Delivery of Care

Whose voice is being heard? And, who is listening?

A much-needed conversation about race, equity and health and the patient-centered medical home in Rhode Island

Photo by Richard Asinof

Dr. Jeffrey Borkan, right, introduces the symposium, "Race, Ethnicity and PCMH: Ensuring Everyone Has a Voice," on June 16 at the Warren Alpert Medical School at Brown University.

By Richard Asinof
Posted 6/22/15
The first organized symposium on race, ethnicity and health within the patient-centered medical home model took place last week – just one day before a white gunman murdered 9 black people in alleged hopes of sparking a race war. The remarkable conversation on race in Rhode Island’s health care delivery system provided a starting point in a discussion long overdue.
When will the removal of lead paint from Rhode Island’s neighborhoods and communities become a health care and educational priority? How will the different models of patient-centered medical homes be evaluated – on outcomes, on patient needs, on costs, on neighborhood values? Who will control the data on race, ethnicity and language mandated by the Affordable Care Act? How will it be integrated into evidence-based research? When will the conversations around health equity zones, toxic stress and health care delivery system reforms converge? When will the need to map health innovation in Rhode Island become a priority?
Of all the scandals dogging N.J. Gov. Chris Christie and his aspirations to run for President in 2016, his role in failing to put some $7 million to $14 million a year into a fund to prevent lead poisoning – he has put in zero dollars since 2011 – may prove to be most egregious and damning.
Christie is not alone is his transgression; some $50 million destined for the fund has been diverted since 2004, according to an Asbury Park Press investigation.
A new report, “Five Social Disadvantages That Depress Student Performance,” by the Economic Policy Institute, says that lead poisoning leads to increased violence and other criminal behavior in adolescents and young adults.
“Lead cleanup is expensive, but it would result in substantial overall savings in reduced special education placements, reduced criminal behavior and greater worker productivity from adults with greater cognitive ability,” the report said.
That’s a message that Gov. Gina Raimondo, the R.I. General Assembly, and the leaders of the health care, education and housing industries need to hear – and to talk about in public – when they talk about budget priorities.

PROVIDENCE – In health care, and in our world, all lives matter

The day before a 21-year-old white gunman opened fire in the Emanuel African Methodist Episcopal Church in Charleston, S.C., murdering nine members of a Bible study class, in the alleged hope of provoking a race war in America, leaders and practitioners in Rhode Island’s health care delivery system gathered to discuss race, ethnicity and health equity in patient-centered medical homes, an innovative team-based approach to primary care.

If you were to do a Google search on the topic of the conference, you wouldn’t find anything, save for the actual conference name itself, said Dr. Jeffrey Borkan, chair of Family Medicine at the Alpert Medical School of Family, as he introduced “Race, Ethnicity and PCMH: Ensuring Everyone Has a Voice.”

The four-hour symposium, held on the afternoon of June 16 at the medical school, was the first-ever conversation to be held on race, equity and health around the context of the patient-centered medical home, or PCMH – either in Rhode Island or the U.S., according to Borkan.

The lack of hits was not so much a problem with Google’s search algorithm, given the escalating tensions over America’s racial divide which are a constant, recurring part of our everyday lives.

Rather, it was, in large part, the fact that Rhode Island is so far ahead of the curve in adopting the PCMH model of health delivery for primary care, compared to the rest of the nation, Borkan explained.

“PCMHs have spread like wildfire in Rhode Island, with about 330,000 Rhode Islanders [receiving primary care] through some 73 practices,” Borkan said, referring to the numbers from the Care Transformation Collaborative, the state’s all-payer program pushing patient-centered primary care for adults, kids and adolescents. “That’s incredibly remarkable.”

Indeed, the PCMH model has been touted as a central component of the state’s health care reform efforts to transform health care delivery. The PCMH model has also emerged as a fundamental building block in the creation of hospitals as an Accountable Care Organization, or ACO, the new business model for health care delivery to replace fee-for-service. The PCMH model is also being expanded beyond adults to serve kids and adolescents. [See link to ConvergenceRI stories below.]

What had not yet been part of the conversation, Borkan continued, speaking to more than 150 people attending the symposium, was the fact that the PCMH model had emerged from “middle-class rationales and assumptions,” focused on cutting costs and improving outcomes in health care delivery – but without a strategy to address the social determinants of health and the racial and ethnic gaps in health care and health equity.

To help remedy that, the symposium, the fifth in a series organized by the Brown Primary Care Transformation Initiative, asked some penetrating questions about what it called “the necessary and new frontier”: the racial and ethnic divide in health care in Rhode Island.

