WAKEFIELD – For much of the past few years, Louis Giancola, the president and CEO of South County Health, has had to navigate the often bumpy road of maintaining the integrity of the last remaining independent, acute care community hospital in Rhode Island.

There have been ongoing conversations about potential partnerships with Southcoast Health in New Bedford, Mass., with Care New England, and, most recently, with Yale New Haven Hospital, the owners of Westerly Hospital.

In each case, South County Health chose to remain independent, not always an easy choice in the engulf-and-devour world of hospital consolidation, with shrinking profit margins and increasing costs.

To survive, in turn, South County Health redoubled its effort to engage with communities it serves, to put the emphasis on achieving the highest rankings for patient safety and consumer satisfaction – and to serve as the convener for the Health Equity Zone, Healthy Bodies, Healthy Minds, focused on improving the behavioral health outcomes for children.

Its primary care providers aligned with the Integra accountable care organization being run by Care New England.

South County Health also served as a pilot program to expand the use of community health teams in the delivery of services.

On Thursday, May 31, Giancola announced his decision to retire after 18 years in the leadership position at South County Health. “The decision was not an easy one because of my deep connection to the organization, staff, and the community,” said Giancola in the news release accompanying the announcement. “It has been my privilege and honor to be part of South County Health.”

Giancola said he would continue in his role until a successor is chosen, in order to ensure a smooth transition.

Exit interview
ConvergenceRI sat down to talk with Giancola in a kind of exit interview on Monday, June 4, to garner his insights into the changing health care landscape in Rhode Island.

As always, on the walk to Giancola’s office, numerous people stopped and asked if ConvergenceRI needed any assistance. There was also the encounter with a support group for cancer patients, which featured a therapy dog, a Golden Retriever sharing hugs, as well as a woman contentedly playing the piano in the space, a far cry from what visitors might encounter in other hospitals around the state.

Here is the ConvergenceRI interview with Louis Giancola, the outgoing president and CEO of South County Health, reflecting upon the changes in the health care delivery system and what they mean for Rhode Island.

ConvergenceRI: With your retirement, you are one the last of the old guard in Rhode Island to leave the health care industry.
GIANCOLA: I don’t like to think of myself that way, but I guess it is true.

ConvergenceRI: At a gathering, I think it was four years ago, at the Shriner’s Hall in Cranston, on a panel discussion with other CEOs, I recall you held up your American Express credit card and asked: why can’t health care function the way we pay for things with a credit card, in order to simplify the financial transactions around health care. Do you remember that?
GIANCOLA: I don’t remember that specific incident, but I know that I’ve said something similar on many occasions. It just seems to me that if you have a Blue Cross or UnitedHealthcare [membership] card, that it should facilitate the process of getting health care and addressing the transaction between the payer and the provider. But we don’t seem to have made a lot progress in that regard.

ConvergenceRI: In writing about the current landscape of the health care industry in Rhode Island, I have often compared in to the Middle Ages in Italy, when the different city states were trying to conquer one another – it was Florence versus Siena, Venice and Rome.

Another metaphor I have used is musical chairs, and when the music stops, you have to find a new partner. You have often been involved in that dance…
GIANCOLA: Yes [chuckling].

ConvergenceRI: Yet, here you are the last independent, acute care community hospital remaining in Rhode Island. How do you see the challenging landscape playing out?
GIANCOLA: I think the challenge is about the broader issue of community, and the lack of what I’ve called a community ethic.

For instance, I feel that Vermont has come together better than we have in Rhode Island to determine what it wants from the health care system. Vermont has either created incentives or been able to gain consensus, whereas we have not.

In Rhode Island, different systems are making decisions without a contextual plan or without a community-wide agreement about what the system should be doing for our state and for the communities that are served.

ConvergenceRI: What do you believe that Vermont has done that has been different?
GIANCOLA: Well, I’m no expert on Vermont. My impression is that they have, in essence, created one ACO [for the entire state], so that they have linked together a lot of providers.

They have created regions where each of those regions is served by a community health team that is supported by the health department, but that works in conjunction with local providers to address the social determinants of health and to serve as outreach from the provider community, in order to try to make sure that you get the maximum impact.

I think that they have flirted with the concept of a single-payer system, then decided to back off.

My sense is that they tried to consciously decide what kind of health care system they want, and they are moving incrementally in that direction.

They have a single medical center in Burlington, and things do seem to radiate from that hub, so that they have, in perhaps a better way, connected their different providers.

