PROVIDENCE – Tim White, WPRI investigative reporter, tweeted on March 29: “[On] a day that had mob digs and Icelandic promo videos, this is probably the most important story yet,” promoting the Ted Nesi interview with Care New England President and CEO Dennis Keefe, discussing the perilous financial situation at Memorial Hospital, following the announcement of planned layoffs of 58 positions at Memorial.

Yes, the story was important.

And, yes, in the midst of the cooler & warmer tourist slogan misfire by Gov. Gina Raimondo and her economic development team led by Stefan Pryor, it was easy for a story about layoffs at the financially struggling Memorial Hospital to get swept away in the raging sea of angry responses that dominated the front pages, the Twitter-sphere and talk radio for much of the last week.

And, for sure, there was a bit of cross-promotional bromance at play here, with a reporter from the same local TV network praising his colleague’s good work.

[Indeed, Nesi does very good work, in ConvergenceRI’s opinion; in turn, Nesi recently praised ConvergenceRI, calling “Life cycle of health care in RI: busy being born, busy living, busy dying,” the lead story in the March 21 newsletter reporting on Memorial Hospital’s travails, a really terrific story and a must-read. To be fully transparent, Nesi and ConvergenceRI were once colleagues at the Providence Business News in 2010.]

But, where ConvergenceRI must draw a bright line is with the use of the superlative, the-most-important-story-yet label, applied by White.

The story did a good job on reporting on the financial tremors raining down on hospitals, but it left out, in large part, an analysis of the causal factors: why are hospitals failing?

Let’s be clear here: What made the story important was not Nesi’s prodigious reporting skills but Keefe’s candor: there were too many medical facilities in Rhode Island competing for too few patients, Keefe told Nesi.

Keefe was telling the truth about a disliked reality that had been well known since 2013, when a study commissioned by the R.I. General Assembly found that there was a surplus of about 200 hospital beds – yet no statewide action had ever been taken to confront this issue.

By proposing to eliminate 150 of 298 beds at Memorial Hospital, as Keefe told Nesi, Care New England was attempting “to right-size” the health care system in Rhode Island. “We’re taking all the slings and arrows,” Keefe said. “We’re willing to be a leader to right-size [Memorial], get it to a better place. It’s happening all over the country – it’s just not happening yet in Rhode Island.”

Translated, Keefe was the first hospital CEO in Rhode Island to take action and cut the number of hospital beds, pending regulatory approval.

The forces of entropy
Because we are talking about conditions in the health care world, it seems apt to use metaphors that employ medical diagnoses to help drive home a better understanding of the facts.

The fiscal pernicious anemia engulfing Memorial – and the resultant outbreak of financial hives at Care New England – are the most immediate visible symptoms of a much larger, more complex industrial disease: the breakdown and failure of the business model of acute care community hospitals serving an economically declining urban core.

Translated, the 20th-century industrial age of a manufacturing economy and its factories that once drove the wealth of cities is over, and with it, the acute care community hospitals built to serve these urban communities are dying. These hospitals don’t work anymore as a sustainable business model. You can count the smokestacks and the church steeples that dominate the skyline, but recognize that it’s a nostalgic skyline of the past.

Accelerating the decline of these hospitals is the way the 21st-century federal reimbursement systems for Medicare and Medicaid are quickly moving away from fee-for-service toward bundled payments and accountable care – what’s been hyped as paying for value, not volume.

In order to capture the reimbursements for a continuum of care for a patient, both within a hospital and outside the doctor’s office, a new kind of metrics is required: population health management analytics.

[If there is ever a 21st-century remake of “The Graduate,” instead of the iconic line, “I-have-one-word-for-you-son, plastics,” the Benjamin Braddock character portrayed by Dustin Hoffman would no doubt be told by his neighbor that, in considering his future, there was but one phrase: population health analytics.]

In turn, population health analytics require the sophisticated use of electronic health records software, which is the major reason why so many large hospital systems have invested big bucks in adopting the Epic health IT software, perceived as the best technological tool to manage population health analytics. To install Epic, Partners Healthcare in Boston has invested more than $1 billion; Lifespan has invested more than $200 million, according to sources, and Care New England about $50 million. [Whether or not Epic will prove to be the best, most nimble health IT system is a story for another day.]

