Lessons from a Health Care Regulator in the 21st Century

Charles Darwin once said, “It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.” This statement exemplifies the work life of a health care regulator, because to be successful in this line of work, your character needs adaptability skills, a bit of fortitude, perseverance, and a decent amount of stubbornness.

In this article we will be exploring some major challenges of and providing perspectives on the work life of a healthcare regulator. It is important to understand these challenges because I believe these are some of the reasons why these positions are hard to fill and why there is quite a bit of turnover.

Working as a health insurance regulator in the twenty-first century is multifaceted; some of the major challenges we face include the constant changing and shifting of federal and state policies (e.g., rules, law, guidelines, and court cases), laws being enacted without supporting legislation, and the advancement of technology. 

For more than half of my two-decade career in health insurance, I have been working as a regulator, reviewing and auditing policies and plan documents for almost every type of health line. Because of its prevalence and complexity, most of my focus is on Qualified Health Plans (“QHPs”). Not only do QHP reviews make up the majority of my professional portfolio, they take up the majority of my time because effective review of QHPs requires ongoing monitoring of the various agencies and institutions that can affect administration and oversight of QHPs. These include, but are not limited to:

Congress	State departments of insurance or legislative websites
Centers for Medicare & Medicaid Services (“CMS”) websites/newsroom	Federal Register
U.S. Preventive Services Task Force (“USPSTF”)	RegTap
Internal Revenue Service (“IRS”)	Health Resources & Services Administration (“HRSA”)
U.S. Department of Health and Human Services (“HHS”)	U.S. Department of Labor (“DOL”)
National Association of Insurance Commissioners (“NAIC”)	Supreme Court and lower courts

While there is seasonality to some of the guidance that may come out, each institution operates on a different timeline and has a different strategy for releasing and publishing polices. Legal arguments and rulings can happen at any time. And each one of them plays a different part in making healthcare policies and plans. Learning where to go and what to look for in each of these institutions, when you are performing a health care plan compliance review, is a special skill. The best way to learn this skill is by on-the-job experience, which takes time, persistence, and self-learning.

As you may have guessed, keeping up with these institutions and their changes can be very overwhelming for regulators and people can easily get burnt out. To keep up with the volume of new regulations, and the pace of the changes, I would strongly encourage compliance teams to either divide up these responsibilities within your team to different team members or invest in some sort of technology that tracks all these institutions. Per my work experience, I have experienced it several times where this task gets placed on one high performing person, and that one person gets burnt out, leaves the job, and takes the knowledge with them.

Another common issue health care regulators face is trying to enforce policy changes without supporting legislation. In the compliance review of forms, we encounter this issue daily. For example, let’s say a law was enacted that revised the definition of a type of healthcare service. The definition, within the new law, entails the level of coverage where the services should be covered and prohibits certain exclusions. What the law does not include is a requirement stating that the Issuer must include this new definition within the plan documents or that the Issuer must notify the consumer that this healthcare service is now covered. When the regulator reviews the form filing for compliance, they find there is no mention of the new healthcare service within the Issuer’s consumer facing plan documents. The regulator follows up with the Issuer, asking for confirmation that the healthcare service is covered, and the Issuer complies by attesting they are up to date with the new policy. The issue is then closed because of the attestation and without the consumer facing plan documents being updated. As a regulator, these findings are incredibly hard to close and move on from, because we know the consumer will probably not understand the level of coverage they have and may not seek coverage when they need it the most.  

Technology is quickly changing the way regulators perform reviews and what information is being reviewed. When I first started working as a regulator, a fellow colleague turned to me and said, “Computers are the worst thing that ever happened to our line of work. We used to hand write our audit reviews, and an office person would spell check, type the letter, and send it to the issuers. Now we have to type our own letters and use multiple systems to send our reviews to Issuers.” They made this comment when we started learning how to use Excel as part of our reviews. My colleague retired about 2 years later and thank goodness they did, because I am not sure how they would have handled using today’s technology. 

Today’s policy form reviewers use a variety of data analytical tools and applications to perform compliance reviews on plan designs, parity in benefits, certain financial reviews, drug formularies review, network adequacy, data validations, and market integrity. The job has changed from performing a contract review for adherence to laws, thoroughly reading a contract, to including data analytic reviews. And as the tools advance, the data gets bigger. And now we are discussing artificial intelligence; can we use it as a tool in our reviews or how do we audit it if an Issuer is using it. This is a lot to absorb from a learning perspective, no matter what stage you are at in your career. 

Reflecting on the challenges that regulators face every day has me wondering how Charles Darwin would have thought of our work. I could see him using one of his popular quotes, “We will now discuss in a little more detail the Struggle for Existence...” Overall, things are going to keep moving forward and fast. My advice to regulators is to remind ourselves to slow down and take the time to reflect on the lessons we have learned, be adaptable, be reasonable, and be responsible, because consumers, whether they know it or not, need us.