PROVIDENCE – Repeal, replace, repair or retain? Congress and the nation appear transfixed by the debate about what to do with Obamacare. After eight years of running against Obamacare, Republicans are now confronted with the cathartic task of saying exactly what they are for, designing their own version of Trumpcare.

Democrats are pushing back, seeking to mobilize resistance. Witness the rally held on Feb. 25 at Rhode Island College, the “Save Health Care Day of Action,” organized by Sen. Jack Reed, Sen. Sheldon Whitehouse and Rep. Jim Langevin, where hundreds showed up to demonstrate how the Affordable Care Act has made their lives better.

Behind the scenes, without speeches, slogans and signs – and with limited coverage by the news media, perhaps a more significant conversation is underway here in Rhode Island: an attempt to redefine the metrics of the state’s future health care delivery system, changing the formula for who gets paid, how much, when, and for what.

Outcomes matter
Whatever the political “outcome” in Washington, the new economic reality in health care is that outcomes matter when it comes to population health. In the future, reimbursements from Medicare, Medicaid and commercial insurers will be made in bundled payments, based upon a continuum of care, with shared risks, based upon population health.

But what does population health mean? Is it defined by zip codes or by ICD-10 codes? Are the boundaries defined by a hospital’s service area, or by membership in an insurance plan? Can population health boundaries cross state lines?

The financial design of the bundled payment business model, often described by the mantra, investing in value over volume, will depend on asking – and answering – some penetrating questions:

• What is health and what is healthy, when it comes to a population? How do you measure the differences in outcomes? Can you benchmark the outcomes in a way that provides a yardstick for rewards and penalties, determining what providers will get paid for providing higher-quality health care?

• Further, how are the risks and rewards shared? How do patients and communities fit into the conversation and the decision-making?

• And, how does place-making and health equity fit into the equation? How can you measure chronic diseases such as asthma, both in terms of incidences and outcomes, without including metrics focused on improving access to healthy housing and levels of air pollution?

• There is, of course, the underlying economic question that frames the conversation: do we have a system of health care delivery, promoting health? Or, do we have a market system, one that maximizes wealth extraction?

These are complex questions to wrestle with. The answers go to the heart of the effort now underway to transform health care delivery in Rhode Island, attempting to move away from the fee-for-service business model toward a value-based system of care delivery.

Most folks, rightly, translate health care questions into a personal equation: how will I be able to pay for my cancer care? Will my Medicaid coverage get taken away? Will my pre-existing condition be covered? How will I afford my medications?

Deep background
For those who may have been asleep at the wheel, the $20 million federal State Innovation Model grant awarded Rhode Island at the end of 2014 by the Centers for Medicare and Medicaid Services is now entering its third year in its effort to transform the health care delivery system in Rhode Island, under the aegis of a statewide steering group known as Healthy Rhode Island.

The vision is filled with the optimistic jargon of health care reform under the Affordable Care Act: “Healthy Rhode Island aims to achieve measurable improvement in health and productivity of all Rhode Islanders, and achieve better care while decreasing the overall cost of care.”

The mission continues: “We plan to transition from a disparate and health care provider and payer-centric environment to an organized delivery and payment system that is outcomes-oriented and person-centric.”

The deliverables included: an “operationalized” value-based care paradigm; a population health plan; redefined clinical outcome measures; an expanded health IT infrastructure; and the promise that 80 percent of Rhode Islanders will have health insurance that links payment to value or quality of care.

Of course, what that will mean under the new era of Trumpcare is anyone’s guess. The funds and resources to accomplish such tasks will be severely constrained, if the Republican Congress has its way.

Still, the conversation continues in Rhode Island, and ConvergenceRI sat in last week to listen to what was being said.

Complex harmonies
Call it an ongoing attempt to compose a symphony of complex harmonies in defining future population health metrics in Rhode Island, amidst the cacophony of the current health care landscape.

Those gathered on Feb. 21 around the conference room at the Rhode Island Quality Institute were not musicians or conductors but health care professionals – doctors, nurses, administrators, agency executives, mental health providers, and consultants.

