Primary care investment slowed rising health care costs in R.I.

AS COSTS RISE: A chart showing the total percentage of primary care spending of total health care spending. Actual figures are higher than the state mandate as a result of individual companies' investment beyond regulatory requirements. / COURTESY OHIC
AS COSTS RISE: A chart showing the total percentage of primary care spending of total health care spending. Actual figures are higher than the state mandate as a result of individual companies' investment beyond regulatory requirements. / COURTESY OHIC

PROVIDENCE –  Annual check-ups and acute care for urgent illness don’t keep people healthy long-term, so Rhode Island’s Office of the Health Insurance Commissioner mandated increased local primary care spending between 2010-2014, slowing health care cost increases to 1.6 percent annually, among the lowest in New England.

Christopher Koller, R.I. health insurance commissioner from 2005 to 2013, the first in the United States named to such a post, began increasing the amount of money allocated by providers to quality primary health care by 1 percent each year starting in 2010.

During an evidence briefing on Capitol Hill in Washington, D.C., July 10, Koller, now the president of the Milbank Memorial Fund, noted his research into European models of high-quality health care informed his decision. “The evidence is really strong about how any high-performing health care system has to have primary care at its core. The evidence is also really strong that we in the United States don’t follow that evidence,” Koller said.

A June Health Affairs article reported the amount of personal health care spending in each state in the nation. Rhode Island’s 1.6 percent yearly increase in personal health care cost is the second lowest in New England, slightly above New Hampshire’s 1.3 percent increase. Maine had the highest cost increase among New England states, with 4.2 percent.

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Corey King, principal policy associate with OHIC, said the agency exercised its regulatory power to require health care providers to increase primary care spending, mainly through the use of care managers to administer to the needs of high-risk patients.

In 2008, 5 percent of total private medical spending was on primary care. Koller’s plan increased that by 1 percent each year, till it reached 11 cents per dollar in 2014, King said.

The strategy is an element of the patient-centered medical home model.

High-risk patients suffer from chronic, long-term conditions such as diabetes or heart disease, said Debra Hurwitz, executive director of the Care Transformation Collaborative of Rhode Island, which promotes care for patients with chronic illnesses through the PCMH approach.

With PCMH, doctors are now focusing more on screenings, including taking proactive steps to identify and treat depression and anxiety disorders in patients, and referring them to specialists. In some cases, a doctor’s care manager is helping patients overcome more difficult obstacles to accessing care, including homelessness.

“These are things that primary care has never really been able to deal with,” before the switch in approach to PCMH, Hurwitz said.

Hurwitz said the CTC is now working with 650 doctors to use PCMH in more than 100 practices, serving about 400,000 patients. “We’re spreading and it’s proving to be effective,” she said, referencing the report.

CTC also reports that 12 primary care practices have begun regular screenings for depression, anxiety and substance use within the primary care setting as part of an effort to integrate behavioral health with primary care.

The PCMH approach has slowed the rise of health care cost increases, King said, partly by heading off more expensive emergency room visits and preventing chronic, long-term conditions from leading to hospital visits.

Additional factors contributing to Rhode Island’s slow health care spending growth include the Great Recession, and an OHIC-instituted annual cap on the allowable price increases that health insurers could pay hospitals during that period, an average of 3.1 percent. Since 2014, OHIC has tied the cap to the consumer-price index, coincidentally also at a current 3.1 percent, King said.

After 2014, OHIC ended its requirement to increase investment in primary care, instructing them to maintain their current 10.7 percent of spending in that area. OHIC assessed the state’s current level of investment in primary care, finding the spending increases had brought Rhode Island in line with spending by other high-spending health care systems in the U.S.

Rob Borkowski is a PBN staff writer. You can email him at Borkowski@pbn.com.

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