They included: how can a PCMH be reshaped to best serve the needs of a diverse population? What does a PCMH look like, from the patient’s vantage point? And, what strategies can best address the structural racism embedded in the primary care system? Good questions.

What you see is not what you get
The keynote address, delivered Dr. Norman Oliver, chair of Family Medicine at the University of Virginia School of Medicine, focused on the need to move to what Oliver termed Population Health 2.0 – looking at health and well being of an entire population.

“To address the social determinants of health and health equity, we need to see the patient not just as an individual but as a member of a family, in a community, in an entire population,” Oliver said, in a soft-spoken voice.

Much of the problem, Oliver continued, is related to what he termed implicit and unconscious bias. “Our visual system is high developed and often overrides the facts of what we see,” he said.

Oliver pointed to several research studies, which had found that despite a person’s belief that he or she was not prejudiced, they were often guided by unconscious bias.

Oliver also spoke about the need to recognize that bias in race and ethnicity was not limited by geography, quoting Malcolm X that “the South was anything south of the Canadian border.” Oliver shared his own efforts to be more aware of his biases when he cared for white, rural Southern patients.

To change perceptions, Oliver suggested that medical schools and hospitals needed to honor and to celebrate the contributions of minorities and not just “old white men,” alluding to the predominant photographs that hang on the walls at the University of Virginia medical school.

When Oliver worked in Alaska as part of a rural Native American community health care system, which was run by the community of patients, and not by a hospital system, he said it changed the patient-caregiver dynamic. “It was very clear that I was working for [the patient’s community],” he said.

Changing policies and attitudes
Following Oliver’s keynote, Dr. Pablo Rodriguez, moderator of the first panel discussion on policy, admitted to this kind of “unconscious bias” when seeing a patient who spoke English with a strong African accent, making it hard for him to understand. Rodriguez told how he had begun to speak slowly, in almost childlike language, to explain things to the patient.

The woman put her hand up and told Rodriguez to stop: in turned out that she was a medical doctor, and she understood the medical condition very well. Rodriguez apologized.

In turn, Rodriguez said he had himself been the victim of a similar kind of “not seeing.” Following a car accident, he was being treated in a hospital, and dissatisfied with a wound’s dressing, he changed it himself. When the attending physician came in, she became upset, demanding to know who had changed the dressing, Rodriguez admitted that he had done it, explaining that he was a doctor. His patient’s chart had not contained that information, only his name.

How to use race, ethnicity, language data
A central question that emerged during the policy roundtable about what kinds of data was being collected on race, ethnicity and data, and how was it being used. While the Affordable Care Act mandated that the data be collected, the unanswered question was exactly how it was being translated and applied into a meaningful, understandable platform of quality care.

The policy panel featured Rodriguez, Dr. Nicole Alexander-Scott, director of the R.I. Department of Health, Dr. Roanne Osborne-Gaskin, Associate Medical Director at the Neighborhood Health Plan of Rhode Island, Roberta Goldman, Ph.D., an anthropologist and a professor of Family Medicine at the Alpert Medical School, and Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services.

Roberts talked about the fact that 80 percent of what matters in health occurs outside of the doctor or nurse’s offices, and promised that the State Innovation Model plan being developed would focus not just on health care providers, but on the places and people who are delivering healthy food, education and housing.

Goldman, as an anthropologist, noted that the term “home,” while positive to many, did not carry that same positive value to many who were living in broken homes and difficult family situations.

Team-based care – and the need to train physicians how to work in a team-based approach in a PCMH, a skill that many lacked, was also discussed.

Patients and practices
A second panel, moderated by Linda Newton, an independent consultant, featured Dr. Nausheen Hussain, medical director at Blackstone Valley Community Health Care, Emmanuel Echevarria, call center manager at the R.I. Patient Information Network, Wunesh Bairu, clinical mental health coordinator at the Pathways Wellness Center in Barrington, and Vanessa Cumplido, nurse care manager assistant at Affinity Physicians in Pawtucket.

Much of the discussion focused on the barrier of language, culture and translation, within “an ocean of emotional stressors” that was health care delivery at the community level.

For Cumplido, it was the patients who refused to see another provider, once a relationship had been established – and spread by word-of-mouth within the community – that a particular provider was the one to see. It was also the fact that many of the bilingual workers she trained as part of her team would soon move onto better-paying jobs.

For Echevarria, it was the lack of medical translation services when patients went to the hospital, recalling his own experiences of having to serve as the translator for his parents in medical settings as a child – a practice that is illegal in Rhode Island for children under 16.

