Delivery of Care

Dancing in the dark, to the beat of wealth extraction

The proposed hospital merger between Brown, Care New England, and Lifespan is launched with a full frontal media blitz – along with a host of unanswered questions

Image courtesy of public relations campaign promoting the merger

The principals behind the proposed merger of Care New England, Lifespan, and Brown University.

By Richard Asinof
Posted 3/1/21
The proposed merger of Care New England, Lifespan, and Brown as an academic medical enterprise built around hospitals produced a massive public relations effort to support the new entity. It will fall to the R.I. Attorney General’s office to ask the hard questions about the proposed merger – and whether the consolidated enterprise will prove to be a sustainable endeavor.
How will future primary care practices function within a consolidated academic medical enterprise where specialty care is seen as the major source of revenue? What is the status of Coastal Medical within the new proposed alignment? What is the track record of Brown University in capitalizing on patents, licensing and intellectual property within the biotech and life sciences world, in terms of job creation and new company formation? How many reporters covering health care in Rhode Island have health insurance plans paid for by their employer? What is the connection between metastatic breast cancer and endocrine disruption from toxins and plastics?
Commendable efforts are underway to promote discussions around diversity and racial equity, in initiatives by United Way of Rhode Island and by Care New England, beginning conversations that have been long overdue in Rhode Island. How needed they are was exemplified by the behavior of the defense attorney representing a Providence police officer accused of allegedly beating a man while he was in custody. The attorney upbraided the African American who was the alleged victim of the policeman’s actions for wearing a “black lives matter” mask.
Dr. Vanessa Northington Gamble, MD, Ph.D., Professor of Health Poilicy and American Studies at The George Washington University, believes that the conversations around health care and racial equity need to be reframed to focus on the lack of trustworthiness of the medical establishment, instead of putting the burden on African Americans in how they express their dissatisfaction with the way they have been treated.

PROVIDENCE – In close encounters of the third kind with the health care delivery system, patients are often asked an array of questions, that are then translated into check-the-box formats in electronic medical records and charts.

• What is your pain level today, on a scale of zero to 10?

• In the last week, have you had any rash, any fever, any intestinal discomfort, or a loss of the sense of smell?

• Have you traveled anywhere in the last week, such as Cancun, Mexico, where the coronavirus is prevalent?

• Have you come into contact with anyone, such as Sen. Ted Cruz, who may have been infected with a virulent inability to tell the truth?

[Indeed, students who are now being seen as part of the new SMART health clinics being deployed by the R.I. Department of Education in two Providence schools are apparently first asked to show their health insurance card.]

What is actually written in our medical charts, however, may have little if nothing to do with critical information necessary to determine the actual health outcomes in our lives – clinical research has found that only 10 percent of what occurs in a doctor’s office is related to health outcomes, with another 10 percent determined by genetics.

ZIP codes, not genetic codes, are more important to health outcomes, according to the findings of the RI Life Index. Can you spell Health Equity Zones?

Still, the flow of money into the health care delivery system is fast approaching a quarter of a family’s annual spending, despite the limited impact on health outcomes.

This story attempts to engage in role reversal: imagine if the hospital CEOs and Brown's president and administrators were the ones being asked the questions, which they would be required to answer, before the merger will be considered or approved.

Welcome to the hard sell café
The proposed merger between Brown University, Care New England, and Lifespan, with the newly signed agreement for an integrated academic medical center, was presented as a “fate accomplished” on Tuesday morning, Feb. 23.

ConvergenceRI did not received the embargoed news release [along with links to the video, and the newly developed new website with the catchy name, HealthierRI.com] until two hours after the embargoed release had been delivered to other major news media outlets, after I called to complain.

The media announcement was, in turn, greeted by a carefully coordinated spin campaign, including a joint message from the R.I. Senate President and the R.I. Speaker of the House, and a message of support sent by soon-to-be-gone Gov. Gina Raimondo, as well as from Sen. Sheldon Whitehouse.

[The disliked reality is that the proposed merger still needs to pass regulatory muster from the R.I. Attorney General and the R.I. Department of Health, not to mention overcoming monopoly concerns by the Federal Trade Commission about how restraint of trade might be created by one health system that would control the lives of three-quarters of all the patients in the state, “by ensuring excellence in health care from birth to end-of-life, including specialty care, in their home state,” according to the first graph of the news release.]

What’s wrong with this photo?
The glossy photo sent out with the avalanche of coordinated publicity tied to the announcement was enough to scare anyone into media submission: six masked, middle-aged white men, looking dour, arrogant and pompous, accompanied by one middle-aged white woman, dressed in their power suits.

