Healthy Rhode Island Reform Act of 2008

Lieutenant Governor Elizabeth Roberts

Healthy Rhode Island Reform Act of 2008

Executive Summary

Overview:

The Healthy Rhode Island Reform Act of 2008 will transform the health care system in our state by putting in place a strong new structure for ensuring that all Rhode Islanders will have access to high quality health care at a price they can afford. This package will immediately start moving to insure over 10% of the uninsured with no new state expenditures, and will establish a serious process for cutting costs and increasing value in our health care system. The legislative package creates a strong and sustainable structure that will make it possible to bring every uninsured Rhode Islander into this new system as money becomes available from the savings accrued through the transformation of the health care system, as well as from other sources. Because the plan focuses on BOTH expanding coverage AND containing costs while increasing value it transforms health care for all of us, not just those who are now uninsured. At its most basic, this legislation is about increasing health care value and access for ALL Rhode Islanders, with the overall result being a transformation of our ailing system into a healthy one.

Aligning Payments to Priorities

In our current system health care providers are paid to perform procedures, not to keep patients healthy. This is bad for patients, bad for doctors, and bad for the system. As we transform our health care system in Rhode Island we need to reverse this and compensate doctors for keeping patients healthy through preventive care and chronic disease management.

The broken compensation system was not built overnight, and it cannot be reformed in a day. However inaction is not an option. In order to ensure real change the Healthy Rhode Island Reform Act of 2008 requires that the state's health planning and accountability advisory council establish a Healthy RI Strategic Plan and Healthy RI Chronic Care Management Program. [Healthy Rhode Island Reform Act of 2008 - Part 1]. The state is a major purchaser of health care on behalf of state employees and Medicaid recipients. This presents a unique opportunity to lead the way in reform initiatives with the health insurance that the state provides. The Healthy Rhode Island Reform Act of 2008 - Part II integrates best practices in insurance coverage, designed to enhance healthy outcomes, into the health insurance that the state provides for state workers and Medicaid recipients effective January, 2009. This means that health insurance provided by the state will include cutting edge chronic disease management, an emphasis on primary care and paying physicians to keep their patients healthy thus leading the way for the state and the nation. Part II of the package goes on to require that all health insurance in Rhode Island integrate these cutting edge practices by January 1, 2010. The Healthy Rhode Island Strategic Plan creates a permanent capacity for the state to incorporate new methods to into a state of the art health system - leaving behind our current "sick care" system. Effective chronic disease management for all Rhode Islanders is only a first step in realizing the potential of this reform.

Organizing Care for Quality and Value

Aligning payments to priorities will go a long way toward bending the health care spending curve downward to a level that is sustainable, but the Healthy Rhode Island Reform Act of 2008 goes further by demanding true cost and outcome transparency and accountability in health care.

One way it does this is through the creation of the Health Care Quality and Value Database within the Department of Health [Healthy Rhode Island Reform Act of 2008 - Part III]. This comprehensive database will shine a spotlight on cost and quality information that has never before been accessible to the consumer or to policy-makers. The Health Care Quality and Value Database brings a laser-like focus on both cost and quality. It creates a user-friendly, online interface that will empower individuals and families to take control of their health care expenditures by providing a tool for them to make rational decisions about many of their health care needs. It will also put in place the resources and tools that will allow policy-makers to access the empirical data that is desperately needed if we are to move toward a rational, evidence based health system.

It is also imperative that our state move ahead to implement Health Information Technology including integrated electronic medical records with appropriate privacy protections. Much work has already been done in this area, and an important piece of the package is legislation that establishes safeguards and confidentiality protections for a Rhode Island Health Information Exchange. The legislation will put in place systems to improve the quality, safety and value of health care, keep confidential health information secure and confidential and use the HIE to progress toward meeting public health goals. Rhode Islanders need to be confident that HIT will be used appropriately and confidentially, and all stakeholders need to work together to ensure that we pass legislation that will earn this confidence.

Covering All Rhode Islanders

13% of Rhode Islanders have no health insurance. This proportion has increased since 2001 and the fastest growing part of this group is working Rhode Islanders. Uninsured Rhode Islanders often have little choice but to access the health care system in the most expensive way: by going to the emergency room. They lack access to preventive care and chronic disease management, so their care ends up being more expensive than it has to be - wrong time, wrong place, wrong cost care. Studies have shown that the uninsured have significantly worse health outcomes than those with insurance, and we also know that the cost of care finally provided in an emergency room is being passed along to everyone else through higher taxes and increased insurance premiums. Uncovered health care costs have become the top cause of personal bankruptcy.

