Delivery of Care

Lifespan, Care New England clash over future RI health market for births

Two largest health systems in the state, much like the city-states of Florence and Siena in medieval times, prepare for battle: the prize is market share in women’s health care

By Richard Asinof
Posted 1/16/17
The war of words has begun between Care New England and Lifespan over plans by Lifespan to build a new, $43 million obstetrics unit atop Hasbro Children’s Hospital, debating whether or not such a large investment duplicates services already being provided by Women & Infants Hospital located a few hundred yards away.
What are the metrics to be used to determine quality of care when it comes to delivering babies? Where will high-risk patients be sent to deliver their children? Will the new proposed obstetrics unit at Rhode Island Hospital seek to capture a higher share of wealthier patients? What kinds of prenatal services will improve the long-term health of newborns within a population health model? When will the state create a health care planning document as the basis for how to make decisions about the future need of facilities?
Often missing from the spotlight has been a long-standing practice embraced by Women & Infants and Brown University medical school where nurse midwives train residents on how to deliver babies. It represents the kind of integrated clinical educational program that has been recognized as a best practice across the nation. Rhode Island was one of the pioneers.
Another event, under the radar screen, is the retirement of May Kernan, the long-term communications director with Care New England and, before that, Women & Infants. Her knowledge and understanding of what happened in the evolution of the Rhode Island health care delivery landscape is something that the School of Public Health at Brown might consider capturing in an oral history that documents what occurred during the last few decades.

PROVIDENCE – No one, really, should have been surprised when Lifespan decided to resubmit its request last week seeking state approval for a certificate of need to build a new $43 million obstetrics facility that could accommodate some 1,600 births in its first year of operation in 2020, according to Lifespan officials.

If approved by the state, the new OB unit, to be newly constructed on two floors atop the existing Hasbro Children’s Hospital, would put Lifespan in direct competition with Care New England’s Women & Infants Hospital, where some 8,800 babies were delivered last year, more than three-quarters of all births in Rhode Island.

At the same time, Women & Infants and Care New England have filed its own letter of intent with the state to renovate its existing labor and delivery rooms.

War of words has begun
In announcing its plans, Lifespan stressed its capability to handle a continuum of care for women.

As reported in a story by WJAR, the proposed unit would give patients access to urgent obstetrics, medical and surgical services in one location, according to Dr. Peg Miller, chief of women’s services at Rhode Island Hospital. Miller touted the approach as “truly integrated care.”

In the same story by WJAR, Women & Infants President and COO Dr. Mark Marcantano countered with a contrasting view: “It makes no sense to us that Rhode Island and Lifespan and would put this application in and seek to disjoint and duplicate and cherry pick this amazing service that we’ve built for citizens of Rhode Island.”

A similar he said, she said dichotomy played out in two stories in The Providence Journal.

In the first story, Miller described the Lifespan approach as “more about linking women’s care in pregnancy with a lifetime approach – before pregnancy, during pregnancy and after pregnancy. This is the next logical step.”

In the second story, Dennis Keefe, president and CEO of Care New England, claimed that approving the request by Lifespan to build a $43 million obstetrics unit would be “destabilizing,” drawing patients, nurses and physicians away from the state’s busiest hospital.

Accuracy of numbers
In the back-and-forth as reported in news accounts, one number, as reported by The Providence Journal in its initial story, struck ConvergenceRI as somewhat odd.

In that story, the spokesman for Lifespan, David Levesque, claimed: Rhode Island Hospital already cares for about 500 patients each year who are transferred from Women & Infants because they experience complications and require care not available at that hospital.

That number seemed overly large. To double-check, ConvergenceRI reached out to Levesque, asking for a breakdown of the clinical diagnoses of those 500 cases, to better understand what precipitated the need for transfers.

Levesque did not respond to the email. Then, in a follow-up phone call, Levesque told ConvergenceRI that he did not have the information available regarding the clinical conditions, and doubted that he would be able to get it before ConvergenceRI’s deadline.

ConvergenceRI also reached out to Amy Blustein, spokeswoman for Women & Infants Hospital, to see if she could verify the numbers claimed by Levesque and provide details of the clinical conditions that caused the need for transfers.

Here are the questions and Blustein’s reponses:
ConvergenceRI: Was the figure cited by David Levesque, 500 transfers a year from Women & Infants to Rhode Island Hospital, an accurate number regarding transfers?
BLUSTEIN:
No, this number is not accurate. The incidence of transferring obstetric patients to Rhode Island Hospital is fewer than one per week. We are working internally to provide a more accurate number.

ConvergenceRI: Can you provide clinical details why they were transferred, i.e., what complications were there that Women & Infants would not be able to provide care for?
BLUSTEIN:
Only obstetric patients requiring trauma care or ICU level of care would be transferred to Rhode Island Hospital.

ConvergenceRI: Why would the transfer of care be seen as something problematic, rather than a sign of the kind of cooperation and collaboration that should exist between hospital systems? Isn’t that the way it is supposed to work?
BLUSTEIN:
We’ve always had a high level of clinical collaboration with Rhode Island Hospital in caring for obstetric patients with specific health issues. Current inter-institutional collaboration of physicians, midwives, fellows, residents and medical students is seamless, highly coordinated and successful.

ConvergenceRI: In terms of the actual transfers, what would be required? A walk down a corridor on a stretcher?
BLUSTEIN:
In high-acuity and emergency cases, patients are transferred by LifePACT [a critical care transport vehicle.]

Regular, day-to-day patients are transferred by stretcher, through a connecting tunnel. This is similar to or even more advantageous than many hospitals’ intra-institutional transfers from one building to another.

Clearly, these are the kinds of questions that will require more investigation by the R.I. Department of Health, to determine which statements are accurate. There is a big gap between 500 transfers a year, which Lifespan claimed, and less than 50 a year, which is what Women & Infants claimed.

Part of an ongoing conflict
At a time when the birth rate in Rhode Island, when measured over the last decade, is declining, and at a time when the population of Rhode Island has remained relatively stable at about 1 million, approving the investment of new resources into competing OB facilities that are literally only a few hundred yards away from each other may not, on face value, make much economic sense.

From a historical context, this latest battle between Lifespan and Care New England is part of a larger, ongoing conflict: the establishment of the Women’s Medicine Collaborative by Lifespan in 2011, for instance, involved the recruitment of a number of former Women & Infants clinicians.

The Lifespan practice group partnership agreement with OB/GYN Associates in 2013 , the largest practice in the state, further divided the world of women’s health care in Rhode Island.

Last year, the decision by Care New England to close its birthing facility at Memorial Hospital, a move that was contested by the union and the providers but not by the people who live in Pawtucket and Central Falls, ended up being supported by the R.I. Department of Health after a comprehensive analysis. [See link to ConvergenceRI story below.]

Now, Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, has been put in the Solomon-like position of having to decide who has ownership of the delivery system for babies in Rhode Island. As in politics, the decision will be the story of who gets what, when and how.

At a time when state funding resources are constrained, when the federal health care policies and funding are being disrupted with the repeal and dismantling of the Affordable Care Act, it also promises to be a time of heightened rhetoric. It will require thorough investigation into the actual numbers around the claims being made.

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