Under New Management

An Interview With TDI's Newest Boss

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Tex Med. 2013;109(10):37-41.
By Amy Lynn Sorrel 
Associate Editor  

The end of the 2013 session of the legislature marked the beginning of new leadership at the Texas Department of Insurance (TDI) as Gov. Rick Perry appointed Julia Rathgeber to the helm of the agency in late May. The Senate unanimously confirmed that appointment in June.

While Commissioner Rathgeber has no direct experience in the insurance industry, she was Lt. Gov. David Dewhurst's deputy chief of staff for the past 10 years, and every piece of insurance legislation that passed the Texas Legislature then crossed her desk at some point. In the health care arena, she worked on everything from the landmark 2003 tort reforms and legislation authorizing preferred provider organizations (PPOs) and exclusive provider organizations (EPOs), to a new law the legislature passed this year that has TDI spearheading the development of standardized preauthorization forms.

But Commissioner Rathgeber's new job does not come without some challenges. She takes over from former Commissioner Eleanor Kitzman, who failed to win reappointment and left physicians with some serious concerns after removing consumer protections from the network adequacy regulations approved by her predecessor, Mike Geeslin.

Commissioner Rathgeber also is searching for ways to help Texans grapple with a new health insurance exchange despite the state's decision to remain hands off. 

Nevertheless, she remains focused on the future of an agency she wants to be perceived as transparent and fair, yet tough on enforcement. In an interview with Texas Medicine in late August, Commissioner Rathgeber said her job is "pretty simple. We are going to follow the law and implement it."  

Texas Medicine: You don't have a background in the insurance industry, but you do have a law degree and experience working in the Texas Legislature and other state offices. Tell us a little bit about how you got to this new position. 

Commissioner Rathgeber: I've worked for the state for almost 23 years, and I absolutely love it. I love government. I love participating in government, and I've been participating in it in a lot of different capacities. I was not prepared for entering this agency, but when Governor Perry offered it to me as an option, I was thrilled. It's a new challenge with new ideas and new people and new issues. It just sounded like a lot of fun, and I don't think there's anything wrong with having a good time in your job. I do feel I was hired to manage an agency full of insurance experts. I have quite a bit of experience working on major pieces of legislation that affect the insurance industry. So I was familiar with the insurance terminology. I also have a lot of experience working with different groups to solve complex issues and address them through legislation, and I think that skill translates reasonably well to this environment. I think Governor Perry was thinking: "Here is somebody who can translate what the legislature wants into implementation in the insurance community." And I hope that I am going to be able to do that. 

Texas Medicine: What are some challenges on your plate right now, and what do you want to accomplish in your tenure at TDI? 

Commissioner Rathgeber: I care very much that people see this agency as being transparent and fair.  Entities that we regulate may not always agree with us - we are a regulatory agency -but [I care] that they understand how decisions are made, that they understand that their input was carefully and respectfully considered, and that decisions are based on sound science and the law. I hope that is the hallmark of our agency in the future.

There are a number of organizations and associations that come by and want to visit, and I love doing that because the more you are able to be accessible and transparent and open, then you have a better working relationship when something goes awry. So I have tried to be very accessible from a meet-and-greet standpoint. At the same time, I am trying to make sure I am spending enough time here in this agency to talk about what we are going to do in the future. A perfect example is one of the meetings I just left: There's an expert panel developing good science for the windstorm association, and that panel held a public hearing so the public could come and talk to them about what next steps they are going to take in developing that science, and there will be additional hearings on the coast. I realize that's not [health care-related], but I hope we are going to see an awful lot of that. Another initiative we have is an initiative to ensure that we can take some options to the legislature to reduce the regulatory burden on Texas businesses. We need to be able to protect Texas consumers, but we also have to be sensitive to the fact that we are a regulatory agency. We don't need to run the businesses that we regulate.

I have priorities that are internal to the agency and priorities that are external to the agency. My internal priorities are to make sure that people are doing a good job, that we base decisions on good science and the law, and that we don't deviate into areas where we are making up policies or procedures that are not statutorily authorized. I'm more of a strict constructionist from that standpoint. Externally, I am very focused on implementing the legislation that passed this last session. We are spending our time and priorities on captives, on windstorm, and on helping Texas businesses handle the Affordable Care Act (ACA). 

Texas Medicine: TMA has been very active in the rulemaking process as new legislation and new regulations come up to make sure the interests of physicians and patients are represented. As commissioner, how do you plan to communicate with and involve the medical community in those public processes?  

Commissioner Rathgeber: We will be continually including TMA, as we have for many years, in the rulemaking process.  I feel it's incumbent upon us to set out our objective and then work with all of the stakeholders to ensure we can achieve that objective in a manner that is the least intrusive and most protective to consumers. The medical aspect of the Texas economy is just huge. It touches so many lives — everybody's lives — in some way, shape, or form, and I don't lose sight of that. 

As we are working to develop regulations that help consumers and businesses, the medical community is one of our clients, and we need to make sure we work with our clients well. And I will continue to involve them to the extent they are interested in participating. 

Texas Medicine: The federally-run health insurance exchange or marketplace is expected to launch in Texas on Oct. 1, and physicians and patients could be dealing with a lot of new insurance products. (See "Ready, Set…?" August 2013 Texas Medicine, pages 49-52.) What can you tell us about TDI's interactions with the federal government in that process and TDI's role in the future? 