The bottom line, however, is that you also need a large-enough patient base to make the numbers work in an accountable care framework, which is why there has been a new wave of consolidation of hospitals, not just in Rhode Island but throughout New England and the nation.

It is one of the reasons why, Keefe explained to ConvergenceRI in an interview in November of 2015, that Care New England and Southcoast Hospital system in New Bedford, Mass., were in the midst of creating a new partnership. [See link to ConvergenceRI story below.]

“Population health management is where everything is headed; you are developing these new payment systems, and you’re at risk for providing the care within these new payment systems,” Keefe told ConvergenceRI.

Increasingly, Keefe continued, “You know this really well, Richard, you have to take on the characteristics of an insurer. If you’re going to be successful in this kind of risk-taking environment, you need scale, and you need geographic coverage.”

“You need to cover enough geography, and then you need the actual members that are served by the entity you’re creating – whether it is an accountable care organization, or the new language around alternative payment models, or alternative entities,” Keefe said.

In thinking about the future, Keefe explained, it requires figuring out “how do you get to that level of scale and geographic coverage, if you really want to be a leader as a population health manager.”

Currently, in Rhode Island, there is only one remaining unaligned acute care community hospital – South County Health. Odds are that the health care delivery musical chairs in Rhode Island will continue, as the state’s hospitals and health care delivery system are consolidated and colonized by out-of state entities, both for-profit and nonprofit.

Malfunction junction
The other big missing piece of the health care puzzle – something that was also not addressed in Nesi’s story – is the lack of a comprehensive statewide health plan to serve as a standard to measure and to calculate the need for new medical facilities, based upon community and patient needs.

The absence of such a statewide plan has also been one of the precipitating factors accelerating the breakdown of Rhode Island’s existing health care delivery system, according to numerous health care policy practitioners.

[Some, such as former R.I. Department of Health Director Dr. Michael Fine, have argued that calling it a health care delivery “system” was a misnomer; rather, it functions much more like a system of “wealth extraction.”]

There is a much longer, tangential tale that can be told about how resources to support statewide health care planning dwindled and disappeared over the last three decades. But, let’s cut to the chase scene.

The entire process for determining certificate of need in Rhode Island was upended in 2014 by the passage of what was termed the Medical Tourism Bill by the R.I. General Assembly, championed by Rep. Joseph McNamara, in order to facilitate new medical facilities being built in Rhode Island that would serve as a place where those outside of Rhode Island could travel to have medical procedures and surgeries done.

Under the law, a year’s moratorium was placed on issuing certificates of need for new health care facilities, and during that time, a statewide inventory of health care resources was to be undertaken. [It was completed in October of 2015; see link to ConvergenceRI story below.] In addition, the membership of the Health Services Council, the group makes recommendations about new facilities, was streamlined.

Last month, just such a new medical tourism $48 million facility was announced, to be located at the Crowne Plaza Hotel property in Warwick, and to be developed by Carpionato Properties. The legislation enabled such facilities to avoid obtaining a certificate of need if some 50 percent of the patients served were from outside of Rhode Island. [State Rep. K. Joseph Shekarchi, a lawyer, is representing Carpionato Properties in the deal, according to a story in The Warwick Beacon.]

The new medical tourism facility is one of a number of proposed new medical facilities now under review by state authorities. They include:

• Rhode Island Hospital, a Lifespan facility, has proposed building a new obstetrics facility with the capacity to handle up to 2,500 births, at a cost of about $35 million to build and another $15 million a year to operate. The request is pending before state health authorities.

• Another pending request now before state health officials is by a Texas firm to build a “Neighbors Emergency Center,” a for-profit freestanding emergency care facility in West Warwick, operating 24/7. A second such freestanding facility is also planned for Bristol. A preliminary review recommended against the proposal, but the final decision is now up to Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health.

Also pending is Care New England’s reverse certificate of need to close the Birthing Center at Memorial Hospital.

