PROVIDENCE – Our airwaves are awash with competition in professional sports these days. We have the NBA and NHL playoffs; Major League Baseball is one month into its 2016 season; there is MLS soccer and European soccer is building toward a climax; and the NFL draft frenzy is peaking, with the draft occurring this week. Throw in the professional golf and tennis tours, the car racing circuits, and boxing and ultimate fighting, who could ask for anything more?

But wait: this summer, we are promised the vicarious thrill of victory and the agony of defeat  in the wide world of international sports competition, when the 2016 Olympics air from Brazil – though public health and political realities may intrude on the games, amidst a widening Zika epidemic and the ongoing impeachment of the Brazilian president over corruption, not to mention the dirty, contaminated water that athletes will have to compete in during the outdoor events. Will there be a disease count as well as a medal count for countries and athletes?

We have become a nation of spectators, our seats at the virtual Coliseum reserved, with new mobile apps to stream all the action, wherever we are. If the real sports broadcast action isn’t quite thrilling enough, we can create our own fantasy games and bet online – and lose money.

And, of course, there is the biggest professional sports/reality-show competition of them all: the 2016 U.S. Presidential election. Here we are, deep into the primary season, with media prognosticators attempting to count the delegates as if they were flowers on the wall, in advance of the Democratic and Republican conventions.

The whirlwind Presidential tours made brief pit stops this weekend in Rhode Island, in advance of Tuesday’s primary vote: Hillary Clinton at Central Falls High School, John Kasich at Bryant University, and Bernie Sanders at Roger Williams Park. Donald Trump is scheduled to appear on Monday at the Crowne Plaza. Go, team, go.

Competition, risk in health care
In health care, in the nation and in Rhode Island, there is different kind of professional competition going on; it is every bit as cut-throat and intense as what is happening on the arena ice, the hardwood floor, the manicured playing fields, or in the presidential town halls. Flagrant fouls, insults and taunts, and vicious boarding hits abound.

Without a scorecard, it’s sometimes hard to follow the health care competition, because coverage is haphazard, other than from the occasional crisis-driven story that breaks out like a rash in between the murder and mayhem and chaos that dominate the limited attention spans of our news.

In the past, ConvergenceRI has often described the conflict in health care as a game of musical chairs: there are too many health facilities competing for too few patients, and when the music stops, everyone scrambles for the fewer and fewer chairs. But that may be too polite a metaphor; the competition has become much more like roller derby.

The reality is that the business models for health care systems in the U.S. are transitioning from fee-for-service to calculating risk for a broader measure of population health.

Regardless of what the next President or the next Congress decides to do with the Affordable Care Act, the health care reform train has already left the station and is picking up speed. Future reimbursements from Medicare and Medicaid – as well as from health insurers – will be weighted for a continuum of care: for services delivered in a hospital or doctor’s office and outside those facilities.

To survive, health care systems need to have a large-enough patient base to make population health management analytics work. The net result is that acute care community hospitals, like small market teams in professional sports, often have a hard time competing: such hospitals are quickly being swallowed up within larger health systems, because there is no, ah, revenue-sharing plan. As Pink Floyd sang: Money, get back, I’m all right Jack keep your hands off of my stack.

The establishment of health insurance benefits exchanges under the Affordable Care Act, at the state and federal levels, were supposed to function as a way to level the playing field: to make the costs and payments more transparent and, in Rhode Island, to create a platform for small businesses to make group purchases, allowing their employees to shop for their health plans.

The failure to increase the definition of what a small business is – from 50 or fewer employees to 100 or fewer employees, scheduled to occur in 2017 – significantly circumscribed the size of the potential market for the exchange in Rhode Island.

As a result, the exchanges tend to serve the have-nots, the individuals who don’t have access to health insurance through a job, and not those who can access insurance through an employer – even as the definition of an employee keeps morphing toward freelance.

Symptoms of the disease
We tend to react to the symptoms, not the disease. The latest move by UnitedHealthcare is an apt example:

• UnitedHealthcare plans to exit the government-run health insurance exchange marketplace in most states, including Rhode Island, the for-profit behemoth announced on April 20. Its market share on the Rhode Island exchange was reported to be about 4 percent.

