Commissioner King on New Regulations to Strengthen Primary Care
RI Health Insurance Commissioner
In February, the Office of the Health Insurance Commissioner (OHIC) finalized new regulations, effective March 20, that mandate commercial health insurers to increase funding for primary care and begin reducing administrative burdens due to prior authorization policies. The new regulations are a preliminary step toward addressing the significant challenges facing primary care in Rhode Island that were documented in OHIC’s December 2023 report: Primary Care in Rhode Island: Current Status and Policy Recommendations. OHIC suggests other actions are needed by state and federal authorities to further sustain the primary care workforce and strengthen access for the future.
We connected with OHIC Commissioner Cory King to weigh in on these important changes and their impact on primary care.
1. The Affordability Standards have guided insurers to prioritize investment in primary care. What primary care progress has this supported in recent years?
Guiding investment into primary care has long been a focus of OHIC’s work. The original Affordability Standards established in 2010 set in motion an increase in primary care funding over a five-year period that supported the creation of the patient-centered medical home (PCMH) model and laid the foundation for value-based payment models. To drive multi-payer participation, OHIC co-convened CTC-RI, which led the transformation of dozens of primary care practices over several years and created a forum for primary care and payer collaboration. In 2015, as practices reached the end of their terms with CTC-RI, OHIC established regulations to ensure continued commercial payer funding for OHIC-recognized PCMHs.
2. How are the Affordability Standards helping Rhode Island address the current primary care workforce crisis?
The Affordability Standards are an important regulatory tool to increase funding for primary care by shifting a greater percentage of the health care dollar to primary care. Funding is an important input to address workforce challenges, but complementary actions are needed. Ultimately, the US needs to train more primary care providers, and we need to offer more up-front financial incentives to encourage students to enter primary care, such as tuition waivers and loan forgiveness.
3. What new or upcoming changes can you share with the primary care community?
On March 20, OHIC’s amended regulations will be effective. The new regulations mandate a multi-year increase in primary care funding by commercial payers. The amendments also improve OHIC’s oversight of prior authorization practices and require a 20% reduction in prior authorization volume. The work on prior authorization was facilitated by prior work performed by CTC-RI. We will continue to work collaboratively with all stakeholders to support access to high quality primary care in the state.
Want more information?
Read the Rulemaking Documents
Public Comments from November 2024
Regulatory & Cost-Benefit Analysis
Final Regulation 230-RICR-20-30-4
OHIC Answers to Common Questions
Why did OHIC issue these new regulations?
The Health Insurance Commissioner has an obligation under Rhode Island law to discharge the powers and duties of the office to “view the health care system as a comprehensive entity and encourage and direct insurers towards policies that advance the welfare of the public through overall efficiency, improved health care quality, and appropriate access.”
With this mandate in mind, in December 2023, OHIC published the report: Primary Care in Rhode Island: Current Status and Policy Recommendations. The report examined state and national primary care data, and drawing on interviews with local primary care providers, identified pressing challenges facing Rhode Island’s primary care system in the domains of workforce, payment, and administrative burdens. The challenges facing primary care are not unique to Rhode Island.
The report concluded with several recommended actions, including amendments to OHIC’s powers and duties regulation (230-RICR-20-30-4), to strengthen primary care in the state by increasing commercial insurer funding requirements. By strengthening primary care, Rhode Island will be in a better position to keep rising health care costs and premiums under control, while promoting access to care and quality. In October 2024, OHIC issued proposed amendments to 230-RICR-20-30-4 and received public comments in November.
What key actions do the new regulations require?
The new regulations require increased commercial health insurer funding for primary care and reduced administrative burdens due to prior authorization. This framework improves OHIC’s ability to hold insurers accountable for the appropriate financing of primary care, which is necessary to ensure a high performing health care system and the provision of affordable health insurance.
- Building on OHIC’s existing Affordability Standards, the regulations define a new annual primary care spending target that is designed to direct a greater proportion of Rhode Island’s commercial health care spending to primary care. This change is calculated to increase commercial health insurer funding to primary care practices over a four-year period. Based on financial analysis performed as part of the rulemaking process, OHIC projects commercial insurer primary care spending, per member per month, to approximately double from 2022 levels by 2029.
- Commercial health insurers are directed to meet the new target by increasing reimbursement rates for primary care services, increasing primary care capitation rates (where the capitated payment model is used), and increasing funding for primary care practice-based population health management resources, including care management, integrated behavioral health, and staffing for team-based care.
- Currently, OHIC requires commercial health insurers to fund care management and infrastructure for OHIC-recognized patient-centered medical home (PCMH) practices. The new regulations decouple primary care PCMH care management and infrastructure payments from total cost of care risk payment models to reduce financial risk to primary care practices and Accountable Care Organizations.
- Building on the work of OHIC’s Administrative Simplification Task Force, the regulations mandate a reduction in prior authorization volume, with preference for requests managed by primary care providers. Additionally, health insurers will be required to follow specified guardrails, submit data and annual attestations on prior authorization practices to OHIC, and participate in a new OHIC-convened statewide advisory committee on prior authorization. OHIC will make the data and attestations public.
What resources made OHIC’s new efforts possible?
In 2022, the General Assembly authorized new program funding requested by Governor McKee for OHIC to create the Health Spending Accountability and Transparency Program. Elements of the program were modelled on the work of the Massachusetts Health Policy Commission. A core focus of the program is the collection, analysis, and interpretation of health care spending data to develop interventions to make health care more affordable. Among other initiatives, OHIC has utilized the resources of this program to dig deeper into primary care spending data and to develop a new approach to measuring primary care spending. This new approach facilities OHIC’s efforts to hold health insurers accountable for appropriate funding of primary care. Appropriate funding of primary care will position the state to make headway against rising health care costs by emphasizing prevention and chronic care management. Going forward, OHIC will annually report primary care spending data, by insurer, as part of its annual reporting under the auspices of the Health Spending Accountability & Transparency Program.
Will OHIC make changes to these regulations in the future?
OHIC will continue to work collaboratively with primary care providers, health insurers, and patient advocates. Supported by public reporting on commercial health insurer primary care spending and the convening of OHIC’s new statewide advisory committee on prior authorization, OHIC will take a data-driven approach and remain open to policy changes to continue to strengthen primary care in the state.
What further actions are needed to solve the problems facing primary care?
A host of state level and national actions are needed to fully address the challenges facing primary care. Some of these actions are included in Governor McKee’s FY 2026 budget proposal, including primary care rate review for Medicaid and new funding for loan forgiveness for primary care providers.