Health care reform at the Health care reform at the state and federal levels: state and federal levels:

Role of the Health Role of the Health Insurance ExchangeInsurance ExchangeLouis “Lou” Giancola, CEO, South County Louis “Lou” Giancola, CEO, South County

HospitalHospitalWorking group participant, HealthRIghtWorking group participant, HealthRIght

Konstantine "Nick" Tsiongas, MDKonstantine "Nick" Tsiongas, MD

Founding chair, HealthRIght board.Founding chair, HealthRIght board.

Quick PC introductionQuick PC introduction

Why this topic?Why this topic?

Psychological Centers’ positionPsychological Centers’ position

The role of the health The role of the health insurance exchange in insurance exchange in

health care reformhealth care reform

Health care reform will bring a number of Health care reform will bring a number of changes to behavioral and medical care in changes to behavioral and medical care in RIRI

One of the most important will be the One of the most important will be the mandatory creation of a health insurance mandatory creation of a health insurance exchange, through which individuals, small exchange, through which individuals, small businesses, and possibly many others will businesses, and possibly many others will be able (or required) to purchase their be able (or required) to purchase their health insurance coveragehealth insurance coverage

Today’s trainingToday’s training

The basic definition and possible The basic definition and possible configurations of the health insurance configurations of the health insurance exchangeexchange

Rhode Island's current proposed exchange Rhode Island's current proposed exchange legislationlegislation

Implications of different possible exchange Implications of different possible exchange configurations and policy decisions that are configurations and policy decisions that are relevant to how the exchange is designedrelevant to how the exchange is designed

Discussion of how Rhode Island's behavioral Discussion of how Rhode Island's behavioral health community should respond to the health community should respond to the health insurance exchange’s inherent health insurance exchange’s inherent potential and threatspotential and threats

Learning objectivesLearning objectives

Participants will be able to:Participants will be able to: 1. accurately describe what constitutes a health insurance exchange 1. accurately describe what constitutes a health insurance exchange

under federal legislationunder federal legislation 2. identify at least three critical considerations for how best to design 2. identify at least three critical considerations for how best to design

a health insurance exchangea health insurance exchange 3. articulate their own preferences for how a health insurance 3. articulate their own preferences for how a health insurance

exchange be designed for RIexchange be designed for RI

2 CE/CEUs for psychologists, social workers, mental health 2 CE/CEUs for psychologists, social workers, mental health counselors, marriage and family therapists, and Psychiatric counselors, marriage and family therapists, and Psychiatric Clinical Nurse Specialists who attend the entire sessionClinical Nurse Specialists who attend the entire session

The health insurance The health insurance exchange:exchange:

An easy purchasing website?An easy purchasing website?

The health insurance The health insurance exchange:exchange:

Or much, much more?Or much, much more? A robust exchange uses its

purchasing power: Designs benefit packages

service delivery standards payment design quality control

Negotiates terms to offer its customers controls costs maximizes consumers’ purchasing power

Reforming healthcare is easy:Reforming healthcare is easy:Everyone has an answer!Everyone has an answer!

Everyone’s efforts cancel each other out

Answer Answer

Answer

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AnswerAnswer

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The current result:

Everyone has an answerEveryone has an answer

An effective Health Insurance Exchange uses purchasing power and its managers’ expertise in health care financing and policy to improve the health care system and control costs. An effective exchange is an active purchaser, designing benefit packages and negotiating terms to offer its customers.

The Health Insurance The Health Insurance ExchangeExchangeassembles these answersassembles these answersinto ainto a solutionsolution

: Representatives across health care interest groups finding consensus around an effective exchange

The solution:A high-quality,

equitable, affordable health care system

for all

An effective exchange is:• Consumer driven and accountable• Easy to use• Integrated, offering access to private and public (including Medicaid) coverage based on users’ eligibility• Accessible, actively linking individuals, employers and other purchasers to available health care supports• Empowering, enabling consumers to understand and make the best health care choices for themselves

Our health care system is broken…It’s time to make it RIght

Contact: Dr. Amy Black, Director, HealthRIghtTelephone: 401-270-0101 ext 120Email: HealthRIght@ripin.orgWebsite: http://www.rihealthright.org/

Lou GiancolaLou Giancola

President and CEO, South County President and CEO, South County HospitalHospital

Introduction:Introduction:

Headline of why I support a robust Headline of why I support a robust Health Insurance ExchangeHealth Insurance Exchange

The challengeThe challenge

Too many Rhode Islanders are uninsuredToo many Rhode Islanders are uninsured Health insurance costs are unacceptable Health insurance costs are unacceptable

and unsustainableand unsustainable Healthcare access, quality, equity, and Healthcare access, quality, equity, and

design are inadequatedesign are inadequate Rhode Island’s leadership in coverage of Rhode Island’s leadership in coverage of

citizens is declining (from 6th in overall ranking citizens is declining (from 6th in overall ranking in 2007 to 11th in in 2009)in 2007 to 11th in in 2009)

Rhode Island lags at controlling care for cost-Rhode Island lags at controlling care for cost-effectiveness (e.g., 35th in 2009 for minimizing effectiveness (e.g., 35th in 2009 for minimizing avoidable hospital use and costs)avoidable hospital use and costs)

