Delivery of Care

Competition or collaboration?

The proposed merger of Care New England and Partners Healthcare, and with it, the creation of a regional enterprise, exposes the illusion of the existence of a Rhode Island health care delivery system

Image courtesy of Care New England website

The cover of the 2016 Care New England annual report. If the planned merger with Partners Healthcare moves forward and is approved, Care New England may have a whole new image next year.

By Richard Asinof
Posted 1/29/18
The planned merger of Care New England and Partners Healthcare moves ahead, despite efforts by Brown University and the Raimondo administration to derail it. How much water Brown and the Raimondo administration are carrying for Lifespan remains an unknown factor.
Instead of trying to prevent the merger between Care New England and Partners, why not put energy into figuring out ways to collaborate on a regional basis? Where is the specific evidence about the potential loss of jobs that will be caused as a result of the merger? When will someone begin to pay attention to the growing efforts by physician group practices to organize themselves as a way to better negotiate with both hospitals and insurers? What is the role that public health can play in the future health care ecosystem? How will wearable devices change the flow of information around health care, giving patients more leverage and control over their own health care decisions? How do nurses and nurse practitioners, the folks who hold up more than half the health care system, fit into the conversation around future academic medical centers?
The takeaway from U.S. Surgeon General Dr. Jerome Adams' visit to the Anchor Recovery Community Center in Pawtucket was that the solution to addiction was not sobriety but connectedness. In addition, Adams endorsed the idea of a inclusive discussion of harm reduction strategies, with communities being the decision-makers around what strategies to pursue, not the clinicians or government officials.
Members of health equity zones in Rhode Island recently met with legislators to share in more detail the way they have chosen to create community action plans, the kind of conversation that has been absent in large part in discussions around the future of health systems in Rhode Island. Translated, when designing future systems of care, wouldn't it make sense to listen to what the patients want and need, and rather than what hospital administrators or university officials desire?

PROVIDENCE – On Thursday morning, Jan. 25, Care New England and Partners Healthcare of Boston announced that they had agreed to enter into a definitive agreement to merge.

While there are still many rivers to cross before the proposed deal becomes signed, sealed and delivered, including regulatory approval from both Massachusetts and Rhode Island, the announcement could be seen as a positive step forward toward the merger.

Unless, of course, you were a vocal member of the institutions attempting to derail the merger – including Brown University and apparently Gov. Gina Raimondo.

Brown University President Christina Paxson had written a letter to the community on Jan. 11, claiming, in hyperbolic language, that as a result of the proposed merger, “The full economic benefits of a strong local academic health system – one that brings in federal grants, generates spin-off companies and creates new jobs in Rhode Island – would be lost, perhaps forever.” [See link below to ConvergenceRI story, “What does health have to do with it?”] Paxson offered no evidence to support her exaggerated claims.

Instead, Paxson proposed divvying up the existing Care New England health system between Brown University and the owner of CharterCARE, Prospect Medical Holdings, a for-profit, California-based health system, with Brown taking control of Women & Infants Hospital and potentially Butler Hospital and CharterCARE getting Kent Hospital.

On Monday, Jan. 22, in a letter sent by Dr. Jack A. Elias, senior vice president for health affairs at Brown and dean of the Warren Alpert Medical School, to Brown faculty and staff, the other shoe dropped: the move by Brown to align itself with CharterCARE was an apparent stalking horse to try to move toward a realignment with Lifespan.

“Throughout our discussions with Prospect, we have been very clear about the importance of our relationship with Lifespan and our view that ultimately Women & Infants, and possibly Butler, should be joined with the Lifespan system,” Elias wrote, as reported by The Providence Business News.

[The letter by Elias may have been written in an attempt to quell concerns voiced by Brown faculty members and other health care industry leaders about the proposed relationship between Brown and the for-profit owner of CharterCARE, Prospect Medical Holdings, located in California.

As Jane Williams, dean at Rhode Island College’s School of Nursing, wrote in a recent letter to the editor to The Providence Journal: “If the invitation is to join in a discussion of Brown’s intent to join with Prospect Medical, a for-profit company based in California, then I hope Rhode Islanders will ask: Doesn’t Prospect Medical represent the “out-of-state consolidation” that President Paxson claims will hurt Rhode Island health care?]

Dr. Timothy J. Babineau, Lifespan’s president and CEO, said his health system was taking a neutral position in response to Brown’s plan, according to The Providence Business News, saying: “Lifespan has not been party to the conversations between Brown and Prospect.” The question not yet answered is: What discussions has Lifespan been a party to?

When power brokers lose power
The inability of Brown, with apparent backing of Raimondo administration, to derail the proposed merger between Care New England and Partners, has led Brown to attempt to influence the decision of government regulators, urging them to consider jobs and economic development, a criteria outside the venue of regulators.