The back row included: Dr. Timothy Babineau, Lifespan’s president and CEO; Dr. James Fanale, Care New England’s president and CEO, Dr. Jack Elias, dean of the Brown Medical School, joined by Christina Paxson, Brown University president.

In the front row of the photograph were: Lawrence A. Aubin, chair of the Lifespan board of directors, flanked by Samuel Mencoff, chancellor of the Corporation of Brown University, and Charles Reppucci, chair of the Care New England board of directors.

Where’s Waldo? Where in the world is Carmen San Diego? And, where in the new, improved corporate hierarchy of health care in Rhode Island, is a person of color, given the enhanced concerns voiced around racial equity?

Swept away by the rising tide
No one reads anymore, unfortunately. People are much too busy, it seems. We are traveling on a perpetual highway of misinformation, which rewards those who can correctly identify the billboard advertising messaging on Twitter and Facebook and Instagram, like contestants on "Jeopardy," where the answers are given in the form of a question.

Much like the “forever plastics” that inhabit our rivers, our oceans, our bodies and the air we breathe, the flow of misinformation around health care is endemic. For some, even the phrase “forever plastics” is too sanguine: the corporations that manufacture products that contain toxics, argued Kerri Arsenault, the author of Mill Town, traffic in deception, but the toxics themselves do not lie, with their promise of disease, economic disruption, and despair.

Arsenault and Rebecca Altman were featured in a story published last week in ConvergenceRI, “Paper or plastic? Sense and sensibility,” connecting the intimate stories of families to the industries that destroyed them, detailing the legacies of the manufacture of paper and plastics and factory towns – and the history of heavily polluted rivers that always seem to run through our lives, carrying with them a legacy of poisonous toxins that bring with them the promise of an early death. [See link below to ConvergenceRI story.]

Did Drs. Elias, Babineau, or Fanale read the story? Unlikely. The good doctors were also unlikely consumers of the other story featured in last week’s ConvergenceRI, “Truly a beautiful day in the neighborhood,” about the efforts of Dr. Annie De Groot, the volunteer medical director at Clinica Esperanza, to provide care to the residents of a Providence neighborhood that were uninsured, under-insured, and unable to access care through the current health care delivery system during the coronavirus pandemic, efforts that were bolstered by a $315,000 award from TD Bank. [See link below to ConvergenceRI story.]

Taken together, the two stories explain much of what has been left out of the conversation around the proposed merger – the uninsured, under-insured immigrant population in Rhode Island. Indeed, a research study published in November of 2018 in the R.I. Medical Journal, “Bridging the [Health Equity] Gap,” found that the work of Clinica Esperanza would save $781,122 annually in uncompensated care costs at emergency rooms, if the program were to be expanded statewide to some 8,000 uninsured Hispanics. For whatever reason, it was an “investment” that Lifespan declined to make, despite the large projected cost savings. TD Bank stepped up to the plate.

Beyond billboard messaging
Here are the questions that need to be asked about the proposed merger, even if the news media seems to be reluctant or incapable of asking them:

1.  How many different IT systems are deployed across the current health systems? How many of them are interoperable? What will be the cost of achieving interoperability? How much of that cost will be borne by patients? How much of the data analysis from the electronic health records are dedicated to squeezing more money out of health care transactions tied to billing, versus data analysis focused on creating better health outcomes?

Translated, the $125 million over five years – or, in reality, only $25 million a year – which Brown University has offered to sweeten the pot for the merger, probably would not even cover the initial down payment needed to pay for a unified, interoperable, electronic health care data system. Where will the necessary capital investments to build and maintain the current health system campuses?

2. How will the merger address the documented findings that the major cause of increases in health care costs in Rhode Island are spikes in the prescription drug costs, both for commercial insurance and managed Medicaid insurance plans, and not utilization?

The evidence was presented to the R.I. General Assembly in the form of a report from the R.I. Office of the Health Insurance Commissioner, showing that the state had blown way past its goal of a 3.2 percent cap on annual medical cost growth, hitting 4.4 percent. [See link below to story, “Prescription drugs, not utilization, are driving high health costs in RI.”]

There is absolutely no mention of higher medical costs being connected to increasing prescription drug costs in the public relations materials about the merger. Is it merely a disliked fact?

Translated, there is nothing within the public relations effort tied to the merger that addresses the cause of increased health care costs tied to increasing prescription drug costs, which means that any promises about increased cost savings to be found in the merger are, at best, without merit.