HealthRIght’s guiding HealthRIght’s guiding principlesprinciples

Access to quality careAccess to quality care

Sustainable costsSustainable costs

Goals for health reformGoals for health reform

All Rhode Islanders covered by 2020All Rhode Islanders covered by 2020

Universally available high quality careUniversally available high quality care

Cost increases limited to Consumer Cost increases limited to Consumer Price Index or lessPrice Index or less

Evidence-based, systematically Evidence-based, systematically evaluated health careevaluated health care

Robust health planningRobust health planning

StrategiesStrategies A powerful, strategically operated exchange A powerful, strategically operated exchange

serving as many Rhode Islanders as serving as many Rhode Islanders as relevantrelevant

Promotion of value- and evidence-based Promotion of value- and evidence-based purchasingpurchasing

Strategic use of all health care dollars to Strategic use of all health care dollars to promote cost-effective achievement of promote cost-effective achievement of health outcomeshealth outcomes

Exchange-driven incentives for documented Exchange-driven incentives for documented qualityquality

Coordination of exchange operations with a Coordination of exchange operations with a robust state-wide health planning processrobust state-wide health planning process

What is a health insurance What is a health insurance exchange?exchange?

Establishment of a health insurance exchange is Establishment of a health insurance exchange is now required under federal health care reformnow required under federal health care reform

The goal of these exchanges is to make it easier The goal of these exchanges is to make it easier for individuals and small businesses to shop for for individuals and small businesses to shop for comparable coveragecomparable coverage

They’re also intended to make it easier for low-They’re also intended to make it easier for low-income people to apply for Medicaid and help income people to apply for Medicaid and help business owners and moderate-income business owners and moderate-income individuals apply for federal tax creditsindividuals apply for federal tax credits

What PPACA requiresWhat PPACA requires

States indicate to HHS whether they will States indicate to HHS whether they will operate an American Health Benefit Exchangeoperate an American Health Benefit Exchange Date: January 1, 2013Date: January 1, 2013

State-based American Health Benefit State-based American Health Benefit Exchanges and Small Business Health Options Exchanges and Small Business Health Options Program (SHOP) Exchanges in operationProgram (SHOP) Exchanges in operation Individuals and small businesses with up to 100 Individuals and small businesses with up to 100

employees can purchase qualified coverage, employees can purchase qualified coverage, including through Medicaid and CHIP programs.including through Medicaid and CHIP programs.

Date: January 1, 2014Date: January 1, 2014

Benefits (and risks) of a robust Benefits (and risks) of a robust vs. minimal exchange?vs. minimal exchange?

Purchasing power to control costsPurchasing power to control costs

Control over benefit designControl over benefit design

Potential for influence over Potential for influence over payment designpayment design

Potential for influence over quality Potential for influence over quality controlcontrol

RI’s current proposed RI’s current proposed exchange legislation (SB exchange legislation (SB

87)87) Placeholder intention (and necessity Placeholder intention (and necessity

under PPACA)under PPACA)

Minimal design requirementMinimal design requirement

Board compositionBoard composition

6 month study and report to legislature6 month study and report to legislature

Potential and likely outcomes (and Potential and likely outcomes (and implications)implications)

RI’s current proposed RI’s current proposed exchange legislation (SB exchange legislation (SB

87)87) Placeholder intention (and necessity Placeholder intention (and necessity

to receive federal funding for to receive federal funding for exchange planning and exchange planning and development)development)

SB 87 establishes the infrastructure SB 87 establishes the infrastructure for a health insurance exchangefor a health insurance exchange

RI’s current proposed RI’s current proposed exchange legislation (SB exchange legislation (SB

87)87) Minimal design requirement:Minimal design requirement:

The functions and operations of the exchange shall not expand beyond the minimum requirements of the federal act. No later than January 1, 2012, the board shall submit a report to the governor and general assembly

RI’s current proposed RI’s current proposed exchange legislation (SB 87)exchange legislation (SB 87)

Board compositionBoard compositionThe exchange shall be governed by an executive board which shall consist of eleven members:

(1) Director of the department of administration (DOA) or his or her designee;

(2) Commissioner of the office of the health insurance commissioner (OHIC) or his or her designee;

(3) The secretary of the executive office of health and human services (EOHHS) or his or her designee; and,

RI’s current proposed RI’s current proposed exchange legislation (SB 87)exchange legislation (SB 87)

Board compositionBoard compositionThe eleven members:(4) Eight shall be appointed by the governor from the

general public, with the advice and consent of the senate, two of whom shall represent a consumer organization and two of whom shall represent small businesses. The balance of the appointments to the board shall be made to provide demonstrated and acknowledged expertise in a diverse range of health care areas including, but not limited to:

(i) Individual health care coverage;(ii) Small employer health care coverage;(iii) Health benefits plan administration;(iv) Health care finance;(v) Administering a public or private health care delivery system;(vi) Purchasing health plan coverage; and(vii) State employee health purchasing

RI’s current proposed RI’s current proposed exchange legislation (SB 87)exchange legislation (SB 87)