Part IV of the Healthy Rhode Island Reform Act of 2008 creates a structure during 2009 and 2010 will reduce the number of uninsured Rhode Islanders. It does this in a number of ways.

The legislation creates a new public/private partnership called the Rhode Island Health Insurance Access Hub (HealthHub RI). By July, 2009 the HealthHub will allow individuals and small business owners to purchase portable, affordable health insurance for themselves, their families, and their employees. HealthHub RI will allow Rhode Islanders to shop online, on the phone, or in person to choose among competing plans for the one that fits them best. Insurance companies will have to compete for business in a transparent environment, and individuals, families, and small business owners will benefit from the bargaining power of the Hub.

HealthHub RI will also play an important role in aligning payments to priorities. The HealthHub board will begin its work in September 2008. It will set standards for a minimum level of coverage acceptable in plans with the HealthHub seal of approval and will allow insurers to make available innovative plans that emphasize preventive care and chronic disease management. The board will also be charged with ensuring that the plans offered will be affordable, flexible, and robust.

To further jump-start the move toward covering all Rhode Islanders, the legislative package includes a bill that calls on individuals and businesses who can afford insurance to take responsibility for coverage. Part V of the Healthy Rhode Island Reform Act requires all Rhode Island residents whose income exceeds 400% FPL ($40,840 for an individual, $82,600 for a family of four) to purchase affordable health coverage through the HealthHub once the Hub opens for business in July, 2009. The Office of the Health Insurance Commissioner estimates that there are close to 15,000 Rhode Islanders (more than 10% of the Rhode Island uninsured) who would be covered by this mandate. Part VI of the legislative package also whittles down the number of uninsured Rhode Islanders by allowing young adults to stay on their parents' family plan through age 25, regardless of student status.

One of the great strengths of our current system is that the majority of Rhode Islanders have access to health insurance through their employers. In order to maintain this strength, Part V not only impacts individuals but also requires employers, (except those with ten or fewer employees) who do not provide health insurance, to pay a health security assessment to the state. This health security assessment goes to the HealthHub for purposes of providing support for insurance for the uninsured. This requirement, combined with the requirement that individuals with sufficient means purchase insurance, will have a combined effect to reduce the number of uninsured Rhode Islanders. Part VII of the legislative package further expands the options for those Rhode Islanders who still need coverage. By opening up the Rhode Island market through reciprocal licensure for health insurers already licensed to do business in Massachusetts and Connecticut more value-priced options will become available to Rhode Island businesses and individuals seeking new approaches to coverage.

This multifaceted approach to insuring every Rhode Islander does not make sense unless it is matched by a commitment our award winning RIte Care program which is a national leader in covering children. The majority of funds used for RIte Care coverage come from the federal government, so every dollar cut by the state removes over two dollars from the health care system. Cutting RIte Care will force children and parents into the emergency rooms. This will cost everyone more in the form of higher premiums and taxes to pay for the resulting uncompensated care. The proposed RIte Care cuts would move Rhode Island’s health care system in the wrong direction, and thus a key element of the Healthy Rhode Island plan is a focus on ensuring that this does not happen.

Although the Healthy Rhode Island Reform Act of 2008 does not call for the expenditure of any new state dollars at this time, most experts say that covering all Rhode Islanders will require additional shared financing down the road. What makes the Healthy Rhode Island Reform Act of 2008 unique is that it calls upon policy makers, state officials and citizens to work together to put in place the infrastructure for change BEFORE new public funds are invested so that we can proceed cautiously and with full information as new investments are considered and debated. It also combines the creation of this infrastructure with a laser-like focus on reducing cost, increasing value and improving health outcomes in the health care system more broadly. The Healthy Rhode Island Strategic Plan and Chronic Care Management program [Part 1], Health Care Quality and Value Database [Part III] and cutting edge innovations in the health plans for public employees and Medicaid recipients [Part II] will all contribute to bending the cost curve for health care in Rhode Island toward affordability. These innovations are supportive of reducing the ultimate cost for covering all Rhode Islanders when Rhode Island is ready to take that final step.

