2018 -- H 7866

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LC005011

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2018

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A N   A C T

RELATING TO INSURANCE -- PRIMARY CARE TRUST ACT

     Introduced By: Representatives Maldonado, Vella-Wilkinson, Bennett, Tanzi, and
Regunberg

     Date Introduced: February 28, 2018

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

     SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended

by adding thereto the following chapter:

CHAPTER 27-82

PRIMARY CARE TRUST ACT

     27-82-1. Short title.

     This chapter shall be known and may be cited as the "Primary Care Trust Act".

     27-82-2. Statement of purpose.

     This chapter proposes to:

     (1) Create a single payment and universal health care delivery system for primary care

health services in this state;

     (2) Require health insurers to allocate a fair portion of their medical spending for primary

care services;

     (3) Designate one or more primary care trusts to ensure the delivery of primary care and

essential health services to all residents of this state;

     (4) Authorize a primary care trust to pay for primary care from a portion of health

insurers' annual medical spending, with financial incentives for providers that provide essential

health services in each community health district;

     (5) Lower the growth rate of state health care spending by empowering primary care

providers to focus care delivery for their patients at the least intensive and most affordable level

of care, when clinically appropriate, instead of more expensive and more intrusive hospital and

specialist health care services; and

     (6) Protect consumers, businesses and primary care providers from the consequences of

anti-competitive consolidation of health care services under the control of hospital organizations.

     27-82-3. Definitions.

     As used in this chapter:

     (1) "Essential health services" means primary care services (medical, pediatric, and

maternity), and those coordinated and integrated services which support the health of patients in a

community health region, such as mental health services, substance use disorder services,

physical therapy, dental and oral services, eye care services, emergency medical services not

provided by a hospital-controlled organization, same-day access to urgent essential health

services, and other services identified by the primary care trust and approved by the office.

     (2) "Health insurer" means:

     (i) A health insurance company;

     (ii) A nonprofit hospital and medical service corporation;

     (iii) A health maintenance organization;

     (iv) The state Medicaid program, and any other health care benefit plan administered by

the state for eligible individuals and families;

     (v) A health care plan administered by the state and any agency or instrumentality of the

state for the benefit of their employees and dependents; and

     (vi) To the extent permitted under federal law, Medicare, and any administrator of an

insured, self-insured, or publicly funded health care benefit plan offered by public and private

entities.

     (3) "Neighborhood health station" means a single clinical entity that provides primary

medical care, urgent care, primary dental care, mental and behavioral health and substance use

disorder treatment to the entire population of a specific geographic area without regard to method

of payment, and actively works to improve the measured population health of that population.

     (4) "Office" means the office of the health insurance commissioner pursuant to chapter

14.5 of title 42 to be responsible for the implementation and oversight of the primary care trust

program.

     (5) "Primary care" means health care services delivered by health care providers:

     (i) Who are specifically trained for and skilled in first-contact and continuing care for

individuals with signs, symptoms, or health concerns, not limited by problem, origin, organ

system, or diagnosis;

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     (ii) Who provide services that are comprehensive, including those of more than a single

discipline;

     (iii) Who provide such services in a coordinated manner, so that they focus on the health

goals of individual patients; and

     (iv) Who provide such services in a manner that ensures each service is effective at

achieving those individual health goals.

     (6) "Primary care provider" means a physician, nurse practitioner, physician's assistant,

primary care medical practice, neighborhood health station, federally qualified community health

center, or other provider of primary care services who contracts with, and is paid by the primary

care trust to provide primary care services.

     (7) "Primary care trust" means one or more nonprofit organizations designated by the

office to provide primary care and essential health services in one or more geographical regions

of the state.

     (8) "Primary care trust program" means the program administered by the office to provide

primary care services to all residents of this state.

     27-82-4. Responsibilities of the office of the health insurance commissioner.

     The office shall:

     (1) Ensure that affordable and quality primary care services are available and accessible

to all residents of this state;

     (2) Identify one or more geographic regions of the state as primary care community

health districts;

     (3) Designate one or more nonprofit organizations as a primary care trust responsible for

the delivery of primary care and essential health services in each primary care community health

district;

     (4) In consultation with the department of health, establish program and administrative

standards for a primary care trust;

     (5) Monitor the capacity and ability of each primary care trust to fulfill their

responsibilities to residents of the community health district; and

     (6) Establish standards and procedures to fund the primary care trusts by annual primary

care trust assessments paid by health insurers.

     (b) The office shall establish, annually, through the rate-setting process, a primary care

trust assessment to fund the primary care trust program. The assessment shall be equal to ten

percent (10%) of total projected medical spending by each health insurer doing business in this

state. At the conclusion of the rate-setting process, the office shall issue an allocation order

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apportioning each insurer's assessment among designated primary care trusts based on the

population of the community health region and the essential health needs of the community health

region. The office may permit variations from the ten percent (10%) assessment not to exceed

plus or minus five-tenths percent (+/- 0.5%) to account for changed circumstances, and the

primary care and essential health care needs of residents. The office shall have jurisdiction over

all health insurers in this state for purposes of imposing the primary trust fund assessment.