I heard recently that they are creating something similar to our Health Equity Zone projects, called RISE Vermont, to make it a statewide program, specifically dealing with the social determinants of health and trying to eliminate disparities.

I don’t know how real or how effective all of this is; however, I do not see us moving in that direction.

ConvergenceRI: Does that mean you are potentially planning a move to Vermont? I read in a recent news story that the state is offering you $10,000 to move to Vermont and then telecommute.
GIANCOLA: I’m not moving to Vermont. As much I loved Vermont, this is my community and I want to stay here.

ConvergenceRI: Do you think that there is an opportunity to travel to Vermont and meet with people to get a better understanding of what they are doing?
GIANCOLA: I don’t know; I’m not sure who you are talking about doing that.

ConvergenceRI: Could that be one of the tools in Rhode Island’s toolbox, intelligence gathering?
GIANCOLA: Definitely. I think we should be learning from Vermont – and from other states. I’m sure that is going on, to some extent. It is not as if people are not paying attention to what is going on in other states. I just think we have difficulty in arriving at a common set of principles about how we are going to govern health care in our state. That’s my interpretation.

ConvergenceRI: At one point, you were very involved, serving as co-chair of the State Innovation Model Steering Committee. Was that a place where, in the best of all possible worlds, that could have served as an opportunity to develop the consensus, similar to what you described happening in Vermont? Do you think that SIM went off track, in your opinion?
GIANCOLA: Maybe it is better to say that I had different expectations. I would not say that SIM has gone off track. I think what it has done is to try to support projects that would move the health care system in a particular direction, by in large, with some success.

I just had expectations that, perhaps, that a consensus about what we wanted from the health care system would be reached, and that turned out to be unrealistic.

ConvergenceRI: Can you describe the efforts that South County Health undertook to become the organizing entity for the health equity zone serving your community? Can you talk about how that relationship developed?
GIANCOLA: We were cognizant of the fact that it was our responsibility to support community efforts to improve health [outcomes], and we were very conscious of the fact that health [care systems] contributed maybe 20 percent toward health outcomes.

And so, we brought a group together to explore how we could make a difference. We became very focused on children’s health, and we embraced some ideas that we wanted to move out into the community. We had grand ideas about structuring the initiative in part as a campaign, almost like a political campaign to improve health and to mobilize and engage with the community broadly around children’s health, and particularly around behavioral health in children.

In the midst of these discussions, the HEZ grant opportunities came along, and we were, I guess, fortunate to have a source of funding to support these efforts. We had a person, Susan Orban, who was prepared to take on the challenge.

We wanted the program to be as rooted as much as possible in the community and not to be strictly a South Couny Health Project. Because we felt, that way, would be able to engage people in the effort, it wouldn’t be us pushing them, it would be the community coming together.

Out of that grew the Healthy Bodies, Healthy Minds steering committee, and we’ve been able to mount some very interesting programs through that coalition, through that collaborative – such as mental health first aid for children and adults.

We’ve also got a parenting education program, we’ve done some things with nutrition, and we’ve tried to drill down on a couple of sub-communities, enclaves where there is a concentration of low-income people with the attendant health and social problems.

We found some really great partners, like the Jonnycake Center, helping to provide the resources for them to be able to hire a community health worker.

ConvergenceRI: What do you think is the best strategy for building community engagement and participation, so that people feel that they belong?
GIANCOLA: It’s a really great question. And, I wish I had insights. What I would say is that it is incredibly satisfying when you see different agencies collaborating, when you see kids being hired for summer jobs, when there are opportunities for kids to go to camp, and that feels really great, when you see that kind of collective impact, even on a small scale. Everything I’m talking about is on a very small scale.

ConvergenceRI: On a larger scale, do you have any insights and observations to share about the health care delivery system in Rhode Island?
GIANCOLA: One of the things that has been striking to me, and I expect that you may have seen the studies, but when you compare us to other countries, such as Denmark, which has about half of our health costs per capita, it turns out that the high costs are not about utilization.

I am not an expert, but these studies suggest that it is not utilization that is driving up medical costs.

The price paid a year for a primary care physician in these developed countries is about, on average, $86,000, where here it is about $200,000, or something like that. And drugs here are 20 percent of the per capita cost of health care.

So, whereas we are flogging away at reducing utilization, and I’m not saying there isn’t an opportunity there, because we all believe we can reduce the number of [unnecessary] ED visits, and we seem to use specialists more than in most other states, and we have very high inpatient behavioral health costs relative to other states, there is an opportunity to look at some of the underlying issues related to health care costs.