PROVIDENCE – When the Special Legislative Commission To Study the Impact of Insurer Payments on Access to Health Care convened for its fourth session on Tuesday, Feb. 25, there was a full agenda of presentations to squeeze into 90 minutes. [Two more sessions are now scheduled for the second week in March.]

Many of the presentations could be considered a health policy wonk’s delight: crunching data in search of answers around the reasons why health care costs in Rhode Island are so high, looking at the role that the rate of reimbursements from health insurers plays in that calculation as a way to control costs and improve outcomes.

Clearly, it was not the kind of news story that is easily captured in 500 words or less, talking in breathless phrases about conflict, murder, mayhem, anxiety and outrage, so there were no other reporters in the room, save for ConvergenceRI.

The message at the end of the session, however, coalesced around a surprising refrain, almost a plea: We need a system of reimbursements in health care that makes sense.

That refrain seemed to mirror, surprisingly, the unexpected answer given when ConvergenceRI first interviewed Dr. Michael Fine in 2011, upon his appointment to become the director of the R.I. Department of Health, asking about how he viewed landscape of the health care delivery system. Fine’s answer: We do not have a system of health care delivery, we have a market of wealth extraction.

Peeling back the onion on high health care costs
First up was Neil Sarkar, interim president and CEO of the Rhode Island Quality Institute and founding director of the Center for Biomedical Informatics at Brown University, who expanded upon his initial presentation that he had given in November of 2019, at the Commission’s first session.

In that presentation, entitled “Identifying Top-Billed Diagnoses in Rhode Island,” Sarkar had ranked and identified the top 10 high cost diagnoses by average, based on the analysis of the All Payer Claims Database [APCD] from 2016 to 2019.

[For policy wonks and data research scientists, the methodology used was: calculating the total cost per diagnosis; group the individual diagnoses into clinical classifications software categories; combine the costs within each category, and then rank and identify the top diagnoses by costs.

As ConvergenceRI had reported, the results were revealing. The top diagnosis by cost was septicemia, or sepsis, bacterial blood poisoning, which was rated fourth in 2016, first in 2017, first 2018, and second in 2019. [See link below to ConvergenceRI story, “Will anecdotal and data evidence converged into legislative health remedies?”]

In his new slide presentation, entitled “Characterizing the Costs of Care in Rhode Island,” Sarkar expanded upon his working hypothesis: “Behavioral and mental health are costly, and in combination with other conditions, are a major factor in health care costs.”

Translated, anxiety + sepsis = a higher cost of care.

To buttress his conclusion, Sarkar included a report published in Health Affairs, with the headline: “Patients with high mental health costs incur over 30 percent costs than other high-cost patients.”

Next, Sarkar looked at women’s health, which emerged from the data as another high cost factor in health care, based upon crunching the numbers. Once again, to illustrate his data-derived conclusion, Sarkar included a story by Leana Kulkami, a Harvard graduate student in public health, entitled: “My uterus costs more than a Porsche.”

Sarkar then presented his updated hypothesis: “Behavioral and mental health conditions are more costly by themselves, and cost less when treated in combination with other conditions. Same is true for women’s health.”

[A larger question, of course, not asked, is the way that health care for women – and for that matter, behavioral and mental health care – is often skewed by the predominant male view of the world, such as looking at pregnancy as a pre-existing condition, rather than an affirmation of health.]

Open wider, please
Next up was Dr. Samuel Zwetchkenbaum, DDS, the Dental Director at the R.I. Executive Office of Health and Human Services Oral Health Program.

Zwetchkenbaum gave a detailed presentation of data analyzing the total visits to the ED for non-traumatic dental conditions by payer, from 2014-2018, as well as a data analysis for the total ED charges for non-traumatic dental conditions, the emergency department use by age, and the disparities in the use of ED by location, by race and ethnicity, as a way of qualifying the unmet needs for dental services.

Zwetchkenbaum then presented slides showing the benefits of increasing the use of dental services in early childhood and for pregnant women, the network of dental providers at community health centers in Rhode Island, a chart showing the dental use by age by Medicaid members in Rhode Island, the impact of low adult dental utilization, and the cost savings when a preventive dental benefit was added to Medicaid.

Zwetchkenbaum concluded with slides that illustrated the dimensions of the dilemma around rate reimbursements and dental care: the fact that dentist participation in the Rhode Island Medicaid program has plummeted and the dental workforce in Rhode Island is declining.

The problem, according to Zwetchkenbaum, is that participation in the Medicaid program by dentists is seen as a kind of philanthropy, given how low the current rates are. Zwetchkenbaum suggested looking at what other states had done, including California, Colorado and Connecticut, to increase participation by increasing rates of reimbursement.

For the children
After brief remarks by Jane Hayward, the president and CEO of the Rhode Island Health Care Association, Benedict F. Lessing, Jr., the president and CFO of the Community Care Alliance, who detailed the deficiencies in rate reimbursements when in came to providing for children’s behavioral and mental health services, repeating the mantra: we need a system of care.

