Managed Care Background Morphs Into Obamacare
Connecticut's new insurance marketplace created to implement the Affordable Care Act is up and running, but the work is just beginning for the exchange's general counsel.
Virginia Lamb, of New London, was appointed to build and oversee the legal department for Access Health CT. As of October 15, the marketplace had enrolled 3,847 individuals for insurance coverage. But it hopes to have 100,000 sign up before the enrollment period ends March 31.
Though the sign-up period is just underway, Lamb has been at her job for quite some time.
Since early 2012, she has worked with her staff of three other lawyers — including Susan Rich-Bye and Tammy Preisner and Chad Brooker — to create policies and codes of conduct for the organization' outreach workers and other employees. They have also prepared informational materials, and trained outreach workers on the legal language to use when signing people up to receive government-subsidized insurance.
More recently, Lamb has turned her attention to more than 60 contracts the health care exchange has entered to meet its obligations, including the lease for a New Britain storefront set to open on October 29. The Connecticut exchange also has several multi-million dollar deals for outreach efforts, including contracts with radio and television stations to raise public awareness though advertisements.
"This is an extremely active place right now," said Lamb. "In many ways, in the role of GC, you have to set up everything to get the business started, so it's very much like being part of a start-up business. For starters, you have to put all of the policies and procedures in place, including a labor policy, an accounting policy."
In that way, she said, the work is really never-ending.
Lamb brings the unique perspective of a lawyer whose career has combined both the health care and legal professions, nearly in equal measure. After earning her law degree, her first job out of law school was working as legal editor, compiling the policies and procedures for a Washington, D.C, hospital. "The hospital administrators hired me to edit their manual, because they needed a lawyer to interpret what was going into it," Lamb said.
A native of the New London area, she returned to Connecticut in 1990, where she put her hospital background to work. She took a position with what was then Manchester Memorial Hospital, moving up to the director of managed care. Part of her job included working to arrange contracts on the hospital's behalf, to ensure it would get paid by insurance providers.
"Managed care was a new concept for hospitals then, and insurance companies were being set up in networks and provider groups," she said. The hospital had to have contracts with these networks, whether PPOs or HMOs, and the contracts often had to be updated.
It was there that she learned to navigate the complicated and "nuanced world," as she puts it, of health insurance networks and managed care.
When the Manchester hospital combined with Rockville General Hospital to form Eastern Connecticut Health Network, Lamb was elevated to a position as a senior vice president overseeing managed care for the network. In that capacity, she worked with state and federal officials to enter agreements for Medicaid and Medicare payments to the hospitals.
During that time, she said, a lot of her efforts were also focused on new treatment programs that were created by the hospitals. For instance, in establishing a diabetes self-management program, Lamb led a team of outside counsel to ensure the treatments would be covered by government-funded programs, including Medicare.
"If you're developing a program" to treat patients, naturally "you want to want to get paid," she said.
She left the position and started a solo practice in the New London area, which included advocating for some of the hospital group's 1,800 employees and many patients who had health care insurance concerns. "I was interested in consulting patients" about being covered for their medical care, "and I got involved in advocacy work for patients," she said. The work included representing clients who had been denied coverage. "You might have someone with a workers' compensation claim," she said. "I handled some veterans' administration claims as well. And some labor law representation. It was very rewarding."
But she missed the hustle and bustle of a busy practice. When Lamb heard about the exchange being created, she had an executive recruiter contact its leadership team and she applied for the position.
Lamb was selected in a competitive hiring process, which sought to bring in a chief legal officer who had both a technical understanding of the new health care law as well as the ability to manage a department.
Kevin Counihan, the chief executive officer of Access Health CT, found that Lamb was the obvious choice among the candidates. "Virginia combines excellent technical skills, with practical and insightful good judgment," Counihan said. "I depend on her for a variety of strategic recommendations in the administration of the Connecticut exchange."
For her ability to supervise the handling of all legal issues that might arise in the operation of the exchange, Counihan said, "Virginia is highly valued."
Though her managed care experience allowed her to largely hit the ground running, there were, of course, differences between her former jobs and her new role. For instance, as a quasi-public agency established by the legislature to satisfy legal requirements of the federal Affordable Care Act, the health care exchange must adhere to public records and open meetings laws. That means the exchange has to hold public meetings and give proper notice of those meetings. The minutes must be recorded, and posted on the exchange's website. "Our office has hired a chief compliance officer," Lamb said.
Access Health CT employees spent much of this past summer getting organized, Lamb said. While outreach workers handed out flyers and health care literature at state beaches, county fairs and concerts, Lamb and her legal team helped make sure the nearly $15 million in federal money allotted for outreach and educational programs was properly spent.
Among the more summer's more complicated tasks was working to revise the exchange's ethics policy, bringing it in line with state law. For example, a restriction was added to all employment contracts that no employee of the exchange could serve as a consultant to a trade association, insurance company or health care provider. "We had to bring everything up to date," Lamb said.
Enforcing The Mandate
Although the Connecticut exchange is for people who don't have insurance or who want to change their health plans opened on October 1, businesses have until January 2015 to give reasonably priced health insurance to employees or risk fines.
The Affordable Care Act provision for companies, known as the "employer mandate" applies to businesses with at least 50 full-time employees, including full-time equivalent workers.
When the deadline kicks in, Lamb anticipates her office will be busy ensuring the mandate is followed by employers. State officials could possibly get involved working with the state Attorney General's Office to initiate legal actions if it's not. When it comes to interpreting the law, Lamb's office has backup in the form of the federal Center for Consumer Information and Insurance Oversight.
"They triage difficult questions, when we are not comfortable that we have clear direction from federal regulations or published guidelines," Lamb said.
Another future part of her job will be defending the Connecticut registry when it denies requests for coverage. Those who are rejected, for reasons ranging from income levels to place of legal residency questions, can appeal to an administrative law judge.
Also looking ahead, Lamb expects that all of the operational policies will need to be refined and updated. "I think going forward, you'll have all of the normal issues of any business, but since we will be beyond the startup mode, there will be contracts to update, things like that. This flurry of activity we're in now is to be expected in the beginning."
Lamb said what keeps her energized during long days, sometimes well after dark, is the commitment of others on her staff. "I think one of the most impressive things about the exchange, is everyone working here is really committed to seeing that people in Connecticut have access to health insurance," Lamb said. "There are a lot of mission-driven people here."•