FAIR Health Board Access Interview with Christopher F. Koller

The current president of the Milbank Memorial Fund and an adjunct professor in the School of Public Health at Brown University, Christopher F. Koller is a health policy expert who served as the health insurance commissioner of Rhode Island, the first such official in the country. Under Mr. Koller’s leadership from 2005 to 2013, the Rhode Island Office of the Health Insurance Commissioner was recognized for its rate review process and its efforts to use insurance regulation to promote payment reform, primary care revitalization and delivery system transformation. Prior to that role, Mr. Koller served as the first CEO of the Neighborhood Health Plan of Rhode Island; he also was the founding chair of the Association of Community Affiliated Plans. In a recent conversation with FAIR Health Access, Mr. Koller spoke about the role of health insurance commissioners and healthcare transparency in the context of an ever-evolving healthcare ecosystem.

FAIR Health: In a September 2017 article you were quoted as saying, “What’s the worst job to have right now? Insurance commissioner.”
a) Which aspects of the healthcare sector today are posing, or will pose, the greatest challenges to the offices of insurance commissioners nationwide?
b) To what extent might the role of insurance commissioners with respect to health insurance regulation evolve over the next few years?

Christopher Koller: Insurance commissioners oversee a variety of different types of insurance, one of which is health insurance. They generally have two primary responsibilities by statute. The first is to guard the solvency of insurers to prevent bankruptcy, and the second is to protect the interest of consumers by ensuring that they have access to the benefits that are outlined in their insurance contracts.

Insurance regulators will be increasingly pulled into cost conversations surrounding health insurance more than for other types of insurance. When our auto insurance becomes too expensive, we rely on the market of auto insurance carriers—and not legislators—to solve that challenge. Auto insurance is primarily concerned with liability in auto accidents, dealing with property damage and some personal injury costs. But when our health insurance becomes too expensive, we become more concerned because we ask health insurers to do much more than auto insurers—we want them to pay for our oil changes, our front end work and damage to ourselves, not just others. Furthermore, if you cannot afford your car, you can take the bus, but those options are not available for healthcare. Health insurance is concerned with our own personal health whose condition we cannot ignore.

We don’t compel our mechanics to fix our cars, but we compel our emergency room doctors and hospitals to treat us. We look at healthcare differently, so insurance regulators will increasingly get pulled into these conversations about cost, and as networks change and narrow, about access, subjects that traditionally have been more significant for Medicaid and Medicare. Regulators also will be pulled into the drivers of our healthcare costs—issues around hospital and provider consolidation, insurer consolidation, provider price variation, pharmaceutical prices and the imbalance between specialty care and primary care in the United States.

Traditionally, policy setting has been the domain of the legislators, but healthcare has become so complex that the legislators need expert counsel, staff and advice. As a result, more and more insurance departments are finding themselves in an advisory role to the policy makers.

FH: Altarum’s Center for Payment Innovation and the Catalyst for Payment Reform’s Price Transparency & Physician Quality Report Card 2017 failed 43 states for lacking adequate price transparency and physician quality reporting websites. What role do you think state leaders and agencies should play in advancing price transparency efforts?

CK: In my view, deductibles and cost sharing are here to stay. And, if we want to help people make more informed decisions about the services that are affected by their deductibles and coinsurance, then price transparency, along the lines of FAIR Health’s efforts in the space, is very important. But, price transparency by itself may not reduce our cost trends. We need to have the right expectations for it.

Information on price variation is also helpful for public policy, not just for consumer price shopping. State leaders can help advance price transparency by promoting the documentation of price variation that exists among providers so that consumers understand it; state officials also can spur both public and private sector efforts to make prices available to consumers. We already have seen some of these efforts. Authorities in Rhode Island, Massachusetts and Minnesota have published documents highlighting the different amounts that providers are paid for the same services to inform policy-making questions.

FH: The national healthcare debate has largely focused on controlling costs and increasing coverage. What other issues should be given greater attention in the public forum?

CK: At the Milbank Memorial Fund, we are trying to understand the underlying cost drivers around cost and access. For example, why is it that we have so much specialty care compared with primary care? However, I also am interested in the longer-term issues to which we have to start paying attention now because they are coming down the road. We need to start focusing our efforts on the effects on our healthcare system of an aging population and increasing wealth disparity. Aging baby boomers will completely transform the way we think about aging and healthcare service delivery. In addition, declining life expectancy and the variation in health status and health outcomes by race and ethnicity will be critical issues to address. Most of the reasons for those issues are outside of the healthcare sector, but the resulting health problems are nonetheless treated by the healthcare sector. Healthcare often is a backstop for treating social ills.

FH: How has the role of cost transparency in the marketplace evolved over the past few years? To what extent has the current healthcare landscape impacted the way in which cost transparency is figuring into the national conversation on costs? What is the future of healthcare cost transparency?

CK: A generation raised on smartphones and consumerism will expect greater access to healthcare information. The system will not automatically change just because people want it. The way in which healthcare consumers interact with our healthcare delivery system might be different from entertainment or investing, but sooner or later technology will impact how we interact with the healthcare delivery system.

Primarily, technology will pull us toward a new way of interacting with the healthcare system, thereby increasing the demand for cost and price transparency for individual healthcare transactions. Each of us, though, is a patient, a healthcare shopper and a community member. We don’t think about the costs and prices for determinants of health—how much exercise and sleep we get, how good our relationships are, for example—but they are all more important drivers of health and costs than doctor or hospital visits.

FH: FAIR Health has striven to lead as a source of independent and objective price and utilization information. How do you see FAIR Health’s role in the healthcare sector and the value of claims data in addressing the system’s current challenges? Looking to the future, what do the next few years hold for FAIR Health?

CK: FAIR Health was organized by its charter as a nonprofit, which differentiates us from many other holders of price information. In some ways, we are doing the job of government but, owing to our independence, FAIR Health enjoys greater flexibility to act than the government itself has. Our primary task will be to continue to serve as a reliable, trustworthy, confidential and comprehensive source of healthcare cost and utilization information as the demand from patients, researchers, policy makers and industry participants for reliable, authoritative information grows.