Delivery of Care

Mapping the colonized world of health care in Rhode Island in 2018

To address the ever-increasing medical costs, we need to be able to create a transparent map of where the money flows and what it pays for

Image courtesy of the Colonial Williamsburg Collection online presentation

A general chart of the western ocean, created by John Seller, published by William Mount and Thomas Page, featured in the analysis by Margaret Beck Pritchard and Henry G. Taliaferro in their book, Degrees of Latitude: Mapping Colonial America, examining the maps and atlases in the Colonial Williamsburg Collection.

Image courtesy of UPMC website

UPMC banner for its 2016 year in review.

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By Richard Asinof
Posted 2/19/18
The current clash of health systems in Pittsburgh offers insights into the existing health care delivery system battles in Rhode Island, and the need for transparency not just in medical costs, but what they go to pay for.
What are the regulatory mechanisms available to Rhode Island to create transparencies for medical costs? Would the R.I. General Assembly consider creating a cap on the annual rise of medical costs? Have the political contributions by leaders in the health industry sector ever been broken down into a database? How do health plans that cover corporate executives compare with individual plans on the health exchange, in terms of benefits and costs? Will patients be able to own and control the use of their own personal health data from wearable devices?
The decision proposed in Gov. Gina Raimondo’s budget to scoop $5 million this year and $5 million next year from the coffers of Rhode Island Housing, coupled with last year’s decision approved by the R.I. General Assembly to scoop $1 million, translates into a $11 million grab to pay for the current budget deficits. At a time when the availability of affordable housing in Rhode Island is at crisis dimensions, when there are waiting lists in Olneyville for affordable housing between three and five years, the money grab from Rhode Island Housing only promises to exacerbate the problems.
From a public health perspective, access to safe, affordable healthy housing has been proven to be prescriptive to cutting down on unnecessary medical costs and improving health outcomes. Likewise, research has documented the economic benefits of investing in affordable housing in building sustainable communities.
The governor’s budget also recommends waivers of lead safety housing certificates for at risk children being placed in relatives’ homes, a kind of absurd notion of putting at-risk children at further risk.
Such budget practices are profiles in cowardice, not courage, particularly at a time when commercial home sales are booming.

PROVIDENCE – In conversations about the future health care landscape in Rhode Island, several innovation ecosystem kibbitzers have recently suggested to ConvergenceRI that Pittsburgh is home to the kind of health care delivery system nirvana that the Ocean State should aspire toward becoming.

Indeed, Pittsburgh was one of the places that former Gov. Lincoln Chafee led a tour of legislators and business leaders in 2011 to promote his vision of “meds and eds” in Rhode Island, as a way to prime the pump for future economic growth.

But, as Carolyn Y. Johnson revealed in her recent story in The Washington Post, all is not quiet on the Pittsburgh front, as two behemoths, the University of Pittsburgh Medical Center, or UPMC and Highmark Health, battle for supremacy in the market trenches. [See link below to the story, “Two visions of the future of health care are at war in Pittsburgh.”]

Johnson reported: “On one side is UPMC, a health system that built its brand on cutting-edge research and university-affiliated hospitals. On the other is Highmark Health, best known as one of the country’s biggest health insurers.”

The story continued: “They could be mirror images of each other, flipped upside down. UPMC started out in the hospital business, then created its own health insurance plan and built a $20-billion-a-year enterprise. Highmark, which reported $18.2 billion in revenue last year, announced in 2011 that it would branch [out] from insurance into hospitals.”

Both UPMC and Highmark have their own corporate towers in downtown Pittsburgh, from which they hurl words and policies at each other. Caught in the middle of the struggle, of course, are the patients, who are finding themselves with few good choices: either forced to find new providers or faced with huge medical bills, often with life and death consequences.

One intriguing detail in Johnson’s story: Medical spending per person in Pittsburgh grew 20 percent from 2012 to 2016, 5 percent faster than the 15 percent growth nationally, according to data analyzed by the Health Care Cost Institute, looking at data from the national employer-sponsored insurance plans.

To put the escalation in medical costs in perspective: in 2003, 17 percent of average family income went to pay for health care; in 2017, it was 30 percent. The projection is medical costs will be 50 percent of average family income by 2025, according to Congressional Budget Office numbers.