Commissioner Rathgeber: We do not have the statutory authorization to implement the ACA. But we will be working with consumers to help them and direct them to the appropriate places and address their concerns to the extent we can. We are working with Texas companies as they struggle to implement the ACA. To the extent we can provide some flexibility in Texas law … we are going to try and do that so we don't put our companies at a disadvantage when they are grappling with something that's really huge and very difficult to implement. We are trying to provide guidance on our website to the extent that we know what the federal government is doing. We've prepared some "frequently asked questions" so businesses can see how we would treat Texas law in light of the ACA. But they are guidance documents to help; they are not implementation of the exchange itself. We have not been included [in communications from the federal government] because Texas has been so clear about its lack of ability to implement the ACA. A number of the major Texas companies that are participating in the exchange are having individual conversations with the federal government, but we are not facilitating that. 

Texas Medicine: Do you have a sense of how many insurance carriers will participate in Texas' exchange, and what kinds of plans will be offered? 

Commissioner Rathgeber: I really don't. We'll know that in another month. The reason I don't want to answer you right now is we have impartial and incorrect information because companies will file with us and then file with the federal government, and then the federal government will negotiate with them. We're saying:  "Go get it right for the exchange and then come back and file with us." And we are very interested in doing that. A number of companies that have decided not to participate in the exchange went ahead and filed early just in case they wanted the flexibility. So we have more filings from companies that will not be participating in the exchange. A number of companies are not sure whether they are going to try to migrate existing books of business into different types of policies, so they filed extra policies they may not use. So we have more information coming in than will actually be in the marketplace. 

Texas Medicine: The federal government said it was ready to launch these exchanges on Oct 1. Do you see that happening? 

Commissioner Rathgeber: I have no idea. I wish the federal government all the best because I don't know how it is going to implement something this huge in such a short time frame. We will work with Texas consumers and Texas businesses to the extent we can to help them as they are struggling to implement and understand what their options are. 

Texas Medicine: TMA was very involved in formulating the new network adequacy regulations on health insurance carriers that were implemented just as you took office. (See "Adequate to Inadequate," March 2013 Texas Medicine, pages 21-25.) You may know those rules involved a very long, arduous process that spanned two commissioners and carried some significant uncertainty for physicians along the way about when, whether, and what was going to be implemented. Where does TDI stand on those rules right now? 

Commissioner Rathgeber: We are implementing them and moving them forward. The rules were adopted and went into effect July 25, and we have received some initial filings under those rules. We thank TMA for its participation in developing those rules. And I hope we will continue that process because we can, as I said, set out an objective that we want to accomplish, but we need help identifying the correct procedures for implementing that objective. 

Texas Medicine: Many of the previously adopted consumer protections TMA and others advocated for were taken out [under former Commissioner Kitzman], and some were eventually reinstated. But TMA still has some outstanding concerns, particularly about the newer network adequacy regulations that were included for EPOs. Is there any chance of getting additional fixes at this point? 

Commissioner Rathgeber: [Not unless] the legislature passes some additional law and we need to adjust them. I think we need to let them operate a little while before we tinker with our rules. That process has been so negotiated, let's let it operate. They are finalized, they are in place, and they are being used. We don't need to be opening up something and leaving someone with the perception that they don't know what rules they are operating under. 

Texas Medicine: Have you gotten to a point yet where there's been any enforcement action on the new network adequacy rules? 

Commissioner Rathgeber: No. There hasn't been enough time. [Health plans] are just now doing the initial [network adequacy] filings. 

Texas Medicine: TDI's role is to regulate the insurance industry and protect consumers. What can physicians expect in terms of enforcement of network adequacy, making sure physicians get claims paid on time, and other health insurance regulations?  

Commissioner Rathgeber: It's pretty simple: We are going to follow the law and implement it. I think physicians have had a good experience with our enforcement authority under the prompt pay laws. They've seen real responses from TDI as we work with the industry to implement the prompt pay laws. And we have done quite a lot of things to make that a streamlined and faster process. So I want to assure everyone that process will continue. 

Texas Medicine: Physicians consider it a big victory to now have new law regulating so-called silent PPOs. (See "Broken Silence," September 2013 Texas Medicine, pages 41-45.) I know it's early in the process, but what can you tell doctors about TDI's role in making sure that law is carried out? 

Commissioner Rathgeber: We are developing the rule charter. The rule charter is how we implement legislation. There is a draft going through our system in house to come up with steps that we will follow in developing those rules. When that charter becomes finalized, it will be available on our website, and we will begin the public input process. We really are going to need TMA's input on those rules in the way they apply in the marketplace, particularly with the registration process. 

Texas Medicine: TDI also oversees the Division of Worker's Compensation (DWC), and a number of physicians interact with those carriers and patients seeking that kind of care. How are you working with DWC in that area? 

Commissioner Rathgeber: DWC Commissioner Rod Bordelon is doing a fabulous job. TDI works with DWC to provide support for some of the main administrative functions. We help with governmental relations; we help with the budget; we help with some of the human resources issues. Otherwise, Commissioner Bordelon handles the policy aspects and the implementation and the enforcement of DWC operations. We work with them and support them in the rulemaking process. But their rulemaking process is a little bit different than the main TDI rulemaking process, and their claims-review process is a little bit different. So it has worked well for him to manage that, and I look forward to working with him. 

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

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