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of Aug. 28, there were 1,228 Medicaid eligibility applications for long-term
services and supports pending for longer than 90 days
The issue is
As of Aug. 28, there were 1,228 Medicaid eligibility applications for long-term services and supports pending for longer than 90 days As Rhode Island headed into Labor Day weekend and the opening day of school next week, any attention focused on Deloitte was probably peripheral vision, due to its signature advertising logo being displayed courtside at the U.S. Open championships in Flushing, New York, a backdrop to the professional tennis matches being played. For the most part, all has been relatively quiet on the Unified Health Infrastructure Project [UHIP] front since the middle of March, when Gov. Gina Raimondo announced that a new contract had been negotiated with Deloitte, including a $50 million, one-time payment. [See link below to ConvergenceRI story, “When it comes to UHIP, money talks, the needy walk.”] Exactly how much of that $50 million will actually reach Rhode Island coffers remains unclear, as the federal government may claw back a sizeable chunk. For sure, there have been a few loud hiccups in the past month: a $2 million fine levied by the federal government against the state of Rhode Island for errors and a lack of quality control in handling Supplemental Nutrition Assistance Program benefits under UHIP, a fine that the state is appealing, offering the assurance that Deloitte will pay the final amount of the fine, according to a statement issued by the director of the R.I. Department of Human Services. And, there has been an uptick in the state’s share of the total $656 million tab for UHIP, rising to $154 million, according to a report by WPRI’s Susan Campbell. But the big news, which has stayed well hidden, under the radar screen, out of the headlines, is the continuing backlog of Medicaid eligibility applications for long-term services and supports – currently at 1,228 pending for longer than 90 days. [That is a small decrease of 87 such pending applications since June 26, which then totaled 1,315, according to EOHHS Director of Public Affairs David Levesque, in response to a query from ConvergenceRI.]
Translated, the UHIP system is still not functioning when it comes to processing Medicaid applications for long-term care in a timely fashion. And that spells “trouble with a capital T” for Rhode Island’s nursing home industry and the state’s aging population – and the state’s budget.
A costly legacy of logjams Beginning in late 2016 and through much of 2017, the R.I. Executive Office of Health and Human Services was forced to make tens of millions of dollars in interim payments to nursing homes and skilled nursing facilities to keep them out of bankruptcy, a financial squeeze caused by the state’s UHIP system, built by Deloitte, and its failure to handle Medicaid eligibility applications in a timely fashion.
The diagnosis at that time: an online application system planned and hyped as part of the botched 2016 launch of the Deloitte system under UHIP never worked.
Now, nursing homes that received these interim payments are diligently working with the federal government and with R.I. EOHHS to reconcile the ledgers on those payments, slowly moving toward resolution.
But, three years later, the glitches that caused the delays in processing Medicaid applications for long-term supports and services have not been solved, pointing to a longer term, systemic snafu.
The problem is that there is still a big lag in processing applications going in the door, as Scott Fraser, president and CEO of the Rhode Island Health Care Association, described the situation in a recent interview with ConvergenceRI.
Fraser has been on the job directing RIHCA for some nine months, having taken the helm from Virginia Burke, who retired in December of 2018 after 11 years. RIHCA is the state affiliate of the American Health Care Association, representing the skilled nursing care industry in the state. Previously, Fraser had worked for Blue Cross & Blue Shield of Rhode Island in corporate public relations and lobbying.
“We asked, what if there are [continuing] problems with the applications going in?” Fraser said. “What if it takes another 90 days or more? We were told: ‘Well, you can always apply for more interim payments.’ Which doesn’t sound to me like it is solving the problem.”
Even if the overall numbers of Medicaid applications pending longer than 90 days are going down, Fraser continued, “If your nursing home has even 10 of those thousand claims [outstanding for more than 90 days], you’ve got a [financial] problem, and you’re going to be chasing problems. It is still a matter that needs to be addressed.” The issue, Fraser said, “is still UHIP; that is what I’m hearing from our members.”
