Delivery of Care

Will anecdotal and data evidence converge into legislative health remedies?

New legislative commission on reimbursement rates and health care access seeks to design legislative remedies to problems caused by low rates paid to providers, fragmented networks, and a lack of access to a continuum of services

Photo by Richard Asinof

The first meeting of the new legislative commission on rate reimbursement and health access was held on Nov. 20.

By Richard Asinof
Posted 11/25/19
Once again, Sen. Josh Miller is providing leadership in addressing key issues around the delivery of health care in Rhode Island, creating a commission to study reimbursement rates and a lack of access to services, bringing together a talented working group of commission members.
Will the work of the commission prompt the R.I. General Assembly to raise the Medicaid reimbursement rates for providers in behavioral health care and mental health, as well as for skilled nursing facilities? What is the current census of residents in skilled nursing facilities in Rhode Island, broken down by diagnosis, by gender, by age, and by health insurance plan? How can the work of health equity zones in Rhode Island assist the commission in its work to identify those who are under-insured and under-served? What is the current waiting time to see a primary care provider for an appointment in Rhode Island? How does the current All Payer Claims Database factor in denial of benefits? What is the current backlog in eligibility applications for long-term care services under Medicaid in Rhode Island?
For the past decade, the nation has been stuck in how to talk about the future of health care, as defined first by the Affordable Care Act and the expansion of Medicaid, and now by the relative costs and benefits of creating a single-payer Medicare For All health plan the best way to transition to such a change. There have been a lot of scare tactics deployed in an attempt to preserve the status quo. Too much money is being made by large consolidated industries in treating health care as a commodity.
Throw in the continuing costs of responding to the plague of opioid epidemic and other substance use disorders, including alcohol, and the epidemic of chronic diseases such as diabetes, heart disease and Alzheimer’s, and the big question facing us all: what is the actual cost of preserving the status quo, which is not sustainable in the long run?
Rhode Island is fortunate to have leadership pushing innovative solutions, such as health equity zones and neighborhood health centers, peer recovery interventions expanded community health teams and growing responsibilities for nurses in the delivery of care.
What has been missing is the recognition, often reinforced in coverage by the news media, who have health insurance plans paid for by employers, that delivery of health care is a highly tiered system based upon wealth: Those that got shall get, and those that don’t shall lose, and it still is news.

PROVIDENCE – When the new state legislative commission to study reimbursement rates and health care access met for the first time on Wednesday afternoon, Nov. 20, the mood around the table was relaxed and conversational, a tone set in large part by chair Senate Health and Human Services Committee Chair Joshua Miller.

He encouraged the members of the new commission to share their perspectives about what the scope and mission of the new commission should be, moving forward. The scope of the commission, Miller continued, could be narrow or broad in nature, saying he wanted to hear from members of the commission before moving to shape and direct the focus of the commission.

“We could go very broad, with the focus on reimbursement globally,” Miller said. Or, he continued, the commission could be more narrowly focused, looking only at Medicaid reimbursement rates and its impact of the rest of the delivery system. “We could have a commission where we could talk only about the potential of hospital mergers and their impact on reimbursement rates,” Miller said. “We could focus just on behavioral health.”

Convergence of anecdotal evidence with data
Miller, in explaining why the commission had been convened, said that what was being sought was “the convergence of the anecdotal to what can be provided through data.”

Many of the stories heard by legislators are anecdotal, that access is a problem, Miller said, reflecting upon his 12 years in the state Senate. The goal is to find out “how much is driven by rates of reimbursement, looking at network adequacy,” he said.

Among the possible questions to be explored include:how long someone has to wait to see a specialist, whether or not the specialist will take the patient’s health insurance, and if they do take the health insurance, do they have to wait nine months to be seen, according to Miller.

Peeling the onion
To begin the conversation, as a launch point, Neil Sarkar, interim president and CEO of the R.I. Quality Institute, and director of the Center for Biomedical Informatics at Brown University, gave a brief presentation, “Identifying Top-Billed Diagnoses in Rhode Island,” based on the analysis of the All Payer Claims Database [APCD] from 2016 to 2019.

The methodology used was shared: calculate the total cost per diagnosis; group the individual diagnoses into clinical classifications software [CCS] categories; combine the costs within each category, and then rank and identify the top 10 high cost diagnoses by average.

The results were revealing. The top three diagnoses by cost were:

Septicemia, or bacterial blood poisoning, was rated fourth in 2016, first in 2017, first 2018, and second in 2019.

Neurodevelopmental disorders, or disorders of brain development in children and young adults, was ranked second in 2016, fourth in 2017, fourth in 2018, and first in 2019.

Encounter for antineoplastic therapies, or targeted cytotoxic chemotherapy or targeted biological therapy, therapies used to combat breast cancer, for instance, was ranked third in 2016, 2017, 2018 and 2019.

The next top four diagnoses by cost over that four-year period were: chronic kidney disease, osteoarthritis, hypertension [high blood pressure] with complications and secondary hypertension, and neurocognitive disorders.