3. Will the new merger create a fourth corporation, separate from the existing not-for-profit corporations? What will be the expanded role of Brown Physicians, Inc., within the new academic health care enterprise? What kinds of payment in lieu of taxes agreements need to be explored for the different not-for-profit corporations, in terms of future land use? And, as part of the merger, will any of the executive salaries and administration staff be cut or trimmed? What are the current salaries for the current CEOs Babineau and Fanale, and Elias, the medical school dean?

Translated, will the R.I. Attorney General investigate whether or not the new merger will add another layer of administration to the delivery of health care, without reducing any of the administrative costs?

4. What is the role of nurses within the future health care delivery system in Rhode Island? The backstop of the health care delivery system is provided not by health systems but by community health centers and their delivery of primary care to more than one-third of the state's residents. Rhode Island has no charity hospital or university hospital; there is a lack of critical ongoing educational support for medical residencies to develop the future workforce in family medicine; further, there is no indication of any collaboration outlined in the merger for training allied health providers and RNs with Johnson & Wales and Bryant universities, among others.

When it comes to health care and particularly hospitals, nurses hold up more than three-quarters of the sky. The video captured by The New York Times about ICU nurses providing care to patients stricken and dying from the coronavirus is a potent reminder of what is missing from the discussion. [See link below to YouTube story, “Inside a COVID ICU, through a nurse’s eyes.”]

As one physician pointed out to ConvergenceRI, “A few years ago, Blue Cross and Blue Shield of Rhode Island sent out a patient brochure showing the medical community, the hub of which was the primary care provider, not the hospital.” The physician called the brochure “a humbling warning shot” across the bow.

5. How will the environmental causes of disease – such as endocrine disruption and cancer caused by the toxic burdens from plastics and petrochemicals – be addressed by the new merger?
One of the major arguments offered in support of the proposed merger, as explained by medical school dean Dr. Jack Elias, is to improve the delivery of cancer care. “If you learned from your doctor the devastating news that you had cancer, you want to go to a place that maximizes your chances of a having a great outcome,” said Elias in the news release. “You want to go to a place where you have the best care you can get from a diagnostic and therapeutic perspective – a place that does cancer research, but that also has the latest in protocol-driven therapies so you can be with your family for many years to come. And, this is the difference that an integrated academic health system can make in patient lives. This is real.”

What is also very “real” is the potential for Rhode Island to create a new funnel for federal funds in the creation of a cancer research center.

For sure, there is some verbiage in the talking points about the merger and plans to “collaborate with payers, including the state government, to develop ways to prevent deadly and costly diseases by reducing smoking, obesity, substance abuse, exposure to environmental toxins [emphasis added] and more.

One of the biggest current environmental threats in Rhode Island is a proposed new facility to dispose of 70 tons of “medical waste” daily, to be built along Division Road bordering the towns of East Greenwich and West Warwick, using what appears to be an unproven technology known as pyrolysis.

What say you, Drs. Babineau, Fanale, and Elias? What about Brown University, President Paxson? Which one of you is brave enough to speak out against the potential environmental threats of such a facility, tied to the disposal of medical waste?

6. How will the proposed merger lead to development of accountable entities for specialty practices? Is the non-hospital centric business model of Ortho RI, with its mission of putting the patient first, provide a more sustainable business model than the proposed consolidated model of care? And, will the new consolidated health enterprise limit the ability of patients to seek care in Boston, particularly when it comes to heart care, cancer care, and orthopedic care?

Many of the recent studies suggest that health care system mergers lead to higher consumer costs, higher employer premiums, and minimal advancements in quality initiatives. Why would this consolidation be different from all other mergers?

Another question for regulators to ask: Would the proposed merged entity see a need for fewer inpatient beds? Which hospitals would be forced to reduce the number of their inpatient beds?

What does public health have to do with it?
The planned merger doubles down on the idea of how the newly unified academic medical enterprise will create a new landscape of economic prosperity, driven by the innovation ecosystem, attracting top talent to further the academic research enterprise, as expressed in the report prepared by CommerceRI, “Rhode Island Innovates 2.0,” published in January of 2020. [See link below to ConvergenceRI story, “What does public health have to do with future prosperity in RI?”]

The problem, of course, is that the report was written before the onslaught of the coronavirus pandemic, which made more visible all the deficiencies within the health care delivery system when it came to racial equity and social disparities in health care. And, the question that the R.I. Attorney General’s office must explore is how the proposed merger will address the failures and gaps made visible by the pandemic?

The reality is that when it comes to “accountable entities,” the existing health systems do not “play ball with primary care groups outside of their owned physician groups, according to one primary care physician. The physician laughed out loud when asked if there was any “sharing” of resources with primary care groups outside the hospital. “No one really has a hospital inside their accountable entity,” the physician said.

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