Framing the storyHow big a story is this? Huge. Overall, the costs for Medicaid in the state budget account for about $2.7 billion annually, roughly one-third of the entire state budget, including both state and federal funds. The majority of that $2.7 billion goes to pay for long-term services and supports. Despite the new statute under the Reinvention of Medicaid law, which mandated the creation of accountable entities for managed Medicaid populations, there is currently no accountable entity for long-term care for supports and services.
Further, the demand for long-term care supports and services under Medicaid is only going to grow in Rhode Island, given the demographic trends, in which the state has the highest percentage of old old residents, people 85 years and older, in the nation.
Not only are there serious difficulties in meeting the increasing demand for services of Rhode Island’s aging population, there are also worries about being able to sustain a workforce to deliver care for everyone.
And, low reimbursement rates for Medicaid still remain a big issue, unresolved, before the R.I. General Assembly.
Here is the ConvergenceRI interview with Scott Fraser, president and CEO of the Rhode Island Health Care Association, whose members are still grappling with the fallout from the botched UHIP launch in 2016.
ConvergenceRI: UHIP is still the issue? FRASER: Yes. It really is. I’m still hearing [about it] from my members. Our concerns are about going in the door, the new applications. That is still an issue.
ConvergenceRI: The last numbers I saw, at the news conference in March when Gov. Raimondo announced the new contract with Deloitte, was that there was a backlog of at least 1,000 pending applications for Medicaid eligibility for long-term care? Is that still the case? FRASER: The last number I saw was several months ago, or two to three months ago. It was about a thousand. I think the numbers have been going down. But, it’s still an issue.
ConvergenceRI: When that happens with the nursing homes that you represent, do they come to you [to ask for help]? FRASER: What I have found is that most times, members will try to handle it on their own.
They have developed relationships with Medicaid and EOHHS that, over the years, they’ve worked with, maybe on a collegial basis, maybe on a contentious basis, but with people who they know, to go to, to try and get the answers. Many times, when members come to me, they are completely frustrated. They’ve tried what they feel are all the proper channels, before asking: Is there anything that you can do? At that point, I will usually get involved, and contact someone, not that I’m going to solve the problem. But I am [going] to elevate it, if you will, to the attention of folks at R.I. EOHHS, and say: “There’s an issue here.”
ConvergenceRI: Are they paying attention? FRASER: Yes, they are paying attention. But, you know, it is a system that is larger than anyone or any 10 people. Yes, they are paying attention; I don’t know if there is an ability to solve the problems yet.ConvergenceRI: Is the problem that the UHIP system itself, that it is still broken and does not work? FRASER: I do think it is the system, as opposed to the people. I really believe that the people in the departments are doing their best to solve the problems. I’m not come across anybody who is – maybe obstructionist is too strong a word. But I haven’t come across anyone who doesn’t want to try to work with members. Because they don’t want to hear people complaining about the issues; they want to see the system running smoothly.
If you were to talk with R.I. EOHHS and Medicaid, I’m sure that they would point [to the fact] that the numbers have come down. But the last number I saw was a thousand pending applications [for Medicaid eligibility], that’s a lot for 80 nursing homes.ConvergenceRI: Beyond UHIP, is there also a problem related to demographic trends, with the increases in Rhode Island’s aging population, and the amount of people who are going to need to drink from the well, so to speak, keeps growing? FRASER: I don’t think it is one or the other. The scenario you’ve pointed out, that we are all aging, is a good thing. It just means [we will need to bring] more and more people into the system, eventually. If the system is having trouble handling the operation now, as more people age – and you know the statistic – Rhode Island has the largest percentage of population over 85 in the nation. I think we’re going to keep that distinction for a while. That’s going to be an issue.