Planning Forward for Success

Comprehensive reform of the health care system is a challenging and complex undertaking that will require an ongoing commitment from citizens and policy makers. The final element, Part VIII, of the Healthy Rhode Island Reform Act of 2008 is designed to guarantee that the momentum for positive change is sustained beyond this legislative session. Part VIII creates a Joint Legislative Task Force to be co-chaired by a Senator, a Representative and the Lieutenant Governor. This core group of elected policy makers will create and sustain momentum for change and will make recommendations for additional reforms.

THE HEALTHY RHODE ISLAND REFORM ACT OF 2008

AT A GLANCE

Bill	Topic	What it does
Part I	Healthy RI Strategic Plan and Chronic Care Management Plan	Recently created statewide health planning group (2007) establishes and implements a plan for chronic care management plan that will apply to all Rhode Islanders by 2010.
Part II	Cutting edge innovations integrated into publicly purchased insurance (Medicaid recipients and public employees)	By January 2009 designation of a primary care physician will be required, chronic care management plan will be part of coverage, and payment reforms in public insurance plans (i.e. pay for performance) will be instituted for Medicaid recipients and public employees.
Part III	Quality and Value “all-payer” database	Expanded authority for existing Department of Health quality measurement group to analyze health outcome and cost data from all sources in Rhode Island. This is a critical building block to bending the cost curve downward.
Part IV	HealthHub RI	Creates the RI equivalent of the Massachusetts “connector.” Board will begin work in 2008, and affordable products will be offered to individuals and small groups by 2009.
Part V	Individual mandate and Employer “pay or play”	Institutes a requirement for individuals at 400% FPL ($40,840 individual, $82,600 family of four) and above to purchase affordable insurance as of July 2009 (coincides with Hub product availability). Also introduces an employer universal health security assessment, with full offset for employers who provide health insurance. The assessment will be approximately $1000 per full time employee per year, with proceeds going support to coverage for the uninsured.
Part VI	Expand coverage to 25 year for dependent children	Removes the requirement that dependent children up to 25 must be students in order to remain on their parents’ insurance.
Part VII	Reciprocal licensure	Enables insurers licensed in MA and CT to offer products in RI without additional licensing.
Part VIII	Joint Legislative Task Force	Creates task force co-chaired by Lt. Governor, a state senator and a state representative to oversee reform efforts from legislative perspective.

Rhode Island HIE Legislation Underway

TODAY'S HITS HEADLINES: 2-13-08

Legislators in the Ocean State have introduced the Rhode Island Health Information Exchange Act of 2008 to facilitate secure patient data exchange as providers prepare to launch an HIE.

The legislation addresses privacy and security issues of an information exchange, which has been under development by the Rhode Island Quality Institute since 2004 through a five-year, $5 million grant from the Agency for Healthcare Research and Quality. The institute partnered with the state to develop the act.

Security measures through the act will ensure patients are aware of the exchange and have given permission to share their data.

The exchange is voluntary for both providers and patients, who will have the right to terminate participation at any time, under the new legislation.

Consumers also will be able to obtain reports of what information is shared and who is accessing it, as well as notices of security breaches. -- by Jean DerGurahian/ HITS staff writer

EHRs & PHRs: iHealthBeat
February 14, 2008

Rhode Island Bill Aims To Facilitate Statewide Health Data Exchange

Rhode Island lawmakers this week introduced legislation aimed at addressing privacy and security issues related to the exchange of patient data as the state prepares to launch a health information exchange, Health IT Strategist reports.

The Rhode Island Health Information Exchange Act of 2008 would ensure that patients are aware of the health information exchange and have given permission to share their data. In addition, the bill would make the exchange voluntary for both providers and patients, and they would have the right to terminate participation at any time. The bill also would give consumers access to what information is shared and who is accessing it, as well as reports of security breaches.

Since 2004, the Rhode Island Quality Institute has been working to develop a statewide health data exchange through a five-year, $5 million grant from the Agency for Healthcare Research and Quality (DerGurahian, Health IT Strategist, 2/13).