In a statement to WPRI’s Ted Nesi, Brown said: “As Rhode Island regulators assess the plan, we urge them to analyze the impact on access to health care, the cost of medical care, and jobs and economic development in Rhode Island, and consider whether a local option would better serve the residents of the state.”

The problem is that those concerns and options are not part of the legal criteria laid out in the Hospital Conversion Act. As Department of Health spokesman Joseph Wendelken said, in response to a question from ConvergenceRI, “Rhode Island General Law lists the specific criteria that the director of the R.I. Department of Health is to use in evaluating Hospital Conversion Act applications [e.g., access to care for traditionally underserved populations, character and competence of the applicant, etc.]. These are the only considerations that would be made.”

Stefan Pryor, secretary of CommerceRI, also took a turn at the microphone at GoLocal LIVE to give voice the Raimondo administration’s concerns.

“My departments are not the regulators per se,” Pryor told GoLocal News Editor Kate Nagle on Thursday, Jan. 25, hours after the decision to move ahead with the merger had been announced. “There could be an element that ultimately comes before us.”

That being said, Pryor continued, “Thousands of jobs are at issue, important health care jobs. And the health care access of Rhode Islanders is at issue. Rhode Islanders shouldn’t have to go north to get their health care. They shouldn’t have to find their way to specialty care.”

The problem with Pryor’s comments, particularly around specialty care, which echo concerns voiced by Brown’s Paxson, is that they do not correspond to some of the facts on the ground.

For nearly a decade, Care New England and Brigham and Women’s Hospital have had a close clinical affiliation, specifically around cardiac care – without any concern ever having been raised by Brown, Raimondo or CommerceRI.

“Since 2009, Care New England and the Brigham have had a close clinical affiliation,” said Brigham Health President Dr. Betsy Nabel, in the news release announcing the decision to proceed with the merger. She continued: “By combining the talent, experience, and resources of our two organizations, we will achieve more integrated, coordinated care offered conveniently – in the right place at the right time – improving outcomes and reducing the rise in health care costs.”

Translated, the merger strengthens a regional collaborative approach.

Enter The Rhode Island Foundation
On Sunday, Jan. 28, Neil Steinberg, president and CEO of The Rhode Island Foundation, entered the fray, publishing an op-ed in The Providence Journal calling for the creation of a “truly integrated Academic Medical Center in and for Rhode Island,” with the goal of improving health and health care services for residents, train high-quality clinicians, and perform groundbreaking medical research.

Without naming Care New England and Partners Healthcare, Steinberg said it was the Foundation’s belief that “one-off defensive deals” did not necessarily lead to the health care [delivery] system Rhode Islanders deserved.

As an alternative vision, Steinberg offered his concept of a statewide Academic Medical Center.

It is, in ConvergenceRI’s opinion, an idea that comes much, much too late to the conversation.

The biggest problem is that there is no health care delivery system in Rhode Island; it is an illusion. What we have, as Dr. Michael Fine often says, is a market-based system of care that is good at extracting wealth, not delivering health.

The business model for the hospital-based inpatient care system, developed as part of the 20th century’s industrial and manufacturing economy, no longer works. The closing of Memorial Hospital is the latest example.

As a state, most hospitals in Rhode Island are too small and too fragmented to survive the economic realities of population health, which demand consolidation of resources. The colonization of Rhode Island’s acute care community hospitals has been underway for more than a decade.

About 90 percent – some say 95 percent – of what shapes a person’s health outcomes occur not in the doctor or nurse’s office, but in the community, related to health equity and the disparities of health. To date, the academic medical research enterprise has not embraced the innovative concept of health equity zones or neighborhood health stations.

There is no statewide health planning protocol or strategy that exists, providing a way to make informed decisions about whether or not there are too many hospital beds, and if there are, no consensus on how and where to cut that inventory.

There is no way to control the ever-escalating costs of medical care, which are scheduled to reach 50 percent of household income in the next decade.

The dissatisfaction of health care professionals – doctors, nurses, community health workers, and therapists – keeps growing, as they are frustrated by the increasing inability to have enough time to care properly for patients, with increasing resentment about how the demands that health IT systems cut into their time with patients.

A bad romance
At the heart of Steinberg’s proposal is the belief that a merger can be forced upon Lifespan and Care New England. Such an arranged marriage may not be in the cards. It was championed at least three times by former Gov. Lincoln Chafee; Gov. Gina Raimondo has pushed for such a merger at least five different times, according to sources, all without success.

Politics – and health care – is still the story of who gets what, when, and for how much.

Instead of spending so much energy fighting the merger between Care New England and Partners, perhaps a better strategy would be to find points of leverage that can increase the collaboration between health systems and academic medical centers across a regional platform.

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