PROVIDENCE – Last week, the Office of the Health Insurance Commissioner approved a series of rate increases for commercial insurance plans, despite opposition from Attorney General Peter Neronha.

Before the ruling by Cory King, the RI Health Insurance Commissioner, ConvergenceRI had run, in detail, the details of the Attorney General’s opposition.

Following the ruling by Commissioner King, ConvergenceRI asked a series of questions about the current landscape of health care regulation. Here are the responses:

ConvergenceRI: What is the status of the proposed rate increases for Medicaid providers? When will they take effect?   
KING: The Medicaid rate increases are scheduled to go into effect October 1^st. EOHHS has launched an informational webpage to help providers understand the administrative steps involved in the rate implementation and follow updates. This information can be found in the link below.

OHIC has begun the second cycle of the provider rate reviews, and our next report is due September 1, 2025. Presently we are working with the providers to understand their highest priority services for review through an independent rate model or “ground up rate build” as we often refer to it. We are also looking to implement some process improvements, based on lessons learned during the rate review cycle in 2023.

ConvergenceRI: What are the conversations you would like to see happen around health care delivery?    
KING: I think there is a robust dialog occurring around health care delivery right now. However, we need to continue to ensure that the dialog is informed by data. The report that was prepared by Manatt for the Rhode Island Foundation is a good example of bringing the data to the forefront of discussion and I have been pleased that people are using it.

Some future areas of inquiry should focus on physician reimbursement, compensation, and ownership structures involving hospitals. As hospital-based systems acquire physician practices, how do these acquisitions impact the financial performance of the corporate entity as a whole? In some instances, the hospitals lose money on their owned physician practices. This is not necessarily an issue that is unique to Rhode Island, based on what I have heard from health policy leaders in other states.

I also think we need to improve our mechanisms for measuring and monitoring access to care. As part of the Medicaid rate review, we found that a paucity of data on access characterized much of the landscape of in-scope social and human services. With the implementation of the new Medicaid rates, it will be necessary to understand how the higher rates will improve access over time. But we need to consistently assemble the data first.

ConvergenceRI: What are the missing details, context and nuance that folks tend to get wrong in discussing health care regulation in Rhode Island?    
KING: Regulatory structures differ from state to state. As part of my involvement with the National Academy for State Health Policy [NASHP] and the Peterson-Milbank Program for Sustainable Health Care Costs, I interact with state health policy leaders from around the country.

We learn a lot from each other. But in my view, there is no single, best way to configure oversight of the health care system. States can have a constellation of agencies, or one big agency that consolidates most functions. There are pros and cons of each approach. The key ingredients to effective regulation and oversight are to have strong regulatory tools that are insulated from regulatory capture, sufficient human and fiscal resources, and goals to guide your work. I have long felt that talk about simply moving agencies around, or putting them together into one place, doesn’t get to the heart of the matter, which is that you need people, authority, and goals.

There are some areas where Rhode Island needs more tools for regulation and oversight. One of the recommendations I made in our annual report on health care spending and quality earlier this year, is that the state should create administrative capacity to collect, analyze, interpret, and publicly report data on provider finances and operating costs. With health system financial performance in the news, and Rhode Island-based systems looking to expand into southeastern Massachusetts, we really need transparency into their finances.

I also believe we need better tools for oversight of physician group practice acquisitions. I am not aware of any formal notice requirements, or cost and market impact review requirements, for large physician group practice acquisitions, by private equity, hospital-based systems, or other entities.

A tale as old as bureaucracy    
Last week, ConvergenceRI spent more than two hours on the phone with representatives of my dental insurer in an attempt to straighten out a glitch and a mistake made by the insurer.

In June, unbeknownst to me, the health insurer had cancelled my dental policy for alleged nonpayment of my monthly bill. I was not notified of this cancellation until the first week in September, in a letter dated Aug. 23.

The problem was that I had paid my bill and I had both the cancelled check and the priority mail receipt proving that my check had been received by the insurer.

In the meantime, I had some very expensive dental work done, under the assumption that I had dental coverage.

After I had complained and filed a grievance, I received a voicemail, which said: “Hi, this is Rose from [the insurer]. I was just calling to let you know that we (went) ahead and reinstate your dental policy. We did find that check and we were able to apply (it) to your account so that your are reinstated and you should have zero hiccups in any of your policy coverage.”

However, when I called back to clarify that the claim filed for the work done in July would result in payment from the insurer, I spent two hours being bounced from the membership office to the dental office and back again. It seemed that although I had been notified that my dental policy had been reinstated, the dental division had not communicated that with the membership division, and my insurance claim would not be honored.

When I attempted to speak to the supervisor, it took another round of transfers before I was able to talk to her. She, in turn, told me that until membership could verify that my policy had been reinstated, no action could be taken on my insurance claim. Because the verification would not take place in time for any checks to be processed this week, it may probably happen next week, after the reinstatement of my policy had been verified.

The level of frustration in confronting apparent errors by the insurer – failure to accurately account for my check, cancellation of my dental policy without any notice to me, reinstatement of my dental policy without any coordination between the membership and dental division – was extremely high.

The bottom line: Even for a patient such as myself, engaged in the delivery of care and in my treatment, and knowledgeable about the health care delivery system, it was exceedingly difficult to navigate through the bureaucracy.