ConvergenceRI: The ability of the state to control the costs of Medicaid for long-term care services may prove difficult. Under the Reinvention of Medicaid law, accountable entities were supposed to be created for all managed Medicaid populations. But, as best as I can determine, there is no accountable entity yet for the delivery of long-term care services. FRASER: Accountable entities [for long-term care services] are something that we’ve heard about, but we haven’t seen in Rhode Island.ConvergenceRI: It is one of the questions that I hope to ask Secretary Womazetta Jones tomorrow, when I interview her. FRASER: I’m not telling you how to do your job as a reporter, but I would sure try and get that question in and see what she tells you.ConvergenceRI: How would you phrase the question? What is the question that you believe needs to be asked about the ability of Medicaid to cover long-term care services and its future functions? FRASER: I don’t have a specific question, but I can give you a general [framework] Secretary Jones obviously has heard about UHIP before she walked in the door. I’m sure she has done some research on it. And, I’m sure she’s heard much more since she arrived, both anecdotally externally, and from her people internally, who may have said: It’s a mess.
I guess the question that needs to be asked is: Has she seen anything that can be done differently? Does she have any new ideas or new eyes that she’s bringing to [the situation]? Is she looking at any new approaches for how to handle it?ConvergenceRI: As a result of UHIP’s botched rollout, some have said that there has been collateral damage done the nursing home industry in the state, forcing many smaller, independently run homes to sell to larger chains. Is that an accurate assessment? FRASER: I don’t know if I would personally characterize it as damage to the infrastructure, in general. As a kind of high-level observation, the lack of adequate funding for Medicaid has caused a number of these mom-and-pop, second and third generation, family-run operations to sell, because they are tired of trying to do their best to make ends meet.
I hear weekly, if not multiple times a week, from some of our members, saying: my father started this, my grandmother started this, the people that work here, the employees, just put their hearts and souls into their jobs, everyday. Our members would love to pay them what they feel they are worth. And, as you know, there is always a call for a higher minimum wage, for higher increases in salaries. Our members would love to do that, but that’s only half the equation. The other half of the equation is: where does the money come from? You have a system that caused some members to have financial problems, with a need for interim payments. Some homes were able to put that aside and say, we know they are going to be coming for it, some day. And now they don’t have a problem paying it back. But other homes, because of the [dire] financial situation they were in, had to use that for the day-to-day operations. Again, I don’t know if it was damaging to the infrastructure, but the whole issue of inadequate Medicaid funding has certainly caused some problems for many of our members.ConvergenceRI: A recent story in The Washington Post by Jeff Stein highlighted a problem that is occurring in Maine – the decrease in the number of availability workers to care for their aging population. Is this also an issue that Rhode Island is facing? FRASER: I believe that it is. Obviously, Rhode Island is an aging state. But what is more concerning is that there are fewer and fewer people to care for the aging population. It is a population swing. I think that is what you are seeing in Maine. There is a need for services, but there aren’t enough people to provide them, even if everyone said, we want to work in a nursing home and do this work.ConvergenceRI: Much of the focus on economic development in Rhode Island has been to attract new young talent to Rhode Island, to spur the innovation economy, in order to make the state prosper. Is there a need to have a change in perception about people as they age as a valuable source of talent? My lead feature story this week told the story of a 70-something woman invited to a photo fashion shoot in New York City, for instance. FRASER: It would not matter to our members how old a person was who was coming in the door and saying, we’d like to work here. But, as I said, just looking at the sheer numbers of the population, and projecting ahead, that’s going to be a real issue.ConvergenceRI: Another issue I wanted to ask you about was the opinion voiced by some that if we could only get people out of nursing homes and back into the community, because that’s what people wanted to be, we could save the state a lot of money. It is an opinion that is heavily laden with emotional tug. The counter argument is that providing someone with dementia 24/7 care in the home is going to be a lot more expensive than if they were in a nursing home or a skilled nursing facility. Is that accurate? FRASER: Absolutely. As I am sure Virginia [Burke] preached to you, as she’s told me: It’s a lot more cost-efficient to have someone in a nursing home for 24/7 care – for food and laundry and everything – than it would be having someone privately in the home. I don’t see it as us vs. them, skilled nursing facilities vs. assisted living; I see it truly as a continuum of care. There are certainly some people – but I have not run into anybody, or had any instance in my first seven or eight months on the job, where I’ve run into residents of nursing homes – that don’t belong there.
