Delivery of Care

Gaining traction

The recommendation by OHIC to increase Medicaid reimbursements by $45 million moves ahead

Photo by Richard Asinof/File photo

Cory King, Acting R.I. Health Insurance Commissioner, speaking at the public forum on Health Care Spending Trends in Rhode Island, held on Monday, May 8.

By Richard Asinof
Posted 9/11/23
The future economic prosperity of Rhode Island hangs in the halance, depending on how the Governor and the General Assembly respond to the recommendations by OHIC to raise Medicaid reimbursements for providers by $45 million.
When will the Boston Globe designate a full-time health care reporter for its Rhode Island market? Will the RIGBH health care summit looking into primary care attempt to tackle the elephant in the market: private equity financiers? When will state regulators look into the apparent conflict of interest regarding Optum, the for-profit division of UnitedHealth, managing behavioral health services for the two largest MCOs in Rhode Island?
On Sunday, Sept. 17, from 12 noon to 4 p.m., the downtown 195 District Park will host the Rally4Recovery event. At a time when there continues to be lots of ongoing discussion regarding the state’s intent to set up a harm reduction center to serve as a safe injection site in Providence, the Rally4Recovery event offers a chance to interact with the numerous agencies and community groups involved with promoting recovery.

PROVIDENCE – Reporting is the art of asking questions and listening carefully to the answers, even if there are no answers or responses forthcoming. And, when the answers are not forthcoming, being persistent.

Last week, ConvergenceRI “broke” the story about the release of a 50-page report produced by the R.I. Office of the Health Insurance Commissioner about its recommendations to increase the rates of reimbursement for Medicaid providers by $45 million.

As with many developments within the health care delivery system in Rhode Island, ConvergenceRI was the only news platform reporting on the report – left standing “naked but not afraid” in the confluence of the rivers of news.

For sure, there were plenty of distractions to keep news reporters occupied – a contested primary to choose the candidates to replace the Congressional seat vacated by David Cicilline, the end-of summer and back-to-school seasonal changes, the beginning of the collegiate and professional football seasons, and the convergence of PVD Fest and WaterFire.

Admittedly, the dense 50-page OHIC report made for difficult reading, given that it delved into the intricacies behind the abject failure to increase Medicaid rates in Rhode Island. The problem with the news media ignoring the report is that the failure to increase Medicaid rates for providers is the linchpin in figuring out solutions to all the crises in health care – the lack of health care workers in hospitals, nursing homes, and community health centers, the reasons behind the breakdown of primary care delivery in the state, the financial instability of major hospital systems, the growing unmet needs for mental health and behavioral health services, the driving force in the cause-and-effect of the flooding of emergency rooms, and a contributing factor to the mounting affliction of homelessness in Rhode Island.

Not to mention the inability of Rhode Island to break free of the economic restraints of a health care system where one-third of the entire population of the state is dependent on Medicaid for its health services.

Translated, the future economic prosperity of Rhode Island is dependent on finding a solution to the low rates of Medicaid reimbursements for providers. And, the Sept. 1 report by OHIC provides a destination where the state needs to go to solve the problems, if anyone is paying attention.

Holding feet to the fire
ConvergenceRI promised to follow up on the initial reporting in the Sept. 4 edition. [See link below to ConvergenceRI story, “New OHIC report recommends $45 M increase in Medicaid provider rates.”

Cory King, the acting OHIC Commissioner, offered these insights into the process and decision-making involved with the Sept. 1 report.

ConvergenceRI: Can you explain why you decided to focus on fee-for-service rates for Medicaid providers?
KING: Our decision to focus on Medicaid fee-for-service rates was driven by the terms defined in the statute. Readers can refer to R.I.G.L. § 42-14.5-2.1. Per the terms of the statute, OHIC’s rate review work was conducted to inform rate setting, which the state has the authority to do for Medicaid fee-for-service rates.

We understood at the outset that decisions on statutory construction needed to be clearly communicated and established through public channels.

That’s why OHIC issued a draft bulletin on project scope in August 2022 for public comment and convened an advisory council. We wanted this work to occur in the light of day and sought to ensure that fundamental decisions on scope were communicated early.

ConvergenceRI: Is there a direct connection between the low rates for Medicaid reimbursements to providers and the ongoing issues in Rhode Island related to primary care delivery?
KING: Given that primary care was out of scope for this review we did not assess this question in the context of the rate review. Separately, I have been undertaking a strategic refresh of OHIC’s primary care strategy. As you are aware, OHIC has a long history of placing primary care on the state’s policy agenda.

