At a time when both individuals and governments are being squeezed ever more tightly by rising health care costs, it is a rare bureaucrat who can figure out how to increase access to care while holding down expenses. But that has been Tricia Leddy’s forte ever since the Rhode Island Legislature passed a landmark law in 1987 aimed at getting prenatal care for low-income women who didn’t qualify for Medicaid. The program, called RIte Start, would be the first step in a dramatic statewide expansion of health care coverage for low-income families and children in the Ocean State.
The law’s goals and timetable were both wildly ambitious: No more uninsured births in Rhode Island and five months to get the program up and running. Not surprisingly, not many people wanted to tackle the job. In fact, there was only one: “I said, ’I can do that,’ ” laughs the 49-year-old Leddy. Leaving her post as head of nutrition in the state’s health department, Leddy became director of RIte Start. Within five months, she had created a one-page enrollment form, a claims and billing system, and a marketing program to get the word out to eligible women. She also set up a system for evaluating the accessibility and quality of the program, as well as the accessibility and quality of the care being delivered through it.
It was an early illustration of Leddy’s great strength, according to Melinda Thomas, a health policy analyst at Brown University, and Leddy’s former boss at the health department. “She figures out where she wants to go based on the population she’s serving — what they want and what they need,” Thomas says. “Then she’ll go through any barrier in making it happen.”
After RIte Start’s implementation, doctors began reporting remarkable improvements in the quality and outcome of pregnancies statewide. Leddy’s driving maxim — that an ounce of accessible, high-quality prevention is worth 10 pounds of cure — was proving itself through RIte Start.
Other health and welfare administrators in the state, as well as legislators and the governor, took notice. In the early 1990s, when the managed-care craze was beginning to sweep the Medicaid world, it gave Leddy and her colleagues an idea. “Human services officials wanted to bring the AFDC population into managed care and the health director wanted to expand RIte Start to help all children,” she recalls, “so the health director and the human services director combined forces.”
The state applied for and received a waiver from the U.S. Department of Health and Human Services to significantly expand the number of people who could benefit from federally subsidized health care. The result was RIte Care, a bold experiment in expanded health care coverage under Medicaid that focused on increasing accessibility to primary and preventive care for children and families to up to 250 percent of the poverty level.
Under the program, eligible families had the option of choosing their HMO or having one assigned to them. The first sign that RIte Care was the right way to go: An amazing 93 percent of RIte Care clients chose their own HMO. The reason, Leddy says, was that most found that given the range of choice, they could stay with their current primary care physician.
Leddy can report on the program’s progress in remarkable detail and with confidence because of RIte Care’s obsession with performance measurement. The rate of uninsured children in the state has dropped from double-digit percentages in the 1980s to less than 5 percent. Client satisfaction with RIte Care has consistently hovered at more than 95 percent. Post-neonatal infant mortality rates among Rhode Island’s Medicaid-enrolled population have dropped significantly (from nearly five to two deaths per 1,000 live births) in the 10 years since RIte Care began. Rates of prenatal care, immunization and lead blood level screening are the highest in the country for Medicaid-eligible populations.
RIte Care is doing all of this while keeping costs down — through aggressive matching of federal dollars, a system of means-tested co-pays and by ensuring that the program isn’t paying for anyone who might be eligible for other types of health insurance. The aggressive approach has allowed RIte Care to keep increases in the cost of the $333 million program (FY 2004) below the rate of growth for commercial coverage.
While such bottom-line results are crucial to the program’s continuity, Leddy argues that the ultimate success of RIte Care is that it improves all participants’ quality of life.
— Jonathan Walters
Photo by Richard Benjamin