Delivery of Care

Plans for a new, statewide health care compact emerge

What’s left out of the conversation may be as important as what’s included

Photo by Richard Asinof

Sen. Sheldon Whitehouse, with Rhode Island Foundation President Neil Steinberg, convened a group of health care leaders to develop a statewide compact for health care delivery. The details of the compact were contained in a draft letter that is planned to be sent to Gov.-Elect Raimondo, R.I Senate President M. Teresa Paiva Weed, and R.I. House Speaker Nicholas Mattiello.

By Richard Asinof
Posted 12/1/14
A new statewide compact on health care delivery has been developed, with selected input, convened by Sen. Sheldon Whitehouse and R.I. Foundation President Neil Steinberg. A draft letter that details the compact’s goals has been written, with plans to send it to Gov.-Elect Raimondo, House Speaker Mattiello, and Senate President Paiva Weed. The compact frames the issues around health care delivery as the need to make a strong commitment to payment reform, to preserve the state’s local control.
What would it take to have a more inclusive discussion around health care delivery, one that puts families and children in the center of the table, so that everyone can own the effort? How can the new collaborative research efforts now underway create a shared platform for metrics and analytics about what interventions work best – in early childhood, in obesity and diabetes prevention, in behavioral health, in end-of-life discussions and care? How can the economics of prevention and front-end investments in healthy communities be factored into avoided health care costs? Would an initiative to have all state employees purchase their health insurance through HealthSourceRI create a market force to drive competition and lower costs? How does the entrance of CVS Health into the primary care sector with its MinuteClinics change the equilibrium in the market? Is there legislative appetite to create a statewide health care plan with teeth to enforce it?
The desire behind the impetus to create a statewide compact, organized by Sen. Whitehouse and R.I. Foundation President Neil Steinberg, can certainly be applauded. The problem is one of inclusion: for all the talk about patient-directed and patient-centered care in the new post-Copernican world of health care delivery, patients, consumers and communities have been left out of the conversation about the compact. Too many people in Rhode Island face a wealth extraction system, not a health care delivery system.
Moving forward, if the new recommended stakeholder group is created, it will be important to answer: who has a seat at the table? Who gets to participate in the discussion? How do the silos get broken down beyond issues of turf? A map of health innovation in Rhode Island would help to broaden the conversation, allowing initiatives to converge.

PROVIDENCE – Under the guidance of Rhode Island Foundation President Neil Steinberg and Sen. Sheldon Whitehouse, a group of “key health care leaders” has created a compact of shared goals and commitments in an effort to address the biggest future challenges facing Rhode Island’s health care delivery system.

The new compact, focused around the idea that reduced health costs can help drive economic development, targets achieving statewide payment reform goals by 2019, including moving away from the traditional fee-for-service payment model toward global payments, using alternative reimbursement models focused on population health management.

The compact also calls the creation of a stakeholder group of providers, payers and consumers to work with the incoming Raimondo administration “to transform Rhode Island’s health care payment system."

In addition, the compact calls for an effort to identify, define and collect data to create a profile of health care in Rhode Island, based on quality metrics and spending, as well as to establish statewide baselines for health care spending and quality for the next five years.

Further, the compact seeks to encourage “consumer engagement” – but did not define what that meant – to increase the selection of high-value care based on cost and quality data.

[Is that consumer engagement related to the still not operational All Payers Claims Database? Is it related to the transparent information on health insurance costs created by HealthSourceRI? Is it related to the effort to create limited networks of providers as a way of cutting costs? All of the above?]

The details of the compact were revealed in a draft letter to be sent to Gov. Gina Raimondo, R.I. House Speaker Nicholas Mattiello, and R.I. Senate President M. Teresa Paiva Weed.

“If we do not affirm a strong commitment to payment reform, we jeopardize the many achievements that have been made. Similar to the Rhode Island banking industry, our health care industry faces the risk of losing local leadership and control as more efficient and national health care organizations develop formulas to deliver care at lower costs,” the draft letter reads.

What’s included
The compact draft letter cites a series of ongoing initiatives, including: the R.I. Chronic Care Sustainability Initiative; Coastal Medical Group’s Medicare Shared Savings program; the three-year accountable payment contract agreement between Care New England, Blue Cross & Blue Shield of Rhode Island, and R.I. Primary Care Physicians; and investments in health information technology, including the implementation of the Epic health IT platform at both Lifespan and Care New England, and the Rhode Island Quality Institute’s CurrentCare, the statewide health information exchange.

Whenever possible, the draft letter said, “We should sustain, scale and build upon these models.”

The draft letter positions both the R.I. Quality Institute and Healthcentric Advisors as key designated agencies to perform the tasks envisioned by the compact.

The draft letter also frames the pending $20 million grant from the Centers for Medicare and Medicaid Services to fund the State Innovation Model, in the context of developing new models of care, including payment initiatives. "By collecting and presenting a dashboard of [nine primary population areas], we can compare our performance and health outcomes against national and regional data," the letter said.

Missing pieces
What’s been left out of the discussion about the compact may prove to be just as important as the details contained in the draft letter.

As Betsy Stubblefield-Loucks, executive director of HealthRIght, wrote in her story in this week’s ConvergenceRI, critiquing last week’s forum sponsored by the R.I. Public Expenditure Council and the R.I. Executive Office of Health and Human Services, three major perspectives were missing: “Consumers, behavioral health practitioners, and public health leaders.”

Without real engagement on these three fronts, Stubblefield-Loucks continued, “There is no way Rhode Island can even begin to ‘bend the cost curve.’”

Much of the Affordable Care Act, she explained, has been focused on how to pay for and streamline medical care, yet access to medical care describes only 6 percent of the major determinants of health.

The biggest determinants of health, some 37 percent, Stubblefield-Loucks said, are related to individual behavior, such as smoking, alcohol and drug use, obesity, violence, accidents, suicide, and sexually transmitted disease. “Yet, as a nation, we spend 2 percent on prevention and 88 percent on treatment. How can we better integrate successful behavioral health and population health promotion interventions?” she asked.

Investing in the front end of health care delivery
In particular, what’s missing from the compact’s discussion are those initiatives at the front end of the health care delivery system now underway in Rhode Island, focused on prevention and wellness, that are community-based. These include: the Centers for Health, Equity and Wellness, or CHEW grants, collaborative efforts to create Health Equity Zones in communities across Rhode Island; the reborn student health clinic at Central Falls High School, which is a partnership between Blackstone Valley Health Care, Memorial Hospital, the Mayor of Central Falls, the city’s School Department, and the R.I. Department of Health; and Continuum, the for-profit arm of the Providence Center, which is developing a new model of behavioral health care.

Also missing from the compact’s discussion is the research component needed to go beyond tracking data and actually quantify evidence-based outcomes, something that is planned to be undertaken by a new research consortium led by Stephen Buka at Brown University, focused on statewide early childhood programs.

In general, the work being done by community health centers – often the place where innovations in health care delivery occur, such as the integration of health IT at the point of care – appears to have been left out of the conversation. The shared savings envisioned by bundled payments need to reward more than hospitals, large physician groups and health insurers – such as the innovative work done by community health centers, and even consumers.

Finally, there needs to be a discussion around health IT in the state that does more than champion the potential of CurrentCare, the statewide health information exchange, and looks at more nimble, agile ways of gathering, sharing and analyzing data across networks. And, there needs to be a more inclusive discussion about the way that the state is investing its health IT money. 

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