For Hussain, it was the need to understand the importance of Portuguese sweetbread – and to taste it – to understand its sweetness and the difficulty of changing the diet of patients for which the bread was such a strong part of their culture.

For Bairu, it was often all the biases against medicine itself – and the way in which prayers and herbs were considered an integral part of health care by the patient, even if there was no evidence to support the homeopathic remedies that were part of a cultural tradition.

Note: Most of the members of the first panel had departed before the start of the second panel, illustrating the disconnect that often occurs between policy and practice, between the worker bees and the directors, in the health care delivery system.

If learning to listen to the patient, in a process where the patients’ voices can be heard, is recognized as critical strategy in addressing race and ethnicity disparities in the PCMH model, then the importance of learning to listen to voices of members of the team must also be recognized, too.


Moving forward
The symposium was not the end but the beginning of the conversation, one that would be continued, Borkan said, in concluding comments, following a brief discussion led by Dr. Joanna Brown, director of Practice Transformation at Brown, summing up key message points and potential next steps.

From the audience, participants voiced concern about the orientation of the PCMH around the issue of cost concerns – and how that filtered the conversation around what the patient needed vs. what was deemed most cost-effective.

One talked about the concept of needing to learn how to listen, in the words of Dr. Doug Eby, in 10 different ways.

Gaps in policy, strategy
The symposium was a rather momentous first step, holding a conversation about racial and ethnic disparities in Rhode Island’s health care system, and tying it to health care reform efforts.

From a policy and strategy perspective, however, there were some surprising gaps not addressed in the conversation.

•  The launch of 11 Health Equity Zones in Rhode Island, underwritten by the R.I. Department of Health with funding from the Centers for Disease Control and Prevention, focused on developing place-based community health collaborations, were not part of the conversation. These health equity zones have consciously been organized around the needs of communities, not health care delivery systems. The convergence with the PCMH model has not yet happened, from a policy perspective, judging from the conversation at the symposium.

•  The work of Healthcentric Advisors, as the Medicare quality improvement organization for most of New England, and its focus on patient-directed, not patient-centered care, was also missing from the table. While some within the PCMH movement have told ConvergenceRI that the difference between patient-centered and patient-directed care is one of semantics, the differences seem to get the heart of conflict identified at the symposium – the need to listen to what the patient wants and needs, not just what the doctor or caregiver wants.

The PCMH model is evolving, and as much as the Care Transformation Collaborative’s all-payer model is currently ascendant, there are other competing visions that could have been included in the conversation. The Neighborhood Health Station model, championed by Dr. Michael Fine, former director of the R.I. Department of Health, is moving ahead, with potential locations in Central Falls, Providence and Scituate. The new Care New England ACO, Integra, features as an integral component the R.I. Primary Care Physicians Corporation under the leadership of Dr. Al Puerini, which has the largest number of PCMHs in Rhode Island – more than 100. To leave the other models out of the conversation, as if they somehow didn’t exist – appears to be a political decision.

•  One motivation in the development of the PCMH model was to create a more efficient, cost-effective way to delivery care, with a focus on preventive care in chronic diseases such as diabetes. Blue Cross & Blue Shield of Rhode Island has invested some $60 million in the PCMH model. But, at the end of the day, the question remains: who gets to share in the savings achieved? Is it the insurer? Is it the state and the general fund as part of a risk-sharing agreement with Neighborhood Health Plan of Rhode Island for its managed care? How do the innovators on the ground – whether it is the community health centers who are achieving the savings by a sophisticated use of health IT at the point of care, or the bilingual community outreach workers – get to share in the rewards? How are the cost-savings passed onto patients, if at all? In terms of financial remuneration, primary care providers are still at the bottom of the totem pole.

•  Measurement of results, and the benchmarking of outcomes, becomes the way that providers will be reimbursed under the new system of population health management with bundled payments for a continuum of care. Panelists at the symposium discussed at length the problem that collecting data about race, ethnicity and language was but a first step; the larger question about how to understand and apply the data still needs to be determined. Within that context is a more intriguing question: who owns the data? And, in terms of outcomes, how do addressing the social determinants of health come into play in terms of ROI?

•  Another major initiative being conducted under the auspices of the R.I. Department of Health – toxic stress from adverse events and environmental toxins, and its detrimental role in the development of infants and toddlers – did not come up in the conversation.

•  Also not included in the conversation was the R.I. Alliance for Healthy Homes, focused on the development of a statewide initiative on eliminating the root causes of many health disparities.

All of these omissions can make for richer opportunities for future discussions – if and when the next organized conversation occurs around PCMHs and racial and ethnic disparities.

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