The move was not a surprise to many analysts, given the evolving business strategy being pursued by the Minnesota-based firm to push its new technology products, to focus on population health management, and to limit its losses from individual health plan policies.

As an example, UnitedHealthcare recently joined with Care New England and its Integra ACO in the first contract to be approved by the R.I. Executive Office of Health and Human Services for a Medicaid accountable entity in Rhode Island, providing coverage for some 20,000 managed Medicaid members.

UnitedHealthcare also holds the contract for health insurance for state employees and retirees in Rhode Island.

Question: What is the context and strategy behind the decision by UnitedHealthcare to withdraw from Rhode Island’s exchange?

ConvergenceRI reached out to Maria Gordon Shydlo, public relations director for UnitedHealthcare, but did not receive any response.

To Ted Almon, chairman of the Claflin Company and a leader of HealthRIght, the withdrawal was “not surprising.”

Here in Rhode Island, he continued, “UnitedHealthcare has always been opposed to the exchange, although they may not acknowledge it publicly. They started their own competitive ‘private’ exchange; they worked surreptitiously through the Chamber to weaken HealthSourceRI [through] a position statement, saying it should be ‘limited’ in various ways.”

As a business strategy, all industries will resist group-purchasing efforts, like those offered through the exchanges, as they consolidate, buying leverage and compressing margins, Almon explained.

“Health insurance has always been able to defeat group purchasing using the same method, cherry picking, or enticing the most attractive groups with teaser rates lower than the group – at least until the group fails from the adverse selection,” Almon told ConvergenceRI. That is why, Almon said, that “association health plans” have never succeeded in influencing overall rates.

In Almon’s opinion, “It is a strategic imperative of UnitedHealthcare that the exchanges not reach the critical mass of covered lives necessary to affect buying leverage.”

He described the latest action by UnitedHealthcare “as a somewhat desperate attempt to be sure that doesn’t happen.” Further, Almon wondered out loud if the vacuum created by UnitedHealthcare’s withdrawal would draw in new players, such as Tufts Health Plan, or expand the opportunity for Neighborhood Health Plan of Rhode Island;.

Question: What’s the status of Tufts Health Plan and its plans to enter the exchange market in Rhode Island?

For the last four years, Tufts Health Plan has danced around answering the question of whether or not it would participate in the Rhode Island exchange.

Even with the planned withdrawal of UnitedHealthcare, that dance continues, based upon responses last week by Tufts Health Plan.

“Our efforts in Rhode Island remain focused on helping large and small businesses provide their employees with access with to high quality, more affordable plans,” Sonya Hagopian, vice president of Corporate Communications and Public Relations at Tufts Health Plan, told ConvergenceRI.

Toward that end, Hagopian continued, Tuft’s partnership with Lifespan, which created a health plan inclusive of Lifespan providers, what she called “our Lifespan Premier Choice product,” represented “just one of the offerings we've brought to Rhode Island to support this goal.”

Translated, Rhode Island’s exchange is apparently not viewed by Tufts as the best way to capture greater market share for its small and large business insurance products. [This is despite the fact that HealthSourceRI is one of the few exchanges in the nation that offers specific health plans and services for small businesses with 50 or few employees.]

Question: What will be the response by HealthSourceRI to UnitedHealthcare’s planned withdrawal? Does it present a future problem?

Maria Tocco, the very competent communications spokeswoman for HealthSourceRI, responded to a number of questions from ConvergenceRI.

“Earlier this week UnitedHealthcare notified the R.I. Health Insurance Commissioner of their intention to exit HealthSource RI’s individual and small group markets in 2017,” Tocco said.

UHC has publicly indicated that they will be leaving all but a handful of states in 2017, Tocco continued. “Customers in UHC health plans through HSRI will not be affected in 2016. However, they will need to choose a new plan for 2017.”

Customers can do this, Tocco explained, during the regular Open Enrollment period that starts in November of this year for coverage beginning Jan. 1, 2017, or when their employer renews. She pledged that HealthSourceRI will work with customers of UnitedHealthcare plans to help them choose a comparable plan for 2017.