They were attending the monthly meeting of the State Innovation Model [SIM] “Population Health/Behavioral Health Plan” workgroup.

The discussion focused in large part of what has been labeled the SIM Integration & Alignment Project – tasked with identifying “state activities that are addressing population health” within the eight designated SIM Health Focus Areas.

These include: obesity; tobacco use; chronic disease [diabetes, heart disease and stroke]; maternal and child health; depression; children with social and emotional disturbance; serious mental illness; and opioid use disorders.

At the Feb. 21 gathering, the group of about 25 participants discussed a written draft of the “expansion” of the Maternal and Child Health focus area in the population health plan. They also discussed a draft of the scope of high-risk patient identification activities under SIM and the R.I. Office of the Health Insurance Commissioner, including how insurers, patient centered medical homes and accountable care organizations are identifying such high-risk patients.

The conversation was at times esoteric, such as debating whether or not “maternal depression” should be included as part of the data sets and metrics in the state’s integrated population health plan under the focus area of “depression” or under the newly created category, “maternal and child health.”

And, as part of that discussion, how best to include maternal education, particularly around recommended intervals between births, and access to long-term birth control immediately following births.

The shorthand heading, “Unintended/Teen Pregnancy,” under the “Mothers” category, drew a request for clarification: were the recommendations talking about unintended teen pregnancies, or both unintended and teen pregnancies? As one health professional said: some 40 percent of all pregnancies were “unintended.”

On a positive note, both childhood lead poisoning and childhood asthma were included in the draft recommendations for expansion of the Maternal and Child Health life course data sets, defined as environmental toxic stress.

So, too, were the categories of substance exposure during pregnancy, smoking during pregnancy, and serious emotional disturbances.

Defining high-risk patients
The discussion around identification activities for adult “high-risk” patients was a bit more contentious. The draft plan for the scope of activities talked about OHIC’s effort to research best practices “by conducting interviews with experts and reviewing academic literature” during the next few months.

In turn, SIM will be tasked with conducting research on high-risk assessments for both adults as well as children and the elderly, and how best to incorporate social determinants into the risk assessment.

Also on the future agenda is to facilitate a debate on the pros and cons of adopting a standardized definition or assessment tool for “high-risk” patients.

There was substantial pushback during the discussion: one participant questioned the perspectives in play around defining “high-risk” from purely a cost-cutting, industry perspective.

Another asked about the where the consumer voice fit into the conversation. A third talked about the potential importance of measuring patient confidence through the “How’s Your Health” assessment tool.

A fourth questioned lack of integration through which the R.I. Department of Education was integrated into the process.

Place-making
Next week, on March 6, at the School of Public Health at Brown University, Dr. Mindy Fullilove will give the inaugural School of Public Health Black History Month Lecture, entitled: “< 3/5’s: Assessing the Costs of 400 Years of Inequality.”

Fullilove, professor of Urban Policy and Health at The New School of Social Engagement, spoke at the inaugural Health Equity Summit in Rhode Island, held on May 7, 2015.

Health equity, Fullilove said, had been “swept away by racism and greed” in cities such as Pittsburgh, through the redlining of city neighborhoods by banks, driving diversity out of the urban centers, pushing black families into increasing crowded neighborhoods that were outside the zone of new investment. [See link to ConvergenceRI story below.]

It is this missing narrative of black cultural history, captured so eloquently by Pulitzer Prize-winning playwright August Wilson in his 10 plays, covering the 20th century, that gets lost in the discussion of defining outcomes and metrics around population health.

The question is: how can Fullilove’s historical perspective be fully integrated into the SIM plan, attempting to redefine the metrics around health outcomes and payment reform?

Further, as the state and the city of Providence move forward with its redesign of the former Route 195 land as a center for biomedical innovation and commercial real estate ventures, how can the vision for future development incorporate both the metrics of population health and the history of how racism and greed shaped place-making?