Readers are invited to send feedback to: ihb@chcf.org

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LEGISLATION TO FACILITATE AND SAFEGUARD SHARING OF PATIENT INFORMATION

Rhode Island Health Information Exchange Act of 2008 will help improve care and make RI a national leader in effective use of health information technology

PROVIDENCE, RI, February 12, 2008 – Legislation to be introduced today in the Rhode Island General Assembly will facilitate and safeguard the sharing of patient information and make the state a national leader in the effective use of technology to improve care. Sponsored by Senate Majority Leader M. Teresa Paiva Weed (D-Dist. 13, Jamestown, Newport) and House Representative Peter F. Kilmartin (D-Dist. 61, Pawtucket), the Rhode Island Health Information Exchange Act of 2008 creates strong patient privacy and data security protections for information shared through Rhode Island’s soon to be launched Health Information Exchange (HIE)—a secure electronic network for sharing patient information and healthcare data with the patient’s permission.

“Patient care today involves a variety of providers and specialists. Unfortunately, practitioners currently have no systemized way to get the whole picture of one’s health care,” said Laura Adams , President and CEO of the Rhode Island Quality Institute (RIQI). “The development of a state wide HIE will allow patients to authorize their doctors and other health care providers to easily, securely and effectively share information with each other when needed in order to improve care, help prevent duplicate tests, and reduce medical errors. To achieve these tremendous benefits however, patients must have confidence in the privacy and security of their personal health information. That’s why we’ve worked hard with the State and the community to develop this legislation.”

Since 2004, RIQI—a not-for-profit community-based group—has been partnering with the State of Rhode Island to lead a community-based effort to design and build a statewide electronic health information exchange under a 5-year, $5 million dollar demonstration grant from the Agency for Healthcare Research and Quality (AHRQ). Rhode Island was one of only six states nationally to receive such a grant.

“The potential benefits of this legislation are tremendous for both patients and doctors,” said Senate Majority Leader Paiva Weed. “The bill gives patients a way to give all of their doctors secure, authorized access to the same complete set of information they need to provide the best possible treatment and care.”

Developed by the RIQI in partnership with the State of RI over the past 18 months, the bill is the product of a comprehensive and broad-based community engagement process that included consumers, consumer advocate organizations, physicians and other providers, insurers, hospitals, universities, employers, and state officials.

“It’s hard to believe that in the age of the Internet, email, and all things digital, our health records are still primarily kept in paper files,” said Representative Kilmartin. “Research shows that consumers also want to use health information technology to obtain the best possible care and to better manage their family’s health. This bill will go a long way towards moving our health care system safely into the digital age for the benefit of all Rhode Islanders.”

The Rhode Island Health Information Exchange Act of 2008 creates a set of critical patient safeguards, many of which go well beyond existing state and federal privacy and data security protections. Baseline consumer protections in the bill include:

• Clear language that participation in the HIE is voluntary – both consumers and providers get to choose whether or not to participate
• The ability to obtain a copy of confidential health care information in the HIE
• The ability to obtain a copy of a Disclosure Report detailing what entities have accessed a patient’s confidential health care information in the HIE
• Notification of any breach of security of the HIE
• The right to terminate participation in the HIE
• The right to request that inaccurate HIE information be corrected
• Strong data security procedures
• The creation of an HIE Advisory Commission to provide community input into the use of confidential health care information in the HIE

“Patients must have confidence in the privacy and security of their personal health information,” said Kathleen Connell, State Director, AARP-RI and a participant in the community legislation development process. “This legislation is the product of a truly collaborative effort designed to balance and reflect the diverse perspectives, needs, and interests of the entire Rhode Island community and we are confident that this bill will help improve the quality of patient care while also protecting consumers’ rights and information.”

"As Rhode Island works toward real health care reform we need to make sure that health information technology is fully integrated into all aspects of the system,” said Lt. Gov. Elizabeth Roberts. “Rhode Islanders need to be confident that this technology will be used appropriately and confidentially, and we need to pass legislation this session that will earn this confidence."

"A statewide health information technology network will save lives, significantly cut skyrocketing health care costs, and help give patients and their families peace of mind," said U.S. Senator Sheldon Whitehouse (D-RI). "As Attorney General, I was proud to have helped establish the Quality Institute, and now in the Senate, I'm working to establish a nationwide health information technology infrastructure that will improve the coordination of care, lead to fewer medical errors, and save our health care system billions of dollars. Here Rhode Island is leading the way."

