Delivery of Care

In a time of health care crises, OHIC puts the focus on finding solutions

OHIC seeks to create a systematic approach to how health care delivery is being financed, creating a continuum of care across payers and providers

Photo by Richard Asinof

R.I. OHIC Commissioner Patrick Tigue.

By Richard Asinof
Posted 9/26/22
Under the new rate-setting law, OHIC has been tasked with conducting a comprehensive analysis of the rates being paid to providers of health and human services to providers working under the umbrellas of R.I. EOHHS.
What is the most appropriate forum to have a conversation around what kind of health system we want to have? And, what are the best state policies to address what we want to achieve in terms of greater health equity? Given the large size of Rhode Islanders who are receiving Medicaid as their health insurance, does it represent the best avenue to create a pathway to achieve social justice – or does it create a permanent underclass of Rhode Islanders? When will the state conduct an audit of the current MCOs who are responsible for managing the health care for more than 300,000 Rhode Islanders?
The retirement of Elizabeth Burke Bryant after 28 years at the helm of Rhode Island KIDS COUNT represents a generational change when it comes to community advocacy and organizing around championing the voices of children in Rhode Island. One of the most recent political victories, the restoration of the rights for immigrant children to be covered with health insurance, regardless of immigration status, is a game-changer when it comes to improving health outcomes, to be able to “Cover All Kids.”
The tenaciousness of Burke Bryant in promoting an “all kids” agenda has made a true difference for two generations of Rhode Island’s children. The RI KIDS COUNT Factbook has become the veritable scripture for lobbying on behalf of children. As someone who has collaborated frequently with Burke Bryant since 1994, our conversations have always had the feel of a mutual admiration society.


CRANSTON – Few would argue with the fact that we are living through a time when the health care delivery system in Rhode Island is disrupted, boiling over in crisis after crisis.

Emergency physician Dr. Megan Ranney, MD, MPH, normally a voice of optimism, recently described the situation in a tweet, saying: “The current model of health care is so broken,” in response to an article published on Saturday, Sept. 24, in The New York Times, entitled: “Profits over Patients.”

The story’s main headline read: “They Were Entitled To Free Care. Hospitals Hounded Them To Pay.” As the subhead explained: “With the help of a consulting firm [McKinsey & Company], the [nonprofit] Providence hospital system trained staff to wring money out of patients, even those eligible for free care.”

In a follow-up tweet, Dr. Ranney quoted at length from the article: “The Times found that the consequences have been stark. Many nonprofit hospitals were ill equipped for a flood of critically sick COVID-19 patients because they had been operating with skeleton staffs in an effort to cut costs and boost profits. Others lacked the intensive care units and other resources to weather a pandemic because the nonprofit chains that owned them had focused on investments in rich communities at the expense of poorer ones.

The excerpt continued: “And, as Providence [hospital system] illustrates, some hospital systems have not only reduced their emphasis on providing free care to the poor but also developed elaborate systems to convert needy patients into sources of revenue. The result, in the case of Providence, is that thousands of poor patients were saddled with debts that they never should have owed, The Times found”

For OHIC Commissioner Patrick Tigue, in an in-depth, one-on-one, in-person interview with ConvergenceRI, when looking at the overall health care delivery system in Rhode Island, the future focus needed to be on creating what he called “a rationalized reimbursement system.

To do this, Tigue continued, it required creating the space to have that kind of in-depth conversations that are often missing in the abrupt debate and dialogue around health care policy and regulations.

In PART One, Commissioner Tigue revealed his innovative plans to create a “next generation” affordability standard, focused on creating an investment strategy for commercial insurers to invest in community-based behavioral health services, the first of its kind in the nation.

In PART Two of the ConvergenceRI interview, Commissioner Tigue detailed his intention to find common ground across all payers to create a more equitable financial structure for a continuum of care in Rhode Island, focused on affordability, quality, and better health outcomes. And, his continuing plans to introduce more additional, “next generation” affordability standards, including one focused on health equity for the commercial payers.

