PROVIDENCE – Christopher Koller, president of the Milbank Fund in New York City, might rightly be called a health care policy wonk. Koller’s career has been steeped in creating and encouraging policies to improve the quality and efficiency of health care service delivery outcomes.

In his current position at Milbank, Koller has described his work as being “to improve the health of populations by connecting leaders and decision makers to the best evidence and experience.”

Indeed, when Koller talks, his language is often chock full of abbreviations and acronyms, using a common shorthand language shared by health care experts – such as UR [utilization review], PCP [primary care provider], and PPO [preferred provider organizations], sometimes making it hard to translate what he is saying into everyday language.

Koller had once been the president of Neighborhood Health Plan of Rhode Island. He then served as the inaugural R.I. Health Insurance Commissioner from 2005 to 2013, helping to shape and to define the contours of the agency, now referred to as OHIC, created by the R.I. General Assembly in 2004, dedicated to health insurance oversight.

Koller was not only the first health insurance commissioner in Rhode Island but the first in the nation. Under his leadership, Koller pushed through what became known as the Affordability Standards, established in 2010, in order to better control costs and to improve investments in primary care, and to encourage the adoption of payment reform strategies.

During his eight-year stint as Health Insurance Commissioner, Koller shepherded the creation of an all-payer pilot program, originally known as CSI-RI in 2008, which began with five primary care practices, focused on developing the care model known as the patient-centered medical home, or PCMH, to improve the delivery of care for patients with chronic conditions.

Today, the PCMH initiative, now known as the Care Transformation Collaborative, has grown to include 128 primary care practice sites, including internal medicine and family medicine, with pediatric practices [PCMH-Kids] being added in 2016. Approximately 695,000 Rhode Islanders now receive their health care from CTC-RI and PCMH-Kids, more than two-thirds of the state’s residents.

Last week, Koller became a new faculty member at the School of Public Health at Brown University, as a professor of Health Services, Policy and Practice, where his work will be focused on translating evidence into health policy and practice.

Renewing a conversation
Given the ongoing disruption of the health care delivery system as a result of the coronavirus pandemic, it seemed as if it would be a good time to renew a conversation with Koller, one of the national “thought leaders” when it comes to putting public health policies into action.

Here is the ConvergenceRI with Christopher Koller, president of the Milbank Fund, who recently joined the faculty at the School of Public Health at Brown University, conducted through email. “Wow, great questions,” Koller said, when sending his responses.

ConvergenceRI: How do you think the traditional office visit will evolve in the post-COVID world for primary care practices?
KOLLER: Telehealth has become more accepted as an option – especially for behavioral health – but much will depend on insurer coverage and payment policies. Will they keep them as options post-pandemic? That will depend largely on what Medicare decides to do.

I also think it is pretty clear that practices that receive more per-person payments can do more team-based care and not rely on having to have a doctor visit.

ConvergenceRI: What are the limits, in your opinion, to the efforts around “Choosing Wisely,” which involves patients saying “No!” to providers when “unnecessary” tests are ordered, tests that are often part of the accountable entity metrics for increased payments to physicians?
KOLLER: Choosing wisely depends on doctors choosing wisely as well as patients. It is supposed to encourage a fuller conversation between provider and patient about risks and benefits of tests and treatments.

[There are] three big limits – information asymmetries [physicians will always know more]; how to account for economic costs of the service [not like buying food where you can assess quality for price]; and, so long as [a treatment] option is available, “doing something” seems more attractive than waiting.

So, I would encourage “choosing wisely” for promoting appropriate care, but not depend on it.

ConvergenceRI: When you first created the Affordability Standards as R.I. Health Insurance Commissioner, it was an attempt to change the escalation of medical costs in the state through the management in the rise in health insurance premiums and by increasing how much was invested in primary care.
With the R.I. initial response to COVID, which organized access to testing through primary care providers, it showed that there was a significant gap between having “coverage” and having access to a primary care provider -- many folks simply did not have access to a primary care provider. How would suggest changing the way that people can access care in a post-COVID world?
KOLLER: I am not sure I understand what you mean about organizing testing through primary care providers and what was shown about access to a PCP.

The lessons of COVID for primary care access include: practices on pre-payment were able to stay open; practices that were “PCMH” could adopt telephone/video and non-physician visits quicker and could reach out to chronically ill.

The public health department/primary care relationship is important but often very informal. Not sure if this is what you are getting at.

ConvergenceRI: One of the hidden barriers to accessing health care is the role that third-party firms play in authorizing approval for care for major insurance firms. Appealing denial of services is a complicated process. What kind of accountability can be placed on insurers to improve this process?
KOLLER: What is your evidence that this is a problem? In the late 1990s, in response to gatekeeper models, Rhode Island developed managed care oversight based on the practice of utilization review.

In the 2000s the market rejected a lot of these practices – with notable exception of behavioral health – for open preferred provider organization [PPO] models that did not require a referral or pre-authorization.

These utilization review [UR] laws are still in place in Rhode Island, now overseen by OHIC. If there is a problem with appeals, OHIC has a lot of authority to investigate.

ConvergenceRI: What are the limits of using claims data to create recommendations for controlling costs?
KOLLER: Claims lag of 4-6 months. Non-claims payment that do not get captured. Knowing who the primary care doc is. Risk adjustment. Absence of self-insured data. All these are limits, but the current OHIC cost growth targets process is still very productive.

ConvergenceRI: Is there a way through regulation to encourage health insurers and hospitals to make investments in affordable housing as a prescription to lowering the costs of care?
KOLLER: Housing is not health care. It is not reasonable to expect insurance to pay for housing costs. But it is very reasonable to expect that sizable insurer and health system reserves be invested locally in ways that improve the health and well being of the community – including housing.

The IRS forms for charitable activities for nonprofit hospitals can be inspected and OHIC can start making inquiries of insurers. It is harder to oversee for-profit players like UnitedHealthcare and CharterCARE.

ConvergenceRI: What questions haven’t I asked, should I have asked, that you would like to talk about?
KOLLER: How does the state oversee provider consolidation? It is a big issue – especially with Lifespan/Care New England [merger] discussion. Future of nursing homes in Rhode Island; we have too many of them. How do they transfer [patients]?