“We value choice and competition, so we’re disappointed by the move,” she said, adding that Rhode Island’s exchange would continue to offer a range of health plan options from Neighborhood Health Plan of Rhode Island and Blue Cross & Blue Shield of Rhode Island.

“UnitedHealthcare has a relatively small percentage of total enrollment, so we do not see this largely impacting our customers,” Tocco said. “We’re confident we’ll be able to help those customers make a smooth transition in 2017 to find plans that meet their health care needs and budget.

Is Tufts Health Plan still considering making an entrance onto the exchange? If they are, when will they announce the move?

Tocco replied: “Any intentions to enter HealthSourceRI in 2017 would occur after mid-May, when the rate/plan filings are due.” The question may be better director to Tufts, she added.

Will the exchange continue to use auto renewal for the 2017 open enrollment?

“Yes. We made the decision last year to implement automatic renewal for this past open enrollment period, and automatically renewed 77 percent, or 26,859 [individual/family market] customers for 2016 coverage. We plan to continue using automatic renewal for existing HealthSourceRI customers when open enrollment begins again in the fall.”

Leveraging buying power of state employees
One of the more intriguing opportunities that Rhode Island is considering is the potential to have state employees choose their health plans through the state’s exchange as a way to leverage their market power. The idea has been discussed with Gov. Gina Raimondo, but it has remained well below the radar screen.

It would certainly change the dynamic around bidding for the next state contract for health insurance. The current state contract with UnitedHealthcare expires in March of 2017.

What is the likelihood that state employees would be encouraged to make their choices through the exchange in coming years? Is such a plan under discussion?

Tocco replied: “HealthSourceRI has had discussions with some of our government partners about the possibility of having state employees enroll in coverage through HealthSourceRI, but no decisions have been made on this topic.”

In turn, Almon said the move to have state employees sign up for their insurance through the exchange in Rhode Island would enormously change the equation, in his view.

“To really be successful in driving rates, the exchange must reach a market share that would allow it to become an active purchaser of coverage, such as what is being done by Covered California on the West Coast,” Almon said. “The exchange would then negotiate with carriers on behalf of the group, driving business to the most efficient [plans], fundamentally altering the landscape of healthcare financing and ultimately delivery.”

Moving forward
In the meantime, signs of downsizing around the exchange continue, with the move of the consumer walk-in center from Providence to 401 Wampanoag Trail in East Providence, on the second floor of an office building adjacent to Route 114.

Finding the new walk-in center promises to be a bit confusing to consumers: it requires making a right-hand exit off Route 114 when traveling south, a left-hand turn over the highway, and then finding the entrance to the center amid two office buildings and a third medical building now under construction.

The health exchanges, once the focus of extremely heated political dialogue, have faded from focus. In Rhode Island, as the roller derby continues to play out, the state health care authorities will make a number of decisions about new proposed facilities on a triage basis, without a statewide health care plan.

• Neighbors, a for-profit Texas-based firm, received preliminary approval from Dr. Nicole Alexander Scott, the director of the R.I. Department of Health, to build a freestanding emergency care facilities in West Warwick and Bristol.

By quirk of law, freestanding emergency facilities do not require a certificate of need. [The R.I. Senate passed a bill this week to address the issue.]

• A new medical tourism facility is planned for Warwick at the Crowne Plaza Property, where, according to law, a certificate of need is not required if 50 percent of the population is from out-of-state. The $40 million-plus proposal, to be built by Carpionato Properties, which owns the Crowne Plaza, is still in the preliminary stages.

There are other pending certificate-of-need applications that will need to be resolved:

• A new obstetrics unit proposed by Lifespan’s Rhode Island Hospital, with a potential capacity to handle 2,500 births a year, to be located a few hundred yards away from Care New England’s Women & Infants Hospital.

• A proposal by CharterCare and its parent, Prospect Health, to open two new heart catheterization facilities.

• The reverse certificates of need to close the birthing center and the ICU at Memorial Hospital.