ConvergenceRI: In the past, within your regulatory framework, you have done assessments around parity that have found the commercial insurers to be less than stellar, my words, in their performance. And, you have “punished” them, once again, my words, assessing financial penalties to have them make amends for their lack of parity, mandated by law. Is this the best way to improve the outcomes around parity in behavioral health care for commercial insurers in the Rhode Island market?
TIGUE: I’m glad you asked the question, because it goes back to OHIC’s functions as an agency. You can really divide our functions into two large categories: one is policy reforms, like the one we talked about, the behavioral health spending standard, based on the primary care spending standard.

The other function, which is equally important, is regulatory enforcement – market conduct examinations or investigations into insurers’ non-compliance – and then taking corrective action, or imposing sanctions on insurers who haven’t been complying

The reason I mention that, in this context, in response to your question, is that I don’t see the behavioral health-spending standard as a way to remediate non-compliance, with behavioral health parity. But, I see it as a way to advance behavioral health access, in order to continue to address the issues around behavioral health parity.

Both [strategies] need to be done in complementary fashion; they are two separate but complementary approaches. Let me give you an example of what we are doing with regulatory enforcement.

We are fortunate to have received a CMS [Centers for Medicare and Medicaid Services] grant to be able to push forward with our behavioral health regulatory enforcement. One really important part of that grant that we are in the process of developing is what will become a semi-annual – meaning twice a year – meaning a twice-a-year, dedicated, behavioral health parity oversight and reporting process for the payers here in the state of Rhode Island.

Simply put, they will have to report to the Office, twice a year, on a series of standard variables, that will allows us to assess their compliance with the behavioral health parity law. And then the Office will be able to take actions, based on the outcomes for those assessments.

So, that’s one example of a regulatory enforcement mechanism. But I think you really said it best, a minute ago, when you said that there were two streams, in order to achieve a policy goal of a high-functioning behavioral health care system, in the commercial market.

In Rhode Island, we need both policy reform to address the issues that are there, and we also need regulatory enforcement actions, to ensure that commercial payers are following the law. It is a both/and, not an either/or approach.

ConvergenceRI: As part of the new law enacted by the R.I. General Assembly during the last session, OHIC was given specific responsibilities to develop a comprehensive assessment and to produce reports regarding the rates for human and social services programs under the umbrella of R.I EOHHS. Can you describe what those responsibilities are?
TIGUE: As part of the FY 2023 budget, OHICs powers and duties were amended to undertake a review of the social and human services programs, and the rates paid by the state to providers of those services.

Reports will be prepared in three tranches: The first is due on January 1, 2023; the second is due on April 1, 2023, and the final set of reports is due on Sept. 1, 2023.

And then, the report will be due every other year, on Sept. 1. A fair way to read the new law is to think of the first two reports, the January and April reports, as foundational reports, as level-setting reports.

OHIC’s role is to be an independent, credible source of information, and to make that information available not only to EOHHS and its agencies under its authority, but also to the Governor and the General Assembly.

ConvergenceRI: And, to the public?
TIGUE: Absolutely. It is all going to be completely public. The law specifically requires the September report to have an opportunity for public input, responses and feedback.

The law doesn’t specifically require it, but because of OHIC’s tradition of strong, transparent public feedback, we will be forming our own advisory council, similar to the Health Insurance Advisory Council, which will convent for the first time, later this month, in September.

The Council will provide OHIC with advice on how to carry out its duties under the review of the social and human services programs. It will be comprised mostly of consumer advocates but also providers.

But the most valuable thing about it, Richard, is it will be fully transparent. I’ve committed to meeting at least monthly, more likely more than that at the outset. We are going to do all this work in the light of day. And, the value for me in that is two-fold.

First, we will benefit from everyone’s feedback, up front, so that we have the benefit of everyone’s best thinking.

ConvergenceRI: Some critics of the process have raised the issue about the process of hiring a consultant to assist your agency with the work, worried that this is just another example of state government paying for a high-priced business consulting firm.
TIGUE: That is an entirely fair question. I can tell you how we are handling the issue. The General Assembly, and the Governor, in signing the legislation, recognized that it needed to have the administrative capacity within state government to do this work well.

I can tell you that we have hired a dedicated FTE for this position; they will start at the end of next week, working directly with myself and my chief of staff, Cory King, to carry out this work.

OHIC certainly has the expertise that is relevant to this, when we are looking at the commercial health insurance premiums. But this analysis requires a distinct kind of expertise in working with the social and human services system. I wouldn’t describe this as simply outsourcing the work.

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