OHIC co-convenes the Care Transformation Collaborative with EOHHS and has led a number of other initiatives for primary care. The present time makes an opportunity to reassess our policies and strategies because primary care providers are facing a host of challenges that ultimately impact patients. Since June OHIC has been conducting structured interviews with primary care providers and practice group leadership to understand the issues that most impact them, and how insurers and the office can work in collaboration with them to address these challenges.

The challenges include workforce shortages, payment models, insurer administrative requirements, and electronic health record documentation demands, just to name a few. We are also reviewing recent literature on primary care, such as the 2021 report of the National Academies of Sciences, Engineering, and Medicine on Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. I plan to report OHIC’s findings later this fall.

I would say that states and the federal government have a lot of work to do to address the challenges facing primary care, in the short run and the long run. We have to ensure that not just Rhode Island, but the nation as a whole, have a sufficient supply of primary care providers to meet our needs.

There is no single intervention that will solve all of the problems we have identified. What gives me confidence that we can make headway in Rhode Island is that we have a long track record of collaboration between primary care and government. I will be happy to talk about this more in the future.

ConvergenceRI: Has Gov. Dan McKee or EOHHS Director Richard Charest or their staff requested a briefing from you about the report?
KING: I’ve been very open with leaders and staff within the executive branch. Governor McKee and Secretary Charest have been briefed. Last December when I assumed the role of acting health insurance commissioner, I defined success for this work as delivering actionable recommendations to EOHHS by the September 1st deadline. This would not have been possible without collaboration with EOHHS along the way.

OHIC was given the space and support to reach conclusions independently and objectively. I have kept EOHHS apprised of the status of this work and have been transparent about my thinking throughout. As I reflect on the last few months, I’ve been very impressed by how well everyone in government has worked together to get the job done and I’m grateful for their collegiality.

People in government recognize how important this work is. There are professionals throughout the agencies and within leadership who apply strategic thinking to health care every day, who are working on policies to address our state’s health care workforce needs and looking to the future. OHIC’s recommendations are just one piece of this overall picture. In my cover letter to the final report, I tried to convey that the state has been making significant investments in our health care system through the mechanism of Medicaid in recent years.

ConvergenceRI: What are your expectations for the public session about the report to be held on Sept. 22?
KING: I’m looking forward to the public forum on Sept. 22. OHIC will be joined by the team from Millman, which is the firm that assisted us with this work. Milliman has been great to work with.

I expect constructive engagement from providers and other interested parties in relation to the specific recommendations. When we were developing the independent rate models, we met with providers and reviewed the model assumptions and inputs with them. We also reviewed data submitted by the providers and engaged in dialog.

I also expect we may receive questions about the implications of the recommendations more broadly. As the report hopefully conveyed, the recommendations are directed to a complex Medicaid financing system. The recommendations are only a starting point. As I stated in my cover letter, the recommendations “represent a destination for reimbursement rates, but do not furnish a road map for getting there.” I look forward to hearing from interested parties on Sept. 22.

ConvergenceRI: What is the best way to engage with the current Managed Care Organizations regarding the need to increase the reimbursement rates for Medicaid providers, moving forward?
KING: I don’t have much insight into the contracting cycle between the Managed Care Organizations [MCOs] and their contracted providers. I think the report lays out ways that the established Medicaid fee schedule impacts reimbursement by MCOs. This can be through market practices or state policy, such as state directed payments.

In the case of early intervention, statute prescribes that private payers must pay at least the Medicaid fee-for-service rate, so if the early intervention rates established by Medicaid increase above the private payer rates, then those private payer rates will be adjusted accordingly.

It was not part of OHIC’s scope to work out the details of how the recommendations will interact with MCO reimbursement. That’s why I stated in the report that our fiscal impact estimates, which are based on Medicaid fee-for-service expenditures only, do not include downstream impacts on MCO reimbursement rates, which will likely increase the total impact materially.

ConvergenceeRI: Do you expect that the report will come up during the RIBGH health Care summit on Sept. 14, at which you will be one of the featured speakers?
KING: It may. I think people are still reading the report and evaluating its implications. As I stated earlier, primary care was not in scope, but OHIC is actively engaged with the issues facing primary care. Beyond work we are doing in the state, there may also be opportunities for Rhode Island to partner with Medicare in the future on innovations that would include a primary care component. OHIC and EOHHS have had some discussions with the Center for Medicare and Medicaid Innovation (CMMI) about opportunities to partner with Medicare through future demonstration projects. We will learn more about the specific details of those opportunities in the coming months.