How will decisions be made?
ConvergenceRI asked the R.I. Department of Health to clarify the status of state health care planning. Here are the responses from Joseph Wendelken, communications spokesman for the agency.

Is there an existing statewide health care plan in place to make decisions moving forward?
WENDELKEN: No, there is not a statewide health care plan in place at the moment.

Is there an ongoing effort to put together such a comprehensive plan under the agency’s strategic direction?
WENDELKEN: Work is being done to develop a comprehensive population and behavioral health plan. Note that this is very different from a “health care plan.”

What is the process for putting such a plan together? Will it be done under the auspices of the R.I. Department of Health or by the R.I. Executive Office of Health and Human Services?
WENDELKEN: The plan is being developed across agencies within the Health and Human Services cabinet. The steering committee for the plan, which Dr. Alexander-Scott sits on, is co-chaired by Secretary Elizabeth Roberts. [I know that you are familiar with the State Innovation Model. This is the SIM Steering Committee.] Editor's note: Lou Giancola, president and CEO of South County Health, is chair of the SIM Steering Committee.

The Department of Health also has staff on a SIM Interagency Work Group. There are many different focuses at this point in the process (e.g., measure alignment, healthcare quality, measurement and technology reporting, patient empowerment, etc.)

[The agency] has developed a series of leading priorities, strategies, and population health goals. We are in the process of developing target metrics and key initiatives/activities for each goal. All of this will be incorporated into the population and behavioral health plan.

Beyond the effort now underway to “harmonize” metrics under the SIM effort, I have heard about a parallel effort to develop metrics around community needs, also being driven by SIM and involving the Hospital Association of Rhode Island. Is the R.I. Department of Health aware of, or involved in this effort?
WENDELKEN: There is a Community Health Needs Assessment Group that the R.I. Department of Health participates in. This effort involves Mike Souza from HARI.

Unpacking disparities
When Brown University President Christina Paxson gave her lecture on “Unpacking the Racial Disparities of Health” in November of 2015, the facts were incontrovertible: across numerous measures, including life expectancy, disease, and economic well being, blacks in America had been on the short end of the stick. [See link to ConvergenceRI story below.]

As the Community Health Needs Assessment Group moves forward, under the direction of the Hospital Association of Rhode Island, with Marti Rosenberg at SIM serving in a coordinator capacity, according to sources, will they incorporate the same kinds of measures that Paxson used? It’s a good question.

Further, who will actually be conducting the community assessments? The nursing faculty and students at Rhode Island College have a good deal of expertise and training in conducting community assessments, but how will that expertise be employed?

Or, will out-of-state experts and consultants be hired to conduct the assessments? And, will the assessments be newly done, or will the information be cobbled together from past assessments and studies? Further, how will community and neighborhoods be able to participate in the conversation?

Because, in moving forward in population health analytics, the key question is: what gets counted? In the current model of population health analytics, the savings and outcomes for a continuum of care is measured for patients that are served by a medical group or a hospital. It is a “community” defined as a group of individuals who are members of a practice, not by zip code of where they live.

How will other factors – such as access to healthy, safe housing, or food insecurity, with access to healthier foods – be counted? Or, how will lead poisoning in Rhode Island – the fact that 13.8 percent of children entering kindergarten in 2014-2015 tested positive for elevated levels of lead in their blood? Or, that some 50 percent of children in Rhode Island were not screened twice – required by law? How is the lack of screening factored into accountability in outcomes and metrics and community needs?

Who will conduct the analysis?
Buried in the legislative weeds this year are proposed changes in the wording of the health information exchange act of 2008, contained in 2016 – S 2463. ConvergenceRI was not alone in being puzzled by what was driving changes, and so we asked Laura Adams, president and CEO of the R.I. Quality Institute, to explain, if she could, the meaning behind the proposed changes regarding “interoperability” between electronic health records, a key component of population health analytics.

Adams voiced her own confusion about who were the political forces behind pushing for such changes.

ConvergenceRI: Why are the changes being made?
ADAMS: The interoperability bill is one that was initially introduced in 2015 but didn’t go anywhere. It was first advanced by the R.I. Medical Society, for reasons that aren’t entirely clear to me. I did talk with Steve DeToy about it, and he said that their intent was to “start a conversation.”