Translated, the head-to-head competition between the health care giants in Pittsburgh keeps raising prices for consumers, instead of lowering them. Why is that?

A second intriguing detail to be found in Johnson’s story: Pittsburgh’s premiums for employer-sponsored health care were still below the national average, a finding that was true before the head-to-head competition began.

Translated, if medical costs keep rising above the national average, yet premiums for employee health insurance are below the national average, who is paying for the extra costs? And, what are they buying? Good questions.

The art of medical costs: anything you can get away with?
To determine who is bearing the burden of the 20 percent increase in medical costs in PIttsburgh, even as premiums for employer-sponsored health insurance remain relatively low, it requires transparency.

Any patient who has ever tried to decipher a large emergency room bill knows what an impossible task that can be. Sarah Kliff at Vox Media has launched an investigative reporting initiative to examine emergency room bills from 2012 through 2018 to identity and to make transparent the disparities in medical costs in emergency room care. She and Vox have asked consumers to share their emergency room bills.

Among Kliff’s initial findings were that emergency rooms code their “facilities fees” to reflect the complexity of care delivered to the patient, and that they often pump up the volume for expensive – and perhaps unnecessary – screenings and tests. Insurance companies, in turn, have begun to pay only for what they deem true emergencies, rather than for health care that doesn’t fit that definition, according to Kliff’s reporting.

But, beyond deciphering the escalating costs in emergency room care, a larger, unanswered, more significant question remains: If consumers are paying more, where does the money go as a result of these higher medical costs?

What does it pay for, specifically? Is it for the higher costs of drugs? Are patients’ bills being assessed a surcharge for investments in health IT? Is it for increasing labor costs? Is it being used to pay for health insurance costs for employees? Is it for administrators’ salaries? Is it being used for advertising campaigns and billboards to increase market share? Is it part of the quotient of the extra costs assigned to medical education?

Translated, how do you explain why two aspirins delivered to a patient in intensive care costs $49?

Or, why was one of three blood tests ordered for a diabetic patient by a primary care doctor not covered by Medicare, putting the patient on the hook for an extra $325 if she decided to have it done? If care is being rationed and the evidence for evidence-based care for chronic diseases is blocked because of high medical costs, who benefits?

What is occurring in Pittsburgh provides a lens, perhaps, to better understand what is happening here in Rhode Island, as the Ocean State grapples with its health care future. If nothing else, it creates an opportunity to ask the questions that need to be asked about medical costs and transparency, in order to follow the money.

Colonizing health care, controlling the data
The nation is in the midst of a dizzying wave of consolidation [a better phrase might be the corporate colonization] of the health care industry sector: hospitals are buying out insurance companies; insurance companies buying out hospitals and pharmacy benefits firms; big pharmacy firms such as CVS are buying out insurance companies; and technology companies such as Amazon joining with banks and wealth managers to develop an alternative platform to better manage health care costs.

Somewhat underneath the radar screen is how companies such as FitBit, Google and Microsoft and Apple are expanding into the wearable device market to capture their fair share of the projected $30 billion future market – and capture streams of health IT data that enable them to target products to customers and connect customers to products.

[Apple, for instance, announced on Jan. 24 that is significantly upgrading its Health app to enable “customers to see their medical records right on their iPhone.” John Hopkins Medicine, Cedars-Sinai and Penn Medicine are among the first to make this feature available to their patients, Apple said.]

What does health have to do with it? Very little, a cynic might argue. The current health care delivery system, or as some have called it, a wealth extraction system, appears to be a method to maximize profits, not improve health outcomes, in the age of population health management and Big Data.

In health care, the standard economic theory on competitive markets may not apply when markets are not competitive, as Eduardo Peter recently wrote in The New York Times about the recent analysis by Brown University economists published by the Washington Center for Equitable Growth.

Rhode Island, because of its small population size and fragmented acute care community hospital system tied to a 20th century manufacturing industry that no longer exists, has witnessed its health care system be colonized during much of the last decade, in a rough and tumble corporate game of musical chairs.