ConvergenceRI also reached out to Senate President Dominick Ruggerio. Here are the responses from the Senate President.

ConvergenceRI: What was the most surprising finding in the report?
SENATE PRESIDENT RUGGERIO: It is not a surprise that Medicaid reimbursement rates for a range of services have been stagnant for far too long. That is why every single member of this chamber – Democrat and Republican – co-sponsored Senate Finance Committee Chairman Lou DiPalma’s legislation, which was ultimately incorporated into the budget, to require the rate review process.

The first step of that process is the OHIC report. This issue continues to be a Senate priority, and I anticipate it will be a significant focus of budget deliberations next session.

ConveregenceRI: What is the likelihood that the Senate will act on the recommendation to raise rates for Medicaid reimbursements by $45 million in the next fiscal year?
SENATE PRESIDENT RUGGERIO: Through the work of Chairman Lou DiPalma and the Senate Committee on Finance, the Senate will continue to take a thorough, thoughtful approach to the budget process as we strive to balance many critical priorities and utilize the resources we have in the most effective manner possible. As we work to enact a responsible budget, the recommendations of this report will be taken into account.

ConvergenceRI: Do you agree with the focus on raising rates for behavioral health, children’s health, and in-home health services?
SENATE PRESIDENT RUGGERIO: Yes. Working to improve the health and wellbeing of Rhode Islanders, especially the most vulnerable members of our communities, remains an urgent priority for the Senate. It is imperative that we also stabilize and strengthen the workforce in these areas.

ConvergenceRI: Which committee will receive the assignment to review the report and act on the recommendations?
SENATE PRESIDENT RUGGERIO: Both the Health & Human Services Committee and the Finance Committee will play important roles in reviewing the report. The Senate Health & Human Services Committee remains a critical conduit for our chamber to hear from providers, community members, and all stakeholders about the challenges we face and the opportunities available to us.

We will rely on the Senate Finance Committee as they review the budget proposals next session. Ultimately, we will work to pass a budget that meets the needs of all Rhode Islanders. In the weeks and months ahead, Senate members and staff will continue discussions with all stakeholders regarding the report and its recommendations.

[Editor’s Note: The Senate President’s office also encouraged ConvergenceRI to reach out to Senate Finance Committee Chair Lou DiPalma. An interview was conducted on Friday evening, and will be included in subsequent coverage.]

ConvergenceRI also reached out to House Speaker Joseph Shekarchi, asking the following questions:
Did you find the OHIC report to be comprehensive, thorough and detailed in its analysis? Did you think that anything was missing? What was the most surprising finding?

Do you think that the recommendation to increase Medicaid reimbursement rates for providers by $45 million in the next fiscal year will have traction?

Do you agree with the report’s findings to focus on behavioral health, children’s health, and in-home health services the correct choices?

Will you be attending the public forum on Sept. 22?

Here are the responses received through the Speaker’s communications office.

SPEAKER SHEKARCHI’S OFFICE: Thank you for your questions. The Speaker in receipt of this report and while he has not reviewed it personally yet, he expects this report will serve as the necessary next step in the ongoing discussions on the best way to ensure access to critical services to those who need them the most.

While he does not plan to attend the planned public comment event later this month, that feedback will be important as will other future public discussions expected to occur before decisions on these issues are made.

ConvergenceRI also reached out to Rich Salit, Public Relations Manager at Blue Cross and Blue Shield of Rhode Island, with the following questions.

What is Blue Cross’s reaction to the OHIC report? Was it thorough in its analysis? Do you agree with the recommendation to increase provider reimbursements by $45 million in the next fiscal year? Does BCBSRI support that recommendation?

How do you think the increase in fee for service rates will impact the rates being charged by MCOs in Rhode Island?

Do you believe that there needs to be a state audit of the current Medicaid MCOs and how they are spending their money? Can you explain the reasoning behind your answer? Will a representative from BCBSRI be attending the public forum that will be discussing the report, scheduled for Sept. 22?

ConvergenceRI also requested the opportunity to conduct an interview with the new chief medical officer at BCBSRI, who began her new job in July.

Here is the response from BCBSRI’s Salit: “Thanks for reaching out. Let me heck on both of these for you.”

Moving forward
At some point, the rest of the news media may – or may not catch up in covering the story regarding raising Medicaid rates for providers in Rhode Island. Questions have also been posed to RI EOHHS and to a number of community agencies. Stay tuned.

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