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“Alignment” for Transformation

NGA: Learning from Each OtherJanuary 14, 2014

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Rhode Island Structure for Alignment2

Executive Committee of Health Care Reform Commission

Lieutenant Governor(Chair)

Secretary of Health and

Human Services

Health Insurance

Commissioner

Director of Administration

Governor’s Policy Director

MedicaidPublic HealthBehavioral HealthFacilities Regulation

CommercialInsurance Regulation

State Employees Health BenefitsExchange

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Examples of Alignment in Rhode Island3

QHP Standards and Certification

• Exchange Develops Standards

• Health Insurance Commissioner certifies Insurers

Eligibility IT System

• Jointly developed, overseen and paid for by Medicaid, Exchange and Department of Administration

Patient-Centered Medical Homes

• Health Insurance Commissioner initiated provider collaborative; “strongly encouraged” insurer participation

• Medicaid engaged in payments after 2 years

• State employees plan to begin payments after legislation

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• Bureaucracy has outlived previous administrations and will outlive this one

• Tone from the top and commitment of cabinet officials will define opportunity for success

Governor leadership critical

• How official talk, formally and informally

• Competing priorities must be resolved ASAP

Alignment is not just policy-based

• Lt. Governor is RI has no administrative authority or oversight

• Served as facilitator for alignment (social workers)

Neutral party very valuable

• Lobbyists and interest groups will test the limits and exploit any weaknesses in the fronts

“Invisible Fence” Theory

Lessons learned in alignment

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• Widespread appreciation of the talent and commitment of State staff – but recognition that the system places great constraints on them

• Several stakeholders in private market lamented State’s inability to “speak with a singular voice” – frustration that the agendas of different agencies/branches are often in conflict with each other

• Frustration due to perception that State continually subjects providers to change; some of which is unnecessary and burdensome

• Concern that State leadership does not adequately understand healthcare marketplace

Trustworthiness of Government QuestionedInterviews with 36 external stakeholders

Interacting with the market

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6

• Give CEOs a single person to discuss strategy and policy

• Provides a place for venting and problem solving

Single point of contact

• Creative development of things that keep people happy

– Aligned quality measures, rather than just a requirement to move to an outcome-based system

Give marketplace carrots first

• When alignment causes strife, call it out and work it out

• There will be times when agencies don’t line up. Don’t force it, fix it.

Admit to internal speedbumps

• Legislative initiatives can be detrimental to marketplace – executive branch can play a critical role in understanding the viewpoints of the market

Fight for some of their interests

Strategies for Multi-Payer Alignment