PROVIDENCE – Curiouser and curiouser, as Alice once uttered in surprise, in the Lewis Carroll classic, Alice in Wonderland.

Last week brought two significant announcements to the world of ongoing musical chairs involving the realignment of health care delivery systems in Rhode Island.

First, South County Health and Yale New Haven hospital called off their talks about a potential merger involving Westerly Hospital. The decision to end the study of a potential merger was deemed “mutual.”

South County Health remains the only independent, unaffiliated acute care community hospital left in Rhode Island, although its physicians are participants in Integra, the Care New England accountable care organization.

Louis Giancola, the CEO of South County Health, said that an announcement of a “major new program” is expected in the next month, according to a story by Frank Prosnitz.

That news was quickly followed by the startling announcement that “Care New England and Partners Healthcare have approached Lifespan and will begin formal discussions to explore how all three health care providers might work together to strengthen patient care delivery in Rhode Island.”

The statement continued, somewhat cryptically: “By combining the talent, experience and resources of our like-minded, provider-based organizations, we envision creating a national model that fully leverages the integration and coordination of care. In doing so, we are better equipped to meet market challenges and mandates to improve outcomes while reducing health care costs.”

Reading the tea leaves
Any attempt to divine what is going on behind the scenes is pretty much dancing in the dark; no one from the hospital systems was talking. The announcement disrupted the narratives of many in the news media.

Here are some possible interpretations in reading the tea leaves:

• While the potential merger of the two largest health systems in Rhode Island and the largest system in Massachusetts offers a vision of extreme market power in the region, the regulatory hurdles for such a merger would seem to be too difficult to overcome.

• Instead, it might make more sense for Lifespan to preserve its independence as a health system but realign itself within the context of a accountable care organization, particularly around the coordination and integration of two or three specialties – such as cardiac care, women’s health, or cancer care.

• The inclusion of Brigham and Women’s Hospital as a new contact in the news release seems to point in that direction, particularly for cardiac care, given the existing collaboration between Kent Hospital and Brigham and Women’s around heart health care.

• The potential coordination of women’s health care, in particular connecting Care New England’s Women & Infants Hospital as part of an integrated collaborative approach with Lifespan’s Women’s Health Collaborative, also appears to be a much sought-after realignment by Lifespan, with Partners providing the parental guidance.

• A third opportunity might be coordination of cancer care. Another interesting dynamic would be the potential collaboration around behavioral health care, particularly given Care New England’s leadership through The Providence Center in addressing responses to the epidemic of overdose deaths.

Where does this leave Brown?
Judging from the statement issued by Brown University following the announcement that Lifespan might be joining the conversation with Care New England and Partners, which expressed surprise at the move, it would not be surprising to see Brown reconcentrate its efforts in developing its Brown Physicians Inc. partnership model.

The key question moving forward for the physician groups is what kind of leverage can Brown help to provide in negotiating contracts with insurers.

An orthopedics powerhouse?
Is there a potential opportunity for South County Health to move more aggressively into a more structured arrangement with Ortho Rhode Island, currently the largest orthopedics group practice in Rhode Island?

The business of health
The annual legislative breakfast hosted by the Rhode Island Business Group on Health provided an opportunity to discuss potential systemic solutions to the high cost of medical care through the imposition of efforts to cut down on unnecessary tests, procedures and imaging.

The convening topic was “low-value” care, with keynote speaker Dr. Mark Fendrick from the University of Michigan School of Medicine and School of Public Health presenting on “value-based insurance design.”

Also speaking was Shannon Brownlee, senior vice president of the Lown Institute, author of the book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.

Among the members of a panel of respondents to the presentations were: Marie Ganim, R.I. Health Insurance Commissioner; Robert Hackey from Providence College, Bob Selle from Ocean State Job Lot, Matthew Collins from Blue Cross & Blue Shield of Rhode Island, and Dr. Michael Fine, the former director of the R.I. Department of Health who is serving as health policy advisor for the city of Central Falls.

Here are some snapshots from the conversation by the participants:

• “What the health care industry is doing makes military contractors look like [pikers],” talking about the fact the U.S. spends $20 trillion a year on health care.

• “Going to the hospital is the third leading cause of death.”

• “Supply drives demand, looking at the 23 percent increase in beds for the neonatal intensive care units between 2007 and 2012.”

• Too many unnecessary procedures are performed by physicians under the rationale, “Just to be safe.”

• “Health care is not a real market.”

• “Do not be surprised if Amazon holds onto a large portion of any savings achieved by reductions in the costs of health care.”

• “As long as drug companies have patent monopolies, they can charge whatever they want.”

As much as some of the participants talked about the need for shared decision-making between patients and physicians, seemingly left out of the conversation at the breakfast were two important groups: nurses, who hold up more than half the health care delivery system, and patients, who were not included in the discussion in terms of voicing what they want and how they define value.

Health equity
In announcing the priorities for the 2018 funding cycles for its “Fund for a Healthy Rhode Island,” The Rhode Island Foundation has shifted the focus of its grants in what seems like a significant change, investing in health equity rather than just health delivery systems.

The focus will be on improving the health of communities, promoting a shared vision “to address the social determinants of health and improve the community’s health.”

Further, in its description of funding priorities, The Rhode Island Foundation said the following: “In addition to quality primary care, we know that factors outside of the clinical setting must be addressed to achieve optimal health outcomes and reduce or eliminate health disparities between groups.”

The description continued: “Roughly 75-90 percent of an individual’s health status is influenced by social and environmental factors – the context in which Rhode Islanders live, work, play, and go to school. These factors are recognized as social determinants of health.”

The description concluded: “Achieving and maintaining good health is more likely when people are part of communities that promote health and healthy choices. Creating healthier and more equitable places requires meaningful, sustained collaboration.”

That represents a remarkable shift in investment strategy by The Rhode Island Foundation.

The nature of structural inequity
On Tuesday, March 6, from 1 p.m. to 4 p.m., at Salve Regina University, the Newport Health Equity Zone is a co-host of “A Groundwater Approach To Racial Equity,” an interactive program that will seek to establish a foundational understanding of how race-base structural inequities impact health outcomes.

“This workshop will provide public health professionals with a basic understanding of how racism is structural in nature, and what that means for our work and the health of the communities we serve,” as the invitation described the event.

Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, will be one of the featured speakers.

The program will feature expert trainers from the Racial Equity Institute.

Meanwhile, back at the ranch
Legislators in Vermont took a small but significant step toward establishing a universal, publicly financed primary health care system in the Green Mountain state, according to a report by VTDigger.

The Vermont Senate Health and Welfare Committee unanimously approved a legislation that would set in motion several years of work toward creating a universal primary care system scheduled to take effect in 2022.

Under the legislation, primary care would be available to all Vermonters without patient cost-sharing, with the goal to decrease “systemwide health care spending.”

“We’re calling it our DIY health care bill,” said Sen. Claire Ayer, the committee chairwoman, according to VTDigger. “Nobody is climbing over fences to do this work for free. But they’ve all agreed to do it. It’s a great thing.”

Rather than mandating creation of a system, the legislation orders detailed planning and analysis, laying out a long list of conditions, including development of appropriate financing that must be met.

Translated, the legislation establishes an ambitious plan to expand access to primary care.

In doing so, the legislation provides a potential roadmap for the R.I. General Assembly to follow if it were to choose to improve access to primary care.