If someone is there for short-term rehabilitation, and they get rehabilitated, they are going home. And that’s the way it should be. Certainly, there are some people who can be cared for in the home, that don’t need skilled nursing care. The next step up would be an assisted living facility, and there are certainly people in assisted living that don’t need skilled nursing care. But it is a continuum. And, there are many people, if not now, at some point, will need skilled nursing care. Personally, my mother was a stroke patient for five and a half years. And she had very serious mental and physical limitations. And, there was no other place she could be than a skilled nursing facility. Other people don’t need a nursing home. But, at some point, as things change, they may. I think there is room for everybody on the continuum, because who would want to be in a nursing home when they can be cared for at home. But, conversely, if it was your family member, you are not going to be seeking care at home if they need a much higher level of care. You’re going to say: I want them in the best place.ConvergenceRI: Or, if you try and provide that care yourselves, it can become a classic burnout situation, one that is difficult to manage. FRASER: Absolutely.ConvergenceRI: Is there a need to make that continuum of care better understood in terms of legislative priorities? FRASER: I know we have tried to do that, for many, many years, long before my arrival. We are continuing to talk to folks in the off-season, if you will, to people at R.I. EOHHS, and we will be speaking with legislator leaders, and hopefully, we can set up a meeting with the governor’s office before the budget is finalized. Because it is a constant drumbeat [in the messaging that] we need to bring to people. There is the Medicaid Inflation Index, which is set by law, but that gets amended every year. In the last eight years, we have not received the inflation index. And, that’s something our members need just to try to cover the costs.
It’s something we have to keep bringing to people’s attention on a regular basis. I wish I had the answer about how to get the legislature to listen.
ConvergenceRI: Often, it seems to me, listening to some of the rhetoric, that there is a tendency, if that is the right word, to make nursing homes the villain in all of this. FRASER: Yes. And, I don’t understand that. I’ve seen that, but I don’t understand it, why a facility that can give such good quality care to a loved one is seen as something negative. The impressions of nursing homes as a place that smells bad, or they are a place to warehouse the elderly, I think those are misperceptions from decades ago. Given the high quality level of care in Rhode Island, I just don’t see it. I see a very caring staff in every home that I’ve been to; I see people who are getting the care that they need. Whether it’s dementia, whether it’s physical rehabilitation, I’m just always amazed, every time I visit one of our members, at the level of professionalism and caring by all members of the staff. But yes, I do sense that general negative undercurrent at times. I always encourage people to visit one of our local facilities. Or, if you’re looking for a facility for a loved one, I’ve already been asked several times, how do I pick a nursing home? I tell them: you know what is right for your loved one. Some facilities have greater devotion to memory care, or might have a full memory care unit. Others might have more skill in short term rehabilitation. I say: you know what your family member needs. Walk in. Use your five senses. Look around. How are people being treated? Are they being spoken to? Try the food. Look at all the ratings. Look at the quality ratings. Because we have good quality homes in this state. Go visit. Talk to the administrators. Talk to the staff. Talk to the residents, if you can.ConvergenceRI: Tomorrow, I will be sitting down for an interview with Secretary Womazetta Jones at R.I. EOHHS. Are there any particular issues that you think need addressing that you would suggest that I asked about? FRASER: We’ve touched on many of them. If I was told that I had 30 seconds with the new secretary, to ask about my concerns, my three concerns would be: UHIP; Medicaid reimbursement, and the lack thereof; and workforce issues. Those are the three key problems that our members are facing.