Delivery of Care

Marie Ganim speaks words of wisdom about health care

The current R.I. Health Insurance Commissioner, who will retire next month, offers her insights about the work that still needs to be done in controlling health care costs

Photo by Richard Asinof

Marie Ganim, R.I. Health Insurance Commissioner, speaks at the 2019 announcement of a compact to limit the growth of health care spending in Rhode Island.

By Richard Asinof
Posted 12/14/20
Marie Ganim, the retiring R.I. Health Insurance Commissioner, shares her insights and observations in an exclusive exit interview about the future challenges for health care regulation in Rhode Island.
What new investments are needed to build out the public health infrastructure in Rhode Island, given the widening gaps revealed by the coronavirus pandemic? Why did the R.I. General Assembly fail to include the proposal to invest in a new public health laboratory as part of the bonds being offered to voters for approval in March of 2021? What questions should the asked of Patrick Tigue, the person nominated by Gov. Raimondo to succeed Ganim as R.I. Health Insurance Commissioner? Will Gov. Raimondo respond to growing pressure from community recovery advocates and medical professionals to create a pilot overdose prevention facility in Rhode Island?
In early March, followed the first diagnosis of a Rhode Island patient with COVID-19, ConvergenceRI wrote: “The spread of the novel coronavirus has exposed a singular truism about the importance of connecting public health to future economic prosperity: our system of health is only as strong as the weakest links within it – the poor, the elderly, the uninsured and under-insured, the residents of nursing homes, and the nurses and front-line health workers who care for patients. The coronavirus does not discriminate.”
Nine months later, the paragraph seems prophetic. The virus has surged again in Rhode Island, with the most vulnerable neighborhoods still bearing the brunt of infection. Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, tested positive for the virus over the weekend and the Governor was forced to go into quarantine.
Even as the first vaccine is to be administered next week to front-line health care workers in hospitals [but apparently not in nursing homes], hospitals are facing a critical shortage of nurses, doctors, and technicians to care for COVID patients.
There is still great resistance by many to changing their behaviors that put others at risk. And, the dividing line for access to health care is often defined by wealth: those who have to stand in line vs. those who go to the front of the line.

PROVIDENCE – In announcing her retirement in January of 2021, Marie Ganim, the third R.I. Health Insurance Commissioner, is passing the baton, so to speak, after more than 30 years in public service. Ganim is one of the more savvy state regulators of the business of health care in Rhode Island. She is leaving during a time of great disruption in the forces surrounding health care delivery.

Ganim became Health Commissioner in June of 2017. She had previously served as Director of Policy for the R.I. Senate. [She, like Dr. Jill Biden, has earned the right to be called Doctor, having received a Ph.D. in Public Affairs from Northeastern University.]

Ganim consented to do an exit interview with ConvergenceRI, conducted through a set of questions emailed to her, as a way to capture her insights and concerns about the work that has been accomplished and the challenges that remain to be addressed.

ConvergenceRI: In a time of such great disruption to the health care delivery system in Rhode Island, what do you see as the most important priorities for OHIC to pursue and maintain in regard to insurance affordability standards?
GANIM: We need to maintain focus on reducing the underlying costs of health care. We know, based on analysis of health care claims data in the All Payer Claims Database [APCD] [conducted] by Brown University, that between 2016 and 2018, 53 percent of the cumulative increase in commercial medical spending was attributed to increasing pharmaceutical drug costs, with price increases as the key driver.

OHIC is working with the Cost Trend Steering Committee to recommend state policy options that could help to lower Rhode Island’s prescription drug costs. As importantly, and related directly to our Affordability Standards, OHIC has established goals to dramatically increase the amount of health spending that is tied to Alternative or Value-Based Payment Models, moving away from payment for quantity vs. quality of care.

To the extent possible, we would like to see health care providers paid according to the number and type of patients that they have, freeing them from having to be constantly billing and seeking approval for services provided.