The Rhode Island Quality Institute (RIQI) is a statewide collaboration of hospitals, physicians, nurses, health insurers, consumers, business, government and academia working together to significantly improve health care in Rhode Island . Founded in 2001, the RIQI’s strategic focus includes building a statewide health care information exchange and interoperability and ensuring the adoption of Electronic Health Records (EHRs) as the foundation for continual improvement in the quality of care. The RIQI is leveraging RI’s unique characteristics (small size, line of sight trust, and governmental accessibility) to demonstrate how the health care system can be improved through collaborative innovation. For more information, visit www.riqi.org.

FACT SHEET - The Rhode Island Health Information Exchange Act of 2008

What is a Health Information Exchange (HIE)?

§ A secure electronic network for sharing clinical information and healthcare data with the patient’s permission.

Why is an HIE necessary?

§ Our current paper-based system is fraught with error and waste. Providers struggle to piece together critical information on patients in emergencies, and are often forced to make clinical decisions with inadequate information.

§ Consumers often see multiple providers (the average Medicare consumer sees 6.4 providers annually). The inability to share information across providers often results in poor continuity of care or compromises patient safety.

All Rhode Islanders will benefit from a statewide HIE that will:

§ Allow physicians and providers to electronically collect, transmit, and share critical medical information in a way that safeguards privacy and security.

§ Reduce medical errors and waste and improve care Empower patients to more easily access information about who has viewed their records

Consumers want a HIE that increases the safety and quality of their care, and safeguards the privacy and security of their personal health information.

§ The Rhode Island Health Information Exchange Act of 2008 creates strong patient privacy and data security protections for information shared through the HIE.

§ Many of these provisions go well beyond existing state and federal privacy and data security protections.

The bill creates numerous explicit consumer safeguards including:

§ Clear language that participation in the HIE is voluntary – both consumers and providers get to choose whether or not to participate

§ The ability to obtain a copy of confidential health care information in the HIE

§ The ability to obtain a copy of a Disclosure Report detailing what entities have accessed a patient’s confidential health care information in the HIE

§ Notification of any breach of security of the HIE

§ The right to terminate participation in the HIE

§The right to request that inaccurate HIE information be corrected

§ Strong data security procedures

§ The creation of an HIE Advisory Commission to provide community input into the use of confidential health care information in the HIE

This legislation is the product of a comprehensive and broad-based community engagement process that included consumers, consumer advocate organizations, physicians and other providers, insurers, hospitals, universities, employers, and state officials.

§ 20 separate opportunities for committees and community members to provide feedback.

§ An online survey to solicit feedback from all community members.

§ A half day workshop bringing together 32 community members and RIQI staff for a facilitated discussion using a combination of multi-voting, and small and large group discussions to address HIE legislation concerns.

§The outcome of this extensive process is a piece of legislation that truly reflects the will of the RI community as a whole, not just the will of a few community voices.

TESTIMONIALS:

“The establishment of the health information exchange will help me take better care of my patients. With more of my patients getting their care from multiple doctors and using multiple labs, x-ray facilities, pharmacies, and hospitals, it is more important than ever that I be able to access all of their information promptly and easily, in order to provide high quality care, reduce the risk of errors, and avoid wasteful duplicate testing.”

Yul D. Ejnes, MD, FACP

Immediate Past Chair, American College of Physicians, Board of Governors

" Rhode Island 's hospitals and the patients they serve will directly benefit from the creation of a Health Information Exchange. Allowing for the electronic sharing of critical patient information will improve care, create efficiencies, and reduce administrative costs. "

Edward Quinlan, President, Hospital Association of Rhode Island (HARI)

"The introduction of legislation to authorize an HIE for Rhode Island is an important first step in improving health outcomes while maintaining patient privacy rights."

Elizabeth Gemski, American Cancer Society - Rhode Island Chapter

Here in Rhode Island , we are fortunate to have a strong spirit of collaboration that is helping to identify and address potential barriers created by new health information technologies. Under the umbrella of the Rhode Island Quality Institute, every constituency of health care, as well as health insurance, consumer and public interest groups are working collaboratively to come up with innovative solutions to improve the quality of health care for all populations. Our diverse stakeholders have worked long and hard to reach consensus on many complex issues so that we can build a health care system that works for everyone. As a result, we are lowering barriers so that Rhode Island physicians—in any size and type of practice— are able to select and use electronic health records. We are working to develop a statewide health information exchange which will connect these electronic medical records and enable continuity of care independent of provider type, location or other circumstance.”

Charles B. Eaton, M.D. M.S.

Director, Brown University Center for Primary Care and Prevention