It apparently resurfaced again in this session as a routine re-introduction of bills that is done by a committee chair for those pieces of legislation that did not go through the entire process in the previous session.

However, I haven’t seen any indication that the R.I. Medical Society is supporting it this year. No one from RIMS was present to testify at the first hearing.

ConvergenceRI: How would the changes re: interoperability be enforced?
ADAMS: That’s a great question, and I don’t know the answer. There are questions that we have about many of the sections, but especially about the following section:

“The HIE advisory commission shall consider the interoperability strategic plan developed by the Rhode Island Quality Institute, and present its review to the Department of Health and the RHIO regarding the implementation of national interoperability standards statewide and the infrastructure required to support the statewide electronic exchange and use of confidential health care information in a secure, private and accurate manner across all EHR systems. Such strategic plan shall include provisions for maintaining a reliable method of identity management across EHR systems, as well as the need for semantic interoperability, and a detailed plan for protecting the systems from security breaches.”

This section may imply that RIQI would have some sort of responsibility for all insuring the interoperability, privacy and security of the products offered by all EHR vendors in the state (“…across all EHR systems.”).

It also says that we’d oversee their identity management systems and their defenses against security breaches. This all seems infeasible on a number of levels, not the least of which is that we have no authority of any kind over free market vendors, not to mention that we don’t have the resources to take on an activity like this, even if we could do it.

It seems that there may be some confusion between EHRs and the [state’s Health Information Exchange. The HIE has all of this in place, so I’m thinking their concern is about the [more than] 50 EHR vendors in the state. But I don’t see how we would comply with this if it became law.

ConvergenceRI: Will these new responsibilities require additional resources, and where will they come from?
ADAMS: We are asking the same question. This is a huge job, much like a regulatory body would take on, and it would require an ample amount of resources to do effectively. We certainly don’t have the funding to do this now, and I don’t see too many sources of ready funding for this kind of work, even if it were possible to do.

The political equation
How decisions get made about future medical facilities and their relative need, if there is no agreed-upon statewide health care planning benchmark, become an inherently political decision: about who gets what, how, and why.

Even with the new statewide population health management plan and behavioral health plan now under development, it will be a plan composed of political choices about where the scant resources of state investment are directed.

Moving forward, there are some lessons to be learned from the cooler & warmer fiasco under the direction of CommerceRI’s Stefan Pryor that apply to population health management analytics:

• Are there local experts who can be hired to do the work, instead of national consultants?

• How can the local expertise be brought into the process early on – such as the RIC nursing faculty – to development the community assessment tools?

• How can the perceived stiff-necked arrogance of Raimondo and her economic development team – where critical questions raised are dismissed as “negativity” – be changed?

• When will communities and neighborhoods be invited into the process as participants?

• And, from ConvergenceRI’s perspective, when will Gov. Gina Raimondo and CommerceRI’s Stefan Pryor honor their words and schedule one-on-one interviews?

From the ashes
There are some who would cheer the demise of the state’s health care infrastructure and a return to a free-for-all, engulf and devour marketplace. From a public health perspective, this would be a disaster.

That said, there are alternative models of care that are emerging – the Neighborhood Health Stations in Scituate and Central Falls, and the development of Health Equity Zones in 11 Rhode Island communities.

There are community-based initiatives that seek to bring access to affordable, safe and healthy housing into the overall community health care equation, such as the Green & Healthy Homes Initiative, and the Sankofa Community Initiative.

There are efforts to democratize the use of data as a tool of policy change and direction at DataSparkRI.

Memorial Hospital may evolve from a acute care community hospital into a successful outpatient facility with an active emergency department, working in collaboration with other local community entities.

In researching this story, ConvergenceRI uncovered a surprising trend: a primary care physician, when asked what was the most important part of the story of health care transformation, offered this: the primary care physicians who were most happy were those who no longer took health insurance, but instead offered care to patients on a regular monthly fee, without any copays. They also did home visits.

“They are the happiest primary care docs I know,” she said.