Delivery of Care/Opinion

Everyone is crying health care, when they do not understand the meaning of the word

A response to a recent editorial by The Providence Journal, “Merger is still the answer”

File photo by Scott Kingsley

Dr. Michael Fine

By Dr. Michael Fine
Posted 8/12/19
By publishing this op-ed by Dr. Michael Fine, ConvergenceRI shares the response to an editorial in The Providence Journal that the newspaper declined to publish in full.
Does the editorial board of local daily newspaper owned by a large consolidated newspaper chain financed by debt equity have a slanted view about the “best interests” of the people? Why is it that health equity and Rhode Island’s innovative approach around health equity zones continues be left out of the conversation? Why do many researchers believe that a partnership with Partners Healthcare in Boston would leverage a more robust research enterprise in Rhode Island? Will health care, and in particular, women’s health care, continue to emerge as the number-one issue that voters are most concerned about in the upcoming 2020 election? When will gun violence, particularly around the prevalence of guns in suicides and in domestic violence murders, be recognized as a public health issue?
The world is divided, it seems, between those with the good fortune to have access to good health insurance plans through employers, and those whose finances are strangled by the ever-rising costs of health care and the ever-increasing labyrinth of bureaucracy needed to access care. What is often missing is the opportunity for a healthy debate – a conversation, a convergence – around the realities of health care in Rhode Island.
The misinformed editorial views of The Providence Journal, mistakenly getting the name and the mission of the R.I. Department of Health wrong, is symptomatic of a much larger problem: the top-down approach to health care will never be able to achieve better outcomes and reduced costs, because the odds are stacked against such wholesale change when the system is predicated on preserving the status quo and controlling the flow of money.
The bottom line is that the problem about arguing about whether health care is a privilege or a human right misses the point: we have made health care into a very profitable commodity. To change that requires a fundamental shift in values.

Editors Note: As the Gannett and GateHouse Media newspaper chains move ahead with their planned $1.48 billion consolidation, creating what would be the largest consolidated newspaper group in the U.S., controlling 260 daily newspapers and more than 300 weeklies, financed by a mountain of debt, which includes among the newspapers under its control The Providence Journal, it raises some fascinating questions about the legitimacy of the editorial views espoused by Rhode Island’s largest daily newspaper, particularly when it recently sought to weigh in on the failed attempt by Gov. Gina Raimondo to broker an arranged marriage between Lifespan, Care New England and Brown University.

In an editorial entitled, “Merger is still the answer,” published on Sunday, Aug. 4, The Providence Journal expressed its disappointment that the merger proposal failed, claiming that Care New England had offered no good explanation for its decision to pull out of the forced marriage.

[Don’t tell that to the employees of Women & Infants Hospital, who broke out in a spontaneous outburst of applause and cheering when it was announced that Care New England was pulling out of the proposed brokered deal.]

The “father knows best” position articulated by The ProJo’s editorial board included the misinformed idea that somehow Gov. Raimondo “refrained from banging heads” and did not exercise her executive authority over the state Department of Health [mistakenly referred to in the printed version as the state Department of Public Health and then corrected in the online version] by making “life difficult for hospital entities that fail to serve the interest of the people.”

In a recent conversation, Dr. Michael Fine mentioned to ConvergenceRI that he had written an op-ed in response to The Providence Journal’s editorial, but that it had been rejected; ConvergenceRI suggested that Dr. Fine send the original version of the op-ed for publication. A very shortened version of that piece then appeared as a letter to the editor on Saturday, Aug. 11.

Here is the original piece by Dr. Fine, who had been a supporter of the merger, with some important caveats, including the need for a state regulatory body to set prices and review budgets.

“Otherwise,” Fine told ConvergenceRI in a story published on June 5, “the new entity will bleed the state dry. I think the merger [of Care New England, Lifespan and Brown into one enterprise] is a good idea – as long as it is a merger that is governed by a hospital regulatory commission that creates budgets and sets prices.”

Fine continued: “We need to create a hospital regulatory commission and a primary care trust, in order to build a health care system, not a market.” [See link below to ConvergenceRI story, “Matchmaker, matchmaker, find me a find, catch me a catch.”