Board compositionBoard compositionBoard members shall not be employed by, consultants to, members of the board of directors of, members of, affiliated with, or otherwise a representative of

an insurer a health insurance agent or broker a health care provider (unless he or she receives no

compensation for rendering services as a health care provider and does not have an ownership interest in a professional health care practice)

a health care facility or health clinic a trade association of insurers

The board shall conduct a training course for newly appointed and qualified members within six months

RI’s current proposed RI’s current proposed exchange legislation (SB exchange legislation (SB

87)87)Requires data-driven decisions to be made regarding Requires data-driven decisions to be made regarding the design and potential of the exchange on the the design and potential of the exchange on the basis of the 6 month study and report to legislature:basis of the 6 month study and report to legislature:

“Data analysis and recommendations regarding the costs, benefits, and market impacts associated with any expansion of the exchange functions and scope beyond the duties articulated in section 1311 of the federal act. Include in this analysis an assessment of the basic health plan option, as well as the estimated impact on premiums associated with mandating expanded participation in the exchange by groups not included in section 1311 of the federal act”

RI’s current proposed RI’s current proposed exchange legislation (SB exchange legislation (SB

87)87)

Potential and likely outcomesPotential and likely outcomes

(and implications)(and implications)

HealthRIght’s vision of HealthRIght’s vision of the RI exchangethe RI exchange

Who are HealthRIght and why they should be Who are HealthRIght and why they should be trustedtrusted

““Robust” exchange- what it would include Robust” exchange- what it would include and how it would operate/achieve goalsand how it would operate/achieve goals

Key reform elements of an effective Key reform elements of an effective exchange:exchange:

Purchasing powerPurchasing power Design expertiseDesign expertise Stake in what’s best for entire system vs. for any Stake in what’s best for entire system vs. for any

specific elements or agents within itspecific elements or agents within it

HealthRIght’s vision of HealthRIght’s vision of the RI exchangethe RI exchange

Who are HealthRIght and why should they (we) be Who are HealthRIght and why should they (we) be trusted?trusted?

HealthRIght is made up of a broad and inclusive HealthRIght is made up of a broad and inclusive group of representatives from small business, labor group of representatives from small business, labor groups, insurers, healthcare provider organizations, groups, insurers, healthcare provider organizations, academic and health policy professionals, the faith academic and health policy professionals, the faith community and a variety of healthcare advocacy community and a variety of healthcare advocacy groups to work together to ensure that all Rhode groups to work together to ensure that all Rhode Islanders have universal access to a quality health Islanders have universal access to a quality health care system that is affordable, efficient, sustainable, care system that is affordable, efficient, sustainable, easy-to-use and equitableeasy-to-use and equitable

HealthRIght’s vision of HealthRIght’s vision of the RI exchangethe RI exchange

““Robust” exchange- what it would Robust” exchange- what it would include and how it would include and how it would operate/achieve goalsoperate/achieve goals

HealthRIght’s belief: a robust exchange HealthRIght’s belief: a robust exchange is an opportunity to create a mechanism is an opportunity to create a mechanism to transform health care, improve public to transform health care, improve public health, and assure that access to health, and assure that access to coverage will be more affordablecoverage will be more affordable

HealthRIght’s vision of HealthRIght’s vision of the RI exchangethe RI exchange

Purchasing powerPurchasing power

Design expertiseDesign expertise

Stake in what’s best for entire Stake in what’s best for entire system vs. for any specific elements system vs. for any specific elements or agents within itor agents within it

What would be required to What would be required to achieve a robust exchange?achieve a robust exchange?

Policy decisions about exchange Policy decisions about exchange designdesign

Who will oppose which elementsWho will oppose which elements(and why)(and why)

Political process involved/required Political process involved/required to achieve specific design outcomesto achieve specific design outcomes

What would be required to What would be required to achieve a robust exchange achieve a robust exchange

that could meet these that could meet these goals?goals?

Policy decisions about exchange Policy decisions about exchange designdesign

Who will be mandated to participateWho will be mandated to participate What coverage elements can be controlled What coverage elements can be controlled

by the exchangeby the exchange What expertise will be available to the What expertise will be available to the

exchange to make these decisionsexchange to make these decisions What role will be played by various current What role will be played by various current

stakeholders (e.g., brokers, insurance stakeholders (e.g., brokers, insurance companies)companies)

What would be required to What would be required to achieve a robust exchange achieve a robust exchange

that could meet these that could meet these goals?goals?

Who will oppose which elements (and Who will oppose which elements (and why):why):

Broader mandated participationBroader mandated participation More coverage elements controlled by the More coverage elements controlled by the

exchangeexchange Whose expertise the exchange relies on to Whose expertise the exchange relies on to

make these decisionsmake these decisions Narrower roles played by current stakeholdersNarrower roles played by current stakeholders

What would be required to What would be required to achieve a robust exchange achieve a robust exchange

that could meet these that could meet these goals?goals?

Political process involved/required Political process involved/required to achieve specific design outcomesto achieve specific design outcomes

Discussion of Discussion of implications for implications for

behavioral healthbehavioral health