Taken together, these cost containment efforts are critical to reduce the hardship that annual increases in insurance premiums and deductibles cause individuals and families in Rhode Island.

ConvergenceRI: The push toward telehealth as a necessity revealed a deep schism, if that is the right word, between legislative priorities of providers and insurers. How have the stakeholder sessions been going? Is there consensus on the legislative action needed?
GANIM: For the most part, yes, there has been general consensus on the value of telemedicine to patients and our health care system.

The final meeting of the Working Group was [held last week] on Dec. 10, and we have identified where the dissenting opinions fall. They seem to be focused primarily on reimbursement for telemedicine or telephone-only care as compared with in-person visits, and how insurers will determine what is a clinically appropriate remote health care service.

We hope to see legislation filed for 2021 that would adopt many of the current emergency provisions permanently into state law. The current Telemedicine state law is too restrictive as it currently stands, and unless amended in 2021, it would greatly restrict access to telehealth beyond the Governor’s pandemic-related Executive Order, which provides the essential flexibility that we are now relying upon.

ConvergenceRI: Earlier this year, STAT published an investigative story about alleged problems with what it described as embedded racism in the algorithms used by Optum in how decisions were made about health care delivery. Is there a need for OHIC to look at the way algorithms are being deployed by insurers in Rhode Island as a way to “manage” costs?
GANIM: Eliminating all types of bias and discrimination must be high on the agenda for all regulatory entities. We need the tools and resources to identify explicit and implicit bias in the documents and procedures that we review and regulate.

Early in 2020, OHIC completed market conduct examinations that looked at insurer policies of discrimination based on behavioral health, and the Office will continue to pursue subtle and obvious forms of discrimination in health care benefit design and management.

The National Association of Insurance Commissioners has formed a Race and Equity Committee that brings together commissioners from across the country with experts to help to inform this work.

It is also important, in direct response to your example, that insurance companies examine their own internal processes and systems using an equity lens.

Simply by constantly asking the question, “Could this process disadvantage a particular group?” it will go a long way toward identifying errors and omissions in our thinking that may lead to the perpetuation of discrimination.

Beyond that, how we identify and address historic racism and inequities in access to health care must be high on our agenda.

ConvergenceRI: Is OHIC tracking the “rebates” that insurers are paying back to members as reduced premiums? If so, how will that information be relevant to future decisions around requested rate hikes?
GANIM: Yes. In the spring OHIC issued instructions for insurers to submit their proposed rebate amounts, methodologies for determining them, and actuarial justification for OHIC’s review and approval.

What we are calling rebates, as you note, are effectively premium credits. To date OHIC has approved $27.1 million in premium credits to individuals and groups. The Attorney General, and others, have noted that the federal medical loss ratio [MLR] rules require that insurers pay rebates [in the form of rebate checks or premium credits] if the insurer’s medical spending falls below 80 percent of earned premium [net of taxes] for individual purchasers and small groups, and below 85 percent for large groups.

The problem with relying on the federal MLR rules to put money in the pockets of consumers in the present context is that they operate on a lag: 2020 claims experience may generate a rebate, but 2020 is part of a three-year, look-back period for calculating the MLR; and payouts, if triggered, won’t occur until 2021 for those who were enrolled in coverage in 2020.

Our individuals, families and small businesses are hurting now and need the cash flow today, so we facilitated and applaud the insurers for taking action this year to issue premium credits.

I’m glad you bring up the question of rate approvals and how the current dynamics of the pandemic will impact future rate reviews. As you know, our office must balance our legal mandates to keep health insurers solvent, ensure consumer protection, and encourage fair treatment of providers.

It is a look at all three of these requirements that we take as we strive to keep premiums down. We must ensure that insurers have the funds to pay providers for care they deliver to the patients that depend upon this coverage, including our recent expansion of Telemedicine.

2020 has been a year of great uncertainty, and this is especially true from a premium rating perspective. OHIC’s process of premium rate review is a prospective exercise where history informs our expectation of the future, but uncertainty and risk are inherent factors we plan for.

