PROVIDENCE – There is so much news swirling about the delivery of health care these days it is, as Firesign Theatre, the comedy troop, once quipped, “hard to tell the ACs from the DCs.”

•    The unraveling of bankrupt Steward Health Care continues.
•    There is now a shortage of IV fluids that is affecting the ability of hospitals to conduct elective surgeries.
•    The proposed sale of the two Rhode Island hospitals owned by the private-equity firm, Prospect Health – Roger Williams Medical Center and Our Lady of Fatima – to the Centurion Foundation is still being negotiated.
•    The state contract for roughly $3 billion a year for five years, awarded in July to two private health insurers, Neighborhood Health Plan of Rhode Island and UnitedHealthcare of New England, to manage the Medicaid Managed Care Organizations in Rhode Island, has been rescinded. That action followed appeals by the two private health insurers, Tufts Health Plan and Blue Cross and Blue Shield of RI, who were not selected.

In his Oct. 15 letter, Jonathon Womer, the state’s Director/Chief Purchasing Office, announced that the contract award was being rescinded and that a new private contractor would be hired to rescore the bids.

According to Kathy Gregg, Providence Journal reporter, Mark Kraics, the deputy Medicaid program director, “got personal” in his response to the appeal raised by Blue Cross and Blue Shield of Rhode Island, as quoted in the Womer letter.

Ironically, the issues that did not seem to be addressed within the contract evaluations were any concerns that had been raised directly to EOHHS by Medicaid providers about the apparent oversized, controlling role that Optum, a for-profit, wholly owned subsidiary of UnitedHealthcare, has been playing in managing behavior health and pharmacy benefits.

As one provider told ConvergenceRI: “It’s frustrating as a provider to know that all of our concerns about Optum’s near monopoly are falling on deaf ears. I’m not sure who is actually looking out for the people who do this lifesaving work every day in spite of the systemic barriers coming from every angle.”

•    The transformation of the health care system formerly known as Lifespan into Brown University Health, and in shorthand, Brown Health, officially took effect on Oct. 15. As part of that effort, the name of Coastal Medical has been rebranded to “Brown University Health Medical Group Primary Care,” with the following messaging attached: “While our name is new, our commitment to you is stronger than ever. Thank you for trusting us with your care!”

One of the questions that remains unanswered is this: How does Brown Health fit together with the medical foundations doing business as Brown Physicians Inc. and what is now known as Brown Medicine?

•    The leadership at CVS has changed, with CEO Karen Lynch ousted and being replaced David Joyner, head of CVS’s Caremark pharmacy benefit management division. In a recent interview with the Boston Globe, Lynch identified the root cause of health care disruption, reflecting upon the fact that 5 million people walk into CVS stores every day: “Health care is complicated, and health care is hard. But why it is hard is because it is not connected. And we have the ability to connect those experiences and make sure that we’re delivering care purposefully and intentionally when and where you need it.”

Beyond the ‘he says this, she says that’ style of reporting    
The wheels on the regulatory bus keep turning round and round at the R.I. Office of the Health Insurance Commissioner, with the release of the latest data analyses around health cost trends. ConvergenceRI reached out to Commissioner Cory King to conduct an interview to capture his insights around what was revealed by the latest cost trends analysis.

ConvergenceRI: What do the latest cost analyses tell us about trends in health care for Rhode Island?    
KING: The latest analyses show a steep increase in commercial health care spending in 2023. This is consistent with the experience we saw in the rate filings this summer. The All-Payer Claims Database [APCD] allows us to drill-down to the specific drivers of spending changes at very minute sub-categories of services.

Reviewing the 2023 commercial data, we found that inpatient facility spending growth was driven by increases in unit payments, outpatient facility growth was driven by increases in utilization, and professional services spending growth was driven by increases in unit payments. Prescription drug spending also continues to rise.

ConvergenceRI: What changes do the data indicate we should look at in terms of policy implementations moving forward? For instance, how does the trend toward outpatient knee and hip surgeries translate to policy changes for hospital costs and stays in skilled nursing facilities?    
KING: I hope that providers and payers will utilize the data to identify areas of opportunity to lower Rhode Islanders’ health care costs. We see opportunities in the data. Site of care is one example. The shift of orthopedic procedures from the inpatient to the outpatient setting has been well documented. The velocity of the shift has been so great that any inpatient facilities that historically relied on a high volume of orthopedic procedures will likely have suffered a loss of revenue.

ConvergenceRI: Do the cost data around mental health include any analyses about increasing medical costs from delays in being able to access care by patients?    
KING: These costs are not directly identifiable in the data as we have presented it. To the extent that delayed access leads to more acute services, like emergency department encounters, or inpatient admissions, the claims are captured in the overall data and cost trends, but not specifically identified as the consequence of delayed access to care in a less restrictive setting.

On the topic of behavioral health, this fall OHIC is completing its first round of data collection on commercial payer expenditures on behavioral health, inclusive of claims and non-claims data. This follows rulemaking in 2023 and I’m looking forward to digging into this information.

ConvergenceRI: Are you planning to do a training session for legislators about how to read, interpret and make use of this new data analysis?    
KING: We have been encouraged to do training sessions for a broader audience, inclusive of legislators. I’m certainly open to this.

In the short run, we will continue to issue special analytic reports, which we have called data stories, monthly that present a topic in a digestible two-pager format. The last one of these we issued focused on the profound shift of orthopedic procedures from the inpatient to the outpatient setting and the impact on overall spending and consumer out of pocket liability.

Our next report will focus on drug rebates and how prescription drug spending is growing at an unaffordable rate even after accounting for drug manufacturer rebates.

ConvergenceRI: How do the recommended changes in legislative authority OHIC is recommending reflect the latest findings of the cost trends?    
KING: OHIC is evaluating legislation to tackle drug prices. The 2023 claims data show continued increases in prescription drug costs, driven by an increase in unit payments. In 2023, commercial retail pharmacy spending increased 9 percent, which was driven by an 11 percent increase in unit payments for a 30-day supply. There are no easy state solutions to address drug prices, but I believe we need to be bold and take action.

ConvergenceRI: What is the status of the primary care group meeting under the aegis of the Governor's plan for addressing changes to the health care delivery system?    
KING: The Primary Care Work Group has discussed and prioritized recommendations to address primary care practice support/workforce retention, payment and investment, workforce recruitment, evaluation/accountability metrics. These recommendations will be finalized at the Nov. 7 Health Planning retreat convened by EOHHS.