PROVIDENCE – Any conversation with Neil Sarkar, Ph.D., the president and CEO of the Rhode Island Quality Institute, no matter how many ideas and equations are going to be exchanged rapid-fire on a virtual white board, the data is likely to circle back and converge around finding common ground focused on optimistic, simple truths about the future of health care in Rhode Island.

Despite all the challenges of our massively disrupted world of health care delivery in Rhode Island in the midst of a deadly pandemic, Sarkar ended the most recent conversation with ConvergenceRI on an optimistic, positive note: “The closer we get to a truly capitated health care delivery system,” he said, “the less we will focus on how much things costs and more on how we are providing the highest quality of care – with the same amount of resources.”

As the person who is directing the state’s health information exchange, known as CurrentCare, and who is the founding director of the Brown Center for Biomedical Informatics, Sarkar often finds himself at the center of numerous statewide data initiatives.

The underlying hypothesis in Dr. Sarkar’s research is that “the integration of unlinked data leads to new information that can be used to inform knowledge about underpinning phenomena in biology and health.”

Translated, Sarkar is a data wonk with an impressive ability to synthesize how to find the meaning in the crunching the numbers.

He is currently a member of the steering committee of the Health Information Technology Strategic Roadmap, which is grappling with developing a new collaborative approach in an attempt to redefine the way that the R.I. Executive Office of Health and Human Services uses data to achieve its mission around public health in Rhode Island.

Sarkar is also a member of the public-private collaborative partnership known as the Compact that is seeking to limit the future annual growth of health care costs to 3.2 percent.

He is also a member of the study commission being led by Sen. Josh Miller to look at health reimbursements, whose work has been in abeyance for the last eight months following the onslaught of the coronavirus pandemic.

And, for good measure, Sarkar is a keen observer of the challenges involved in redefining health care during a time when telehealth, once considered a novelty, has become the mainstay of how patients and providers communicate while staying safe from the spread of the virus.

The scheduled half-hour for the interview with ConvergenceRI never seems quite long enough before Sarkar has to rush to attend another virtual meeting. Here is the ConvergenceRI interview with Sarkar, which took place the last week in January.

ConvergenceRI: What are the latest developments around the development of the HIT Strategic Road Map? Have you gotten any further direction about your participation as a stakeholder?
SARKAR: The work is starting. And, I think, when we spoke last, one of the things that did come out of that, for all the right and obvious reasons, was that RIQI does have a seat at the table.

We’ve had two meetings of the larger group. The group is working on getting their bearings. Not everyone is necessarily a data person, if you will, so it requires understanding some different types of jargon that end up getting used in these circles. There is a lot of work to be done. The good news is that the work is being one in alignment with various activities going on across the state.

The good news is though, is that the work is definitely being done in alignment with the various things that are going on across the state.

I also think, and this may come across as an excuse, but everybody is very pre-occupied with the work that each of us is doing in our respective organizations, and trying to trudge through and hope we don’t break anything.

ConvergenceRI: When you say, “I hope we don’t break things,” what do you mean?
SARKAR: A lot of the infrastructure that we have ended up having to set up in public health, and we are not unique ins this across the country, is really designed to address the particular situation we are in, being the pandemic, and the infrastructure is not necessarily built out for long-term use, shall we say.

And, that is absolutely a reflection that the nation, as a whole, has not truly invested in public health infrastructure.

One of the things that we have learned, if you are looking for a silver lining, is that there does need to be more focused investment in public health and public health infrastructure, including the data side of things. And, I think we are all resigned to that.

ConvergenceRI: Ddi you get a chance to read the story in last week’s ConvergenceRI that talked about the latest OHIC paper that was delivered to the R.Il. General Assembly, which determined that the first two years of data trends cost analysis of medical costs showed a 4.4 percent annual increase, compared to the goal of a 3.2 percent annual rate of increase in medical costs.
SARKAR: Yes, I read it. With the predictions we are making right now, I wonder how much of that will need to be recalibrated in terms of modeling, given that we began in what was truly the yesteryear in health care.

I think a lot is changing, in terms of how health care will be utilized. I think things like telehealth are going to have a pretty marked impact on the overall costs of care.

A lot of the assumptions around health care are going to be changing in the next three years. If we do the best we can with the data that we have, we can hope that we will end up in a better place as a result.

ConvergenceRI: One of the striking outcomes of the study, at least in my opinion, was how much the rise in medical costs was directly tied to the rise of prescription drug costs.
SARKAR: I don’t think that was a surprising thing. I think what was gratifying was that the data is now actually showing that.

ConvergenceRI: Still, with the rise in medical costs pinpointed the rise in prescription drug costs in both the Medicaid and the commercial insurance markets, does it provide an opportunity to drill down deeper to understand what is driving those costs, and what could be potential solutions. One physician suggested that a piece of the puzzle might be the autofilling of prescriptions by big box pharmacies, although he could not cite any evidence.
SARKAR: I think there may be a piece of the puzzle that is due to auto-refilling of prescriptions. I don’t think that anyone is trying to purposely do the wrong thing. I think that the system is doing the best that we can.

I think we need to understand that there are efficiencies that always come at cost.

So, you put in some kind of automation, with all the right intentions, I think the thing that we need to be looking at is: what is the purpose of the automation. It is something that needs to be guided by a physician or with pharmacist’s input – and not just between a patient and a system.

If I were to guess, there are probably a lot of medications that are just being ordered and they probably don’t need to be. On the flip side, you want to make sure that key medications that are needed for support of chronic care patients are available between visits with a physician.

So there is an interesting balance point. I think we are very early in that discussion.

ConvergenceRI: How will telehealth change the equation around health care delivery, and what kinds of data do we need to gather to measure its impact?
SARKAR: This is a very long discussion; people have been talking about telehealth for a very long time, trying to justify how much it should cost or shouldn’t cost, and whether a televisit costs the clinician as much time as an in-person visit.

The pandemic took over all of our lives almost a year ago and changed that – telelhealth became one of the only ways that we were able to provide care. And OHIC and the payers in our state all stepped up and said: we agree. We need to put safety first, and now we need to make sure that the telehealth visit is paid for, in an appropriate way.

I think when we are past this, we need to look at how does telehealth fit in with the rest of care for an individual, or a group of individuals, and try to understand what is the real cost.

Are there ways that one could look at telehealth as a very powerful surrogate for many primary care visits, and for many specialty consults, that can be used as a “pre-visit,” if you will.

As a patient, I may end up telling the same story over and over again, for 10 minutes of my 15-minute visit, and if we could pre-empt some of that, I think it would make for a more beneficial discussion between a provider and the patient. That’s the end goal.

I think every health care provider is doing the best that they can, and telehealth has always been there in the wings, but nobody really was sure how to use it. And, now we are using it. And, I don’t know what the right answer is, how much it is actually worth in terms of how you monetize that, compared to an in-person visit.

ConvergenceRI: Will it also require changing the coding for how providers are reimbursed?
SARKAR: I have a longer view on this. We’re moving toward capitation. Which means that coding will no longer be focused on getting the right level of reimbursement, that data will be recorded for clinical purposes, not for billing purposes.

With that shift, we will be doing the things that need to be done for managing our patients. And, there are segments of health care today that are doing a very good job of this – pediatric providers do a phenomenal job at this. They are not thinking about how do you bill for that service; they are taking care of their patient population.

I think there is going to be a shift as you get further and further away from fee for service payments. To truly capitate care, you are taking care of the health of an individual, not the health of their wallet.