One area of careful consideration each year is the insurer’s contribution to reserve [CTR], which is basically the “bank account” that insurers tap into for unanticipated higher claims experience.

In years where the insurer’s medical spending exceeds expectations, the CTR is effectively eaten away and the carrier may break-even or incur a loss. For individual and small group rates in 2021 we tried to cut the CTR requests significantly, yet still allowed some reserve contribution to address the great uncertainty about medical spending in 2021.

Between COVID-19 admissions likely to be incurred from January to March of 2021, vaccine administration costs, and pent-up demand and disease exacerbation from delayed care, we could see a spike in medical spending.

Overall, I think we adequately balanced our statutory objectives in this year’s rate review. Small group average rate changes across insurers ranged from a 0.5 percent decrease to a 2.9 percent increase. These are quite low and have not received much attention. Average rate increases in the individual market were between 3.3 percent and 4.7 percent, and Rhode Island enjoys some of the lowest premiums in the individual market in the nation.

ConvergenceRI: The work by the Senate Commission on health insurance reimbursements chaired by Sen. Josh MIller has been in hiatus because of the coronavirus. If and when its work resumes, what recommendations would you like to see emerge, for your perspective?
GANIM: OHIC will be wrapping up market conduct examinations on network adequacy that we hope will help the commission identify where gaps in services exist and what commercial insurers are doing to address those gaps.

ConvergenceRI: Does OHIC need more resources to perform its responsibilities?
GANIM: Each year, OHIC struggles to maintain a total complement of staff through the state budget process. OHIC has requested two new positions to be a part of the Governor’s proposed FY 2022 budget. These would replace the two positions that OHIC lost in FY 2020 and have identified funding sources so as not to add state costs.

Meanwhile, OHIC is actively applying for federal grants to supplement state resources to help us more fully meet the public’s expectations and needs for consumer protection, network adequacy and premium affordability.

ConvergenceRI: What are the most important lessons that your have learned during your time at OHIC as commissioner?
GANIM: I have learned how hard and respectfully that the OHIC team and so many other state employees work to help the citizens of Rhode Island; the critical role of a Governor’s clear vision and strong leadership in achieving difficult policy reform; and the importance of collaboration among state agencies to ease confusion and maximize the best possible outcomes for consumers.

ConvergenceRI: Do you have any immediate plans for your retirement? Do you see yourself teaching?
GANIM: I have enjoyed teaching in the past, so that is a possibility. I am open to new opportunities that allow for a more flexible work schedule.

ConvergenceRI: In terms of policy moving forward, what do you think the R.I. General Assembly should focus on in its future legislative agenda related to health care?
GANIM: Hopefully, the Assembly will take up more of the consumer protection provisions of the Affordable Care Act to adopt into state law. It is critically important that the Medicaid program be supported and not be reduced, since it is both a lifesaver for patients and families and a lifeline for our essential health care providers.

The Assembly could play a valuable role in reducing pharmaceutical costs – and to address the administrative burdens placed upon health care providers. And, if federal policy changes and funds become available for this purpose, Rhode Island would be a state that could experiment with expanding public insurance options to help with the affordability challenges that confront many of our consumers.

ConvergenceRI: What questions haven't I asked, should I have asked, that you would like to talk about?
GANIM: In coming months and years, I look forward to seeing the product of the foundation laid at OHIC to develop a multi-stakeholder and multi-payer investment in a balanced and resourced continuum of behavioral health care services in our state.

OHIC is poised to begin this transformative work with the help of a R.I. EOHHS study of our behavioral health service gaps and needs, and with federal funds being sought to undertake this multi-payer effort to ensure the right care at the right place and time.

Being focused on improving mental health and substance use treatment outcomes and access to services has been a rewarding priority for the OHIC staff.

OHIC being awarded the Mental Health Association of RI’s “Hero” award for 2020 was a proud moment for a team that gets little recognition for the valuable but often invisible role of being a state regulator.

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