Here is what Dr. Fine wrote, in full, in response.

PROVIDENCE The Providence Journal editorialist got the broad outlines correct but got the name of our Department of Health, our politics and the need for coherent policy wrong in its Aug. 4 editorial on the need for a merged academic medical system.

Yes, we should have merged care New England, Lifespan, and Brown years ago, and yes, egos and arrogance got in the way.

But the notion that the governor can or should act by using the regulatory authority of the R.I. Department of Health to achieve a political purpose is wrong-headed, and the notion that all we need to do to turn us into Pittsburgh is make this merger happen is hallucinatory.

The regulatory function of the R.I. Department of Health is and must function in a way that is impartial, fair, and that protects the health and safety of all Rhode Islanders, without any political or even policy biases if that regulatory function is to be effective, widely trusted, and supported by the courts.

Levers
State government has three of four levers that could be used to encourage, incentivize and enforce the merger of these three entities: we can use our contracting power, through Medicaid and the purchase of state employee insurance; we can use our oversight of charitable assets, which resides with the R.I. Attorney General; we can use our oversight of health insurance purchasing, which sits with the R.I. Office of the Health Insurance Commissioner; and we can and should use the regulatory process for licensure [which is different from using the inspection and investigation process, which The Journal implies could be used to “make life very difficult” for hospitals].

But while those levers might help, none of them are likely to help quickly. None of them get at the fundamental health policy misunderstanding that underlies The Journal’s editorial. And, all of them can be picked apart by a legislature that is fickle, has little health policy direction, and is too easily influenced by entities that are large employers and can afford expensive lobbyists that, in turn, can too easily bamboozle legislators and the public.

Different from Pittsburgh
We are different from Pittsburgh. There is a major academic medical enterprise 50 miles away. Pittsburgh, the Research Triangle in North Carolina, Houston, Austin, Atlanta, New Haven and Philadelphia all started their biotech enterprises at least 25 years ago, so it is unlikely we could compete with them, given we are 25 years behind.

Those enterprises create new costs and contribute to income inequality because they are creating expensive products that don’t [necessarily] improve the public’s health and are usually paid for at the public’s expense, since the bulk of their products are paid for by Medicare and Medicaid and public employees’ insurance.

The notion that a merger would employ economies of scale to cut costs is also wrong-headed. There is strong evidence that hospital consolidations increase costs, as the merged entities exploit their monopoly power to increase costs. We cannot and should not allow a merger without creating a hospital regulatory commission that has the power to set hospital prices.

Policies that promote best health outcomes
In addition, we need a health policy that consolidates the function of our health purchasing and oversight mechanism and has the statutory authority to build and guide a health care system that produces the best health outcomes at the lowest cost.

We need a focus on cost, so that our health insurance costs are 20-30 percent less than that in surrounding states, so employers locate here and we can rebuild our economy.

We must begin by providing robust primary care to all Rhode Islanders in every Rhode Island neighborhood and community, because a mountain of evidence shows that providing primary care to all is the best most affordable way to improve health outcomes while reducing cost. [Primary care reaches only about 50 percent of Rhode Islanders today.]

Finally, we need a health workforce strategy that creates career ladders for Rhode Islanders from Rhode Island communities, so that our students can learn here, train here and practice primary care here, and so that our health care strengthens our communities, because our communities are what gives Rhode Island its verve, its vibe and its resiliency.

Only about 10 percent of Brown’s Alpert Medical School class comes from Rhode Island. Our nursing schools are much better at educating Rhode Islanders. [The question is:] Are we educating the health workforce we need? Either Brown needs to change, or we need to build a public primary care medical school so that all Rhode Islanders have the world-class primary care they deserve.

Rhode Island can and should lead the nation by producing the best health outcomes at the lowest cost, in the state with the strongest economy. We can win at this, if we understand that the prize is health, not a biomed economy, if we align our politics with the best policy -- and then keep our eyes on that prize, and put Rhode Island and Rhode Islanders first.

Michael Fine, M.D., is a family physician. He served as the director of the R.I. Department of Health from 2011-2015.

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