Health care professionals are closely monitoring the fallout of new regulations the R.I. Office of the Health Insurance Commissioner established this year that are intended to give a boost to primary care doctors.
In March, the commissioner’s office updated its affordability standards – regulations created in 2009 designed to lower costs and boost health care quality – requiring insurers to reduce prior authorization requirements and allocate more money for primary care. The update comes after a report OHIC released in December
2023 that found primary care practices were facing several challenges with payments and administrative burdens.
Under the new regulations, commercial insurers will have to raise the amount they spend on primary care service from 5% of the money they collect in premiums to 10% by the end of 2028. Data from 2022 shows that insurers’ investments in primary care fell from 6% to 5%, according to Cory King, the health insurance commissioner.
“We have a health care system that is out of balance,” King said. “Primary care’s share of total resources in the health care delivery system is declining, but primary care is the segment of the delivery system that has a great deal of influence over the rest of the health care dollar.”
The update also reduces the number of situations in which a doctor has to get an insurer’s approval before a patient can receive certain tests, procedures, or medications. Such authorizations are meant to control costs, but doctors say they can delay care and create extra administrative work.
The regulations now say insurers must drop prior authorization requirements by 20% by the end of 2026. The reductions must be relative to the number of prior authorization requests issued in 2023 and OHIC may consider steps insurers took to reduce these before 2023.
OHIC’s new regulations are bolstered by a law the General Assembly passed this year to create a three-year pilot program banning insurers from requiring prior authorizations for “medically necessary” services ordered by a primary care doctor.
Insurers have raised concerns that removing too many prior authorizations could lead to unnecessary services and, ultimately, wasteful spending and higher costs.
OHIC also plans to track the effects of cuts to prior authorization requirements and submit annual reports to the General Assembly. But King says the effects of fewer prior authorizations have been minimal so far.
“None of the insurers have come running to me saying, ‘We have to increase our health insurance premiums for next year materially,’ ” King said. “We’ll find out with experience, though.”
Indeed, insurers are wary of the new affordability standards.
Both Blue Cross & Blue Shield of Rhode Island and Neighborhood Health Plan of Rhode Island raised concerns about the timeline to meet the requirements.
The combined effect of raising primary care spending by insurers and reducing prior authorizations could make health care more expensive, said Kristen Shea McLean, senior vice president and general counsel for Blue Cross in a Nov. 15 letter to regulators.
“Mitigating the impact to affordability will be even more challenging if insurers are required to rush through implementing these changes without sufficient time for thoughtful analysis,” Shea McLean said.
Initially, the deadline for reducing prior authorizations was proposed for the end of 2025, but after Blue Cross raised concerns about timing, OHIC agreed to delay it for a year.
Blue Cross didn’t have the same luck with its suggestion to delay the deadline for increases to primary care spending. And neither did NHPRI, which suggested pushing the higher primary expense target from 2028 to 2032.
Now the insurer has changed its tone.
“Efforts to bolster primary care are critical to strengthening Rhode Island’s health care system and enabling preventive care, which, in the long term, will lower the total cost of care by reducing costly hospitalizations for conditions that could have been addressed earlier,” said Blue Cross spokesperson Rich Salit.
Starting in October, Blue Cross plans to eliminate all prior authorizations for primary care services and will continue to look for ways to relieve administrative burdens while “balancing affordability for its members,” Salit said. Also, by January 2026, Blue Cross’ rates for primary care providers will rise 30% for fully insured members – a move that contributed to more than 20% of the insurer’s proposed 2026 premium increases.
Others, including Integra Community Care Network LLC, the state’s largest accountable care organization, suggested that OHIC set more-ambitious targets in the years leading up to the 2028 deadline to increase primary care spending by insurers to 10%.
But OHIC declined, saying it tried to balance financial considerations of health insurers with the need to boost resources for primary care.
“We would not be seeing an increase in primary care investment by the commercial payers unless this office mandated it,” King said.
Overall, primary care advocates are supportive of OHIC’s updated regulations.
“The evidence is clear: When we invest more in primary care, we spend less on health care overall,” said Noah Benedict, CEO and president of Rhode Island Primary Care Physicians Corp. “While an increase to 10% is a promising start, realizing the broader benefits of primary care will require continued and expanded investment.”
Stacy Paterno, executive vice president of the Rhode Island Medical Society, agrees but says it will take time to see significant effects from the new regulations.
“The updated affordability standards are a meaningful step toward improving access and reducing administrative burdens,” Paterno said. “We’ll be monitoring their impact closely.” n