Lessing’s presentation was followed by a brief talk by Br. James Martino, the president and CEO of Ocean Tides, Inc, and chair of the R.I. Coalition for Children and Families Rate-Setting Committee, whose slide deck analyzed the steps in process involved in rate setting.

Out of time
With time running out and the R.I. Senate about to go into session, the bells ringing, Sen. Josh Miller, chair of the Commission, allowed for brief public comment remarks by ConvergenceRI, who had requested an opportunity to speak before the commission.

In rapid-fire delivery, ConvergenceRI presented his takeaways as a reporter, having followed the commission’s deliberations:

• There is little accountability or legislative oversight of the R.I. Medicaid office and how it handles contracting and its setting of reimbursement rates, particularly with its private contractors. Details have been willfully “obscured” by state officials, in my opinion. [A study conducted by Milliman on R.I. Medicaid rates for behavioral health and mental health services, for instance, completed in 2019, has yet to be made public. Miller said that he hoped that the report would be forthcoming in the next month, before the commission finished its deliberations.]

Solution: Create a regular, legislative-required audit of Medicaid contracts and rates, every year or every two years, which would provide sunlight, a cure to many bad practices.

• When it comes to behavioral health and mental health care, continued low rates of insurance reimbursements to providers have crippled any efforts to address the growing unmet needs and to provide a continuum of care. [I was surprised to learn that some providers, because of problems with being paid on time by MCOs, were forced to borrow money from R.I. EOHHS, money that is still being paid back, similar to what happened with nursing homes and interim payments made in the aftermath of the UHIP fiasco.]

Three specific problems stand out when it comes to reimbursement rates for mental health and behavioral health services. They include:

1. There is no cohesive, congruent insurance model for providing behavioral health and mental health services in coordination with treatment of substance use disorders. Only 6 percent of patients who have been diagnosed with both conditions receive holistic care for both, according to a data analysis conducted by the chief medical officer at BHDDH.

Solution: Create a statewide pilot model of enhanced reimbursement rates for an integrated, holistic, continuum of care, with providers being paid by insurers on comparable basis with neighboring states of Massachusetts and Connecticut.

There was a pilot program called HealthPlan, launched in March of 2014, a collaborative initiative between Blue Cross and Blue Shield of RI, The Providence Center, Care New England, Butler Hospital, and Continuum Behavioral Health, a for-profit division of The Providence Center.

As ConvergenceRI reported in 2016: “The goal was to create a patient-centered continuum of mental health care delivery, delivered by a team of psychiatrists, therapists and case managers, with customized services for each patient, paid for with one monthly co-payment.

“Translated, the model of care sought to expand upon the model employed by many community health centers for behavioral health care and apply it to the commercially insured patient population.”

However, for whatever reason, the research findings on the success of the pilot program have never been published, as best as can be determined. [See link below to ConvergenceRI story, “Choosing a different path on the road to health, wellness.”

2. There is no comprehensive database to record and analyze the diseases and deaths of despair – from alcohol, suicide and drugs. Anecdotally, numerous providers and community advocates have told me that the co-morbidity of alcohol use disorder is present with some 80 percent of all overdoses. EMS transports for acute alcohol intoxication, for instance, is not a condition that is tracked by the All Payer Claims Database, even if it is one of the leading “impressions” for EMS transports at hospital emergency rooms.

[See link below to ConvergenceRI story, “Painting by numbers: Coloring in the landscapes of despair.”]

Solution: Create a statewide database in Rhode Island for the diseases and deaths of despair, including suicide, alcohol and drugs, to be published every year by the R.I. Department of Health, and funded by the R.I. General Assembly. If you can’t measure it, the work will not get done, the health care services will not be provided, and adequate rates of insurance reimbursement for a continuum of care will be absent from the equation.

3. There is no accurate data for a census of skilled nursing facility patients, who they are, how old they are, what are their medical conditions [how many suffer from dementia, Parkinson’s and Alzheimer’s disease, how many are diabetic, how many have depression, etc.]. Similarly, there is no accurate data for about the workforce that is taking care of patients in these facilities [how old are they, what is their training, how much do they make an hour, what is the rate of turnover and churn, etc.]

While we can identify the demographic trend that Rhode Island has the highest percentage of “old old” residents – people who are 85 years and older, we have no comprehensive data upon which to track how services are being delivered to one of the state’s most vulnerable populations, who is providing those services, and how low rates of insurance reimbursement are jeopardizing a continuum of care.

Instead, what we have are “symptoms” of the problems: despite state law to the contrary, a large backlog exists for Medicaid eligibility claims that have not been processed in 90 days, with more than 800 pending at last count, continuing to put skilled nursing homes at risk financially, four years after UHIP was first launched.

Solution: Create a statewide database in Rhode Island that tracks patients in skilled nursing facilities, their medical conditions, and the workforce taking care of them [on a de-identified basis]. Without being able to quantify the demand, the unmet need, or the workforce churn, reimbursement rates become guesswork to manage existing [and inadequate] programs of care. If you can’t measure it, the work will not get done.