Start with this action plan
By Jonny Williams, Rhode Island Current
For a new patient visit — about 15 to 30 minutes long — Rhode Island physicians get reimbursed by Medicare $75.05, according to the federal insurance’s fee schedule. Cross over to Connecticut and that visit will bag physicians in that state $77.93. Physicians in metro Boston enjoy a higher rate: $81.64.
The differences may seem inconsequential, but over time they can cost providers and health care systems millions of dollars.
For every primary care provider South County Hospital employed in fiscal year 2023, it lost about $280,000. In total, the hospital lost approximately $4 million, according to figures provided by South County Health, the health system that operates the 100-bed hospital in Wakefield.
“Most health care delivery systems that employ primary care providers have sheltered the providers, their staff, and offices and infrastructure from these harmful reimbursement policies for decades,” said Brian Kwetkowski, assistant vice president of physician services at South County Health and medical director of primary care at South County Medical Group, in a statement provided to the Rhode Island Current. “This often comes at a high cost to an organization’s financial health.”
Addressing these disparities is the task of Cory King, the state’s top health insurance regulator. The Office of the Health Insurance Commissioner (OHIC) recently released a report assessing the state of primary care in Rhode Island. According to the report, primary care in the state is like an ailing patient in need of care.
Many physicians are aging and considering retirement. Those who remain are facing burnout from strenuous workloads and onerous administrative tasks. Doctors-in-training, seeing greener pastures elsewhere and their senior colleagues short-changed by Medicare reimbursements, are leaving Rhode Island and setting up practice in other states.
The report released Dec. 12 concludes that these challenges — workforce shortages, Medicare payment complications and administrative burdens — are reaching a “critical juncture,” and decisive action is needed to ensure equitable access to primary care in the state.
King, who is OHIC’s acting health commissioner, outlined recommendations to address these challenges. Among these are plans to increase reimbursements for some medical services, such as evaluation and management, provided by primary care physicians. OHIC also will seek commitments from health systems to increase compensation and improve support for physicians.
“We will leverage these relationships to make it clear that our intent is to ensure that additional investments in primary care reach primary care providers and their practices,” King said via email.
But King says the top priorities for OHIC “are the planned revisions to our commercial primary care expenditure target to push additional investment to primary care and our efforts to reduce administrative burden by addressing the prevalence of prior authorization.”
In 2010, OHIC created a primary care expenditure target for commercial health insurers. Commercial insurance providers were required to increase their expenditure on primary care by 1 percentage point per year over a five-year period.
According to King, this supported the creation of care delivery models and pay-for-performance incentives for practices. King said OHIC will define new methodology for tracking primary care expenditures and set new targets.
Less prior authorization, please
A chief concern for physicians — as well as a cause for burnout — is administrative burdens such as prior authorization, a process through which physicians get approval from insurance companies to provide services for patients. The process is often tedious, and physicians often find themselves acting as middlemen between patients and insurance providers.
The OHIC has convened a task force, comprised of insurers and providers, to address prior authorization. OHIC is seeking regulatory solutions to this issue, King said
“I would like to reduce the number of services that are subject to prior authorization by examining approval rates and other factors,” King said. “If a service has a high approval rate, we should consider taking it off the list. This will reduce the volume of prior authorization requests.”
The report, however, highlights a discrepancy between physicians and insurers here. When it comes to prior authorization, insurers tend to view it favorably, while physicians do not.
Other recommendations to improve payment processes will require buy-in from insurers and providers. Executive and legislative action is also needed to make primary care jobs more competitive by increasing pay for physicians and offering loan forgiveness.
Peter Hollmann, chief medical officer at Brown Medicine and president of the Care Transformation Collaborative, a network of providers convened by OHIC and the Executive Office of Health and Human Services, said the report addresses many of the concerns of primary care physicians. He is also encouraged by the report’s recommendations and believes they are achievable.
“This is really critical if we are going to have good health of our population [and] be able to recruit employers,” Hollmann said.
He added primary care physicians also have other concerns not included in the report, such as dealing with the cost of medications and limited access to specialty services, such as mental health care, but some of these may be outside the purview of OHIC.
Kwetkowski, from South County Health, also emphasized that challenges with health care spending in Rhode Island are larger than what OHIC’s report addresses.
“Although some of the solutions OHIC lays out may help alleviate challenges in the primary care space, the problem is significantly more expansive than primary care alone, and so, too, are the challenges,” he said.
R.I. has more primary care doctors than national average
King and OHIC spent nearly a year working on the report, which included interviewing health professionals, insurance company representatives and other stakeholders. OHIC also hired Bailit Health, a consulting firm, to help conduct a review of primary care in the state.
Not all news in the report is bad. In some ways, Rhode Island is performing better than most states. According to data from the Health Resources and Services Administration, Rhode Island currently has more primary care providers relative to population than the national average — about 300 per 100,000 people, compared to an average of 232 per 100,000 people nationwide.
Fewer Rhode Islanders also report lacking a personal health care provider than other Americans across the U.S., according to The Commonwealth Fund, though racial and demographic disparities exist.
“Rhode Island is poised to make progress because providers, payers, and advocates have been engaged in collaborative efforts to support primary care for over a decade,” King wrote in the report.
“This history and successful track record of providers, payers, and government working in collaboration to support access to high-quality primary care will serve us well.”
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Rhode Island Current is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Rhode Island Current maintains editorial independence. Contact Editor Janine L. Weisman for questions: info@rhodeislandcurrent.com. Follow Rhode Island Current on Facebook and Twitter.