Thursday, January 29, 2009

Rhode Island's Health Insurance Commissioner and the Patient Centered Medical Home

The Disease Management Care Blog virtually attended a very interesting January 28 webinar sponsored by the Patient Centered Primary Care Collaborative. Access to this kind of learning experience is one of the advantages of PCPCC membership. (Hint -by the way, it’s free).

The topic was a fav of the DMCB, the Patient Centered Medical Home, titled ‘What is it? Why is this important to employers?’ There were two speakers, and it was the second, Christopher Koller, who really caught the DMCB’s ear.

First, some background. Chris Koller is the Health Insurance Commissioner for Rhode Island. Every State has an Insurance Commissioner, but the DMCB thinks Rhode Island is a distinct outlier because of two unique features:

First, this State has a Commissioner for just health insurance. As far as the DMCB is aware, other States don’t carve that function out, let alone put a former health insurance executive in the post.

Secondly, while State Departments of Insurance are charged with 1) protecting consumers (from unscrupulous insurers who refuse to pay up) and 2) assuring insurers’ solvency (preventing an insurer from declaring bankruptcy and walking away from its debts in the event of a bad year), this Commissioner is additionally charged with protecting providers and ‘encourag(ing) policies that improve quality and efficiency…’ and ‘encourag(ing) and direct(ing) insurers toward policies that advance the welfare of the public….’ This goes well beyond the usual role of being a simple regulator.

One of the centerpiece policies of the Rhode Island Health Insurance Commissioner? You guessed it, The Patient Centered Medical Home.

So what’s the big deal? The vast majority of other PCMH pilots underway are typically being sponsored by a single insurer or are happening on a limited regional basis. Rhode Island has one that is called the Chronic Care Sustainability Initiative, and the difference is that it’s state-wide. More importantly, all of the major commercial insurers (the Blues Plan, United and Neighborhood Health) plus the State Medicaid program plus the State Employees Benefit Plan, the Business Group on Health and other self-insured entities are participating, using a single:

a) set of criteria to accredit a physician practice as a PCMH,

b) contract (with $3 PMPM),

c) fee schedule and

d) set of quality measures.

This is not regulation, it’s intervening and jawboning. This is what many consumers want.

The DMCB wonders if the activism of a State level officer at the level of a Insurance Commissioner may emerge as a key ingredient for the success of the PCMH. Without it, insurers will not only be reluctant to cooperate with their competition but fearful of appearing to anti-competitively collude. What’s more, this gets government Medicaid and the private commercial plans on the same page. This can also act as a safe harbor for further cooperation on other future initiatives. By the way, the same approach is being used in Pennsylvania, though it isn’t the Department of Insurance. Rather, it’s the Governor’s Office of Health Care Reform that is leading (and maybe browbeating?) the multi-stakeholder parade.

Last but not least, the DMCB is very impressed with the ability of the States to execute on novel health care initiatives. By the time ObamaCare passes Congress and the first data arrive from the Medical Home Pilot years from now, Rhode Island and Pennsylvania may long have the answers we need. These State residents won’t need Washington’s Czars telling them what to do and how to do it.

Any problems here? The DMCB is aware of several. There seem to be a relatively low number of involved physicians (N=28), which may make the results hard to assess at that unit of measurement. It may also make the results less generalizable and there is no guarantee that all physicians will want to participate, even if the pilot is successful.

Secondly, the evaluation will be performed by the Harvard School of Public Health. The DMCB has high regard for HSPH, but it thinks that decisions about insurance design and affordability are fundamentally more of an actuarial than a health services exercise. Ideally, it's both.

Finally, this is a test of the PCMH only, without any later generation features such as additional remote telephonic coaching, synergistic benefit and pharmacy designs, consumerism and yes, intelligently designed information and technology registry and decision support.

The DMCB wants to keep an eye on Rhode Island. The State's Motto? Hope. The DMCB’s view? Hopeful over what one State is up to and hopeful that if the PCMH is successful, it works in a multi-payer, State-wide environment.

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