how can such apparent racial biases in the software algorithms be identified and remedied?A fourth question: Is there a connection between the racial equity biases identified by the STAT investigative report in the algorithms deployed by Optum and the very low reimbursement rates paid for behavioral health and mental health services in Rhode Island?A fifth question: If you are a board member of Neighborhood Health Plan of Rhode Island, which employs Optum to manage delivery of health services for Medicaid patients, do you need recuse yourself from participation and discussions around racial equity as part of the new Equity Leadership Initiative by the Rhode Island Foundation?Translated, if you want to address racial equity in Rhode Island, will it require removing those who may be directly profiting from the practice of racial health disparities from being decision-makers?Who will be held accountableThe apparent racial bias embedded in the algorithms deployed by Optum is not the only alleged problem that has been identified with the way that Optum has behaved in its management of the delivery of health services. Frequently, payments by Optum to providers have been delayed, forcing the providers to have to borrow money from the state to stay in business, according to executives of a leading community agency involved in mental health and substance use services.In a ConvergenceRI interview published on Feb. 17, 2020, with Susan Storti and John Tassoni of the Substance Use and Mental Health Leadership Council of Rhode Island, Storti and Tassoni revealed that delays in timely payments from Managed Care Organizations such as Optum had forced their member agencies to borrow money from the state in order to be able to stay in business. [See link below to ConvergenceRI story, “Show me the money.”]As ConvergenceRI reported in the story: “We have so many of our providers which belong to this agency that are on the cusp of going out of business, who have sold property, who have given paychecks to individuals and told them not to cash them until a week later, because they are not getting reimbursed by the MCOs in a timely manner,” Tassoni said, the anger rising in his voice. “That’s horrible.”
Further, ConvergenceRI reported: The MCOs, Tassoni continued, get a huge lump sum check from the state, usually between the first and the seventh of every month. “They get this huge sum of money to provide third-party services to pay our people,” he said. “We had people who had to sell a condo in Newport in order to make payroll.”
Is the problem that the MCOs are not distributing the money in a timely fashion? ConvergenceRI asked.“Correct,” said Tassoni.“It waxes and wanes,” Storti said. “Sometimes, they are very good, and there are other times, if there is a glitch in the system….” payments can go awry.
While efforts have been made to rectify the billing situation, Storti continued, “The members will tell you: it’s good until it’s not good, because when it goes bad, it goes really bad.”And, at one point [because of delays in payments], when individual agencies could not meet payroll, the only option that they had was to go to the state and borrow money from the general fund, through the offices of Medicaid and R.I. EOHHS, according to Storti. “And now, they are in the process of paying the money back.What does health care have to do with it?All health care is personal; all health care is complex; all health care is expensive. Further, the crises in affordable housing, in health care, in the economy, and in the environment are all intimately connected.The links between racial equity and health outcomes have been made more transparent by the coronavirus pandemic raging in our midst.“The impact of COVID tracks the pre-existing [and unconscionable] health disparities faced in low-income/majority BIPOC [Black, Indigenous, and people of color] neighborhoods,” tweeted Jennifer Hawkins, the executive director of ONE Neighborhood Builders on Saturday, Oct. 17.The numbers continue to climb precipitously, with more than 8.3 million cases and more than 224,000 deaths in the U.S., and 1,152 deaths in Rhode Island. How many deaths will it take ‘til we know that too many people have died?
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Richard Asinof is the founder and editor of ConvergenceRI, an online subscription newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island.