     (c) The primary care trust assessment shall constitute a health care service funding

contribution under chapter 7.4 of title 42. The primary care trust assessment shall be

administered, collected, and enforced as a health care services funding contribution in accordance

with chapter 7.4 of title 42, except that each health insurer shall pay its assessment directly to one

or more primary care trusts in accordance with the allocation order issued by the office at the

conclusion of the annual rate-setting process.

     (d) The office may:

     (1) Promulgate rules and regulations necessary to establish standards and procedures as

are required or desirable to carry out the purposes of this chapter; and

     (2) Re-designate another nonprofit organization as the primary care trust for a community

health district, if, after consultation with the board of directors of a primary care trust, the office

determines that the primary care trust has failed to propose or implement an adequate community

health plan.

     27-82-5. The primary care trust - Establishment and duties.

     (a) A primary care trust shall be governed by a board of directors. One-half (1/2) of the

board shall be composed of primary care providers and providers of essential health services in

the community health district. One-half (1/2) of the board shall be composed of community

members residing in the community health district. The articles of association or other governing

document of a primary care trust must be approved by the office. The appointment of initial

directors shall be made by the office within ninety (90) days following the effective date of this

chapter for a term not to exceed twelve (12) months. The articles shall include a mechanism for

subsequent directors to be elected by providers and community members for two (2) year terms.

     (b) The primary care trust shall:

     (1) Be responsible for the delivery of primary care services within its community health

district; and

     (2) Develop and implement a community health plan, approved annually by the office.

The community health plan shall describe how the primary care trust shall:

     (i) Provide primary care services to all residents of the community health district;

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     (ii) Provide essential health services, and expand the availability of essential health

services to all residents of the community health district;

     (iii) Improve the health of residents in the community health district as measured by not

more than four (4) population health indicators including, but not limited to, smoking, body mass

index, and vaccination rates. Such measures shall be adopted by rule or regulation by the office,

in consultation with the director of the department of health;

     (iv) Ensure patient access to primary care during evenings and weekends; and

     (v) Include other elements as are designed to maintain and improve the health of all

residents of the community health district.

     (c) The primary care trust shall reimburse primary care providers on a per capita, or on a

fee-for-service basis.

     (d) Primary care providers and other providers of essential health services who enter into

an agreement with the primary care trust to provide coordinated essential health services shall be

reimbursed with per capita payments. Per capita payments shall provide a financial incentive for

primary care providers to offer essential health services, and to increase the percentage of

residents in the community health region that receive essential health services.

     (e) Primary care providers who do not enter into an agreement with the primary care trust

to provide coordinated essential health services shall be reimbursed on a fee for service basis, in

accordance with a fee schedule established by the primary care trust.

     (f) The primary care trust may establish per capita payments or fee schedules with or

without patient cost sharing.

     (g) Primary care services provided to Medicare beneficiaries and beneficiaries of other

health plans offered by the federal government shall be reimbursed by Medicare and such other

federal health plans or agencies until such time as an agreement with the federal government can

be reached to incorporate the primary care trust as the reimbursement mechanism for such

patients.

     27-82-6. Divestment of primary care practices controlled by hospital organizations.

     (a) This section is intended to:

     (1) Protect consumers and businesses in this state from anticompetitive markets and

financial burdens resulting from the acquisition of primary care services by hospitals and hospital

systems.

     (2) Empower primary care providers to practice quality and cost-effective health care free

from undue control by hospitals and health insurers.

     (b) On or before twelve (12) months following the effective date of this chapter, the

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office shall issue an order to show cause why each hospital doing business in this state which

owns or has a controlling interest in a primary care provider practice, or which employs primary

care providers should not divest itself from all or a portion of such practices and employees. The

office shall issue a divestment order, after notice and an opportunity to be heard by the hospital,

and after affording other interested parties and the public an opportunity to comment on the

proposed divestment order.

     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- PRIMARY CARE TRUST ACT

***

     This act would create the "Primary Care Trust Act" to:

     (1) Create a single payment and universal health care delivery system for primary care

health services in this state;

     (2) Require health insurers to allocate a fair portion of their medical spending for the

delivery of primary care services;

     (3) Designate one or more primary care trusts to ensure the delivery of primary care and

essential health services to all residents of this state;

     (4) Authorize a primary care trust to pay for primary care from a portion of health

insurers' annual medical spending, with financial incentives for providers that provide essential

health services in each community health district;

     (5) Lower the growth of state health care spending by empowering primary care

providers to focus care delivery for their patients at the least intensive and most affordable level

of care, when clinically appropriate; and

     (6) Protect consumers, businesses and primary care providers from the consequences of

anti-competitive consolidation of health care services under the control of hospital organizations.

     This act would take effect upon passage.

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