The new health care map of Rhode Island
Imagine a new map of Rhode Island drawn by a cartographer that reapportioned new boundary lines in Rhode Island according to its health systems, the same way that European powers once carved up the African continent into colonial empires, or, for that matter, North America.

“Maps were used to promote settlements, facilitate trade, acquire land, and settle boundary disputes,” as Margaret Beck Pritchard and Henry G. Taliaferro wrote, based on their book, Degrees of Latitude: Mapping Colonial America, examining the maps and atlases in the Colonial Williamsburg Collection. “More than any other resource, maps tell us the story of how Europeans took possession of the land by royal claims based on discovery and exploration, by companies comprised of private investors who wanted to establish settlements, or by wealthy individuals asserting personal holdings.”

[Often left out of the mapping narrative was the fate of indigenous peoples already living in the “new world” and the imported labor workforce of slaves, prisoners and indentured servants in the colonies.]

Here is a brief plot summary of the episodic soap operas of hospital acquisitions in Rhode Island during the last decade:

Westerly Hospital is owned by Yale-New Haven, which bought the previous owner, Lawrence + Memorial Hospital in New London, Conn., which purchased Westerly Hospital after it went into receivership. South County Health, the last remaining unaffiliated acute care community hospital in Rhode Island, is currently in conversations to merge with Yale-New Haven. Translated, color the new map of the southern tier of Rhode Island’s hospitals and health systems in yale blue as they become part of Yale-New Haven’s larger footprint.

Landmark Medical Center in Woonsocket was bought in 2013 by the for-profit California-based Prime, after five years in receivership. The sale followed an abrupt decision by Steward Health Care not to buy Landmark after more than a year of courtship. Prime recently took the for-profit Landmark and donated it to Prime’s nonprofit foundation, reaping large tax benefits. The move came under scrutiny after Prime officials lied to the R.I. Department of Health about the transaction, resulting in a $1 million fine. Translated, color the new map of northern tier of Rhode Island’s hospital and health systems in poppy red that is now controlled by Prime, a California entity.

CharterCARE, including Roger Williams and Fatima hospitals, is now owned by the for-profit Prospect Medical Holdings, a California company. CharterCARE has also been active in expanding its footprint in western Connecticut. Translated, color a quadrant of map in roman purple, to represent the former Catholic health system run by the diocese and Roger Williams that is now controlled by a California for-profit entity.

Any maps attempting to portray the territory of Care New England, the second largest health system in Rhode Island, are in flux, given the pending merger with Partners Healthcare in Boston. Memorial Hospital in Pawtucket, acquired in 2013, is now closed. Women & Infants Hospital is the state’s flagship maternity hospital, where most of the births in the state occur. Butler Hospital, a psychiatric hospital on the East Side of Providence, Kent Hospital, an acute care community hospital in Warwick, and The Providence Center, a community mental health facility, are also part of the map. Translated, color those parts of the map in pink stripes, because they overlap other territories.

A map of the territory of Lifespan, the largest health system in Rhode Island, has a major presence in and around Providence, with Rhode Island Hospital, Hasbro Children’s Hospital and The Miriam Hospital, along with Bradley Hospital, a children’s psychiatric facility in East Providence. Add in Newport Hospital on Aquidneck Island, and Lifespan’s territorial arc resembles a kind of gerrymandered voting district, with overlapping edges of disputed territories. Translated, color those parts of the map in burnt sienna.

Both Chafee and Gov. Gina Raimondo attempted to force an arranged marriage between Care New England and Lifespan and failed – at least six times, by ConvergenceRI’s count, reminiscent of the way that European royalty once attempted to expand their empires through arranged marriages. [Cue up Lady Gaga’s “A Bad Romance.”]

[An irony, of course, is that Women & Infants Hospital and Rhode Island Hospital – the flagship facilities Care New England and Lifespan – are connected by a tunnel, where health care professionals collaborate on a daily basis, unencumbered by corporate boundaries, doing what is best for their patients.]

Also, nipping at the borders is Southcoast Health, headquartered in New Bedford, Mass., which has aggressively sought to move its urgent care centers to edges of Rhode Island, including a new urgent care facility opened in 2017 at a shopping strip mall in Seekonk, Mass., as well as outposts of physician group practices in Bristol and in Providence.

The question is: how do you define a Rhode