Rounding out the list of the top diagnoses by cost were: spondylopathies, or disorders of the vertebrae, cardiac dysrhythmias, heart failure, live born, acute myocardial infarction [heart attacks], and chronic obstructive pulmonary disease.

Translated, these are the diagnoses where the health care delivery system charges the most money for care delivery, according to codes in the APCD.

Marie Gamin, the R.I. Health Insurance Commissioner, praised the analysis, saying: “The APCD being used in data-driven assessments are so critical. I am thrilled to see it as part of the discussion. It has never been used in this way before.”

In turn, Miller summarized some of the inherent challenges presented by Sarkhur’s numbers.

“One of the things I would like to have more information on is accurate data, so when we talk about adjusting reimbursement rates to [achieve] a continuity of care, we understand part of [the answer] may be an increase in the rates for some services,” he said. “Does an increase in the rates really mean an increase in expenses? Can we have a high impact on those expensive diagnoses by creating better access to more early diagnoses and more early treatment?”

Miller continued: “It may be more expensive if you reimburse at a higher rate, but be less expensive systematically.”

During the public comment, one physician concurred, saying: “I was looking at the list of [highest-cost] diagnoses, such as septicemia and hypertension, and all of these are affected by a person’s ability and willingness to access care. I would say that there is very good data to show that [the reasons are] cost-based for patients that delay care.”

Chiming in
Noah Benedict, the COO of the RI Primary Care Physicians Corporation, spoke about the multifaceted problems created by low Medicaid reimbursements. As a result, many primary care practices are faced with limiting the number of Medicaid patients being seen to 25 percent of their “panel.” Certain providers are no longer taking Medicaid patients, Benedict said.

“You get to a critical point in your practice that if [you] take any more [Medicaid] patients on, they’re going to struggle with their business model,” he said. “ I think that is exactly where the discussion should go.”

Because, Benedict continued, “that small amount of uptick for providers who want to be able to take on more Medicaid [patients] will save exponentially later down the line, because [the patients] are truly being managed. If they are not in a primary care practice or in a community health center, they are not being managed.”

A representative from the R.I. Executive Office of Health and Human Services said that the state Medicaid office had just completed a rate review and that the information and data would be available to be shared by the end of the year.

Digging deeper
The problem with Medicaid patients, one commission member said, is that it is “multi-factorial.” It is not just the reimbursement rates, she continued, “It’s also the fact that these patients do take a little bit more time and the cases are more complicated. These are very complex patients,” adding that it required more than looking at reimbursements.

There were conversations about the lack of access to child psychiatrists, given the sparse number of providers, and the fact that few, if any, accepted insurance. Another gap identified was the lack of dental providers in the state, and the fact that rates for adult dental providers under some insurance plans had not increased for 24 years.

Another commission member, Susan Storti, the president and CEO of the Substance Use and Mental Health Leadership Council, said it was important to remember that when focusing on reimbursements, there was another group who were left out of the equation altogether, the people who could not afford or access services.

Paying attention
There were no TV cameras present covering the commission hearing, no radio reporters, and no newspaper reporters, no other news media save for ConvergenceRI. But there were a number of health advocates that were paying attention and who spoke up at the end of the meeting, part of the policy of inclusion that Miller stressed as being an important part of the commission’s ground rules.

Representatives from the R.I. Parent Information Network, Rhode Island Kids Count and the R.I. Healthcare Access and Affordability Partnership, or HAPP, spoke.

The representative from HAPP challenged the commission to consider the opportunity to enact a single-payer, Medicare For All, health plan for Rhode Islanders, and to push for a state audit of the private NGOs that were involved in delivering health care services under Medicaid.

Miller pushed back, saying: “We can walk and chew bubble gum at the same time. We can consider future plans that are very, very ambitious, but we can also look at how to improve the existing networks and structures,” adding that improving the existing system through legislation would not preclude other conversations.

Members of the commission include: Sen. Miller; Neil Sarkar, Sen. Louis P. DiPalma; Sen. Thomas J. Paolino; R.I. Health Insurance Commissioner Marie Ganim; R..I. Executive Office of Health and Human Services Secretary Womazetta Jones; Rhode Island Medical Society President Dr. Peter A. Hollmann or his designee; Dr. David Kroessler, a community-based psychiatrist; Rhode Island Health Center Association President and CEO Jane Hayward; Substance Use and Mental Health Leadership Council President and CEO Susan A. Storti; Blue Cross Blue Shield of R.I. Chief Medical Officer Dr. Matthew Collins or his designee; United Healthcare Chief Medical Officer Dr. Ana R. Stankovic or her designee; Hospital Association of Rhode Island President Teresa Paiva Weed or her designee; CODAC Behavioral Healthcare President and CEO Linda E. Hurley; Delta Dental President and CEO Joseph R. Perroni or his designee, community-based psychologist Peter M. Oppenheimer; and RI Primary Care Physicians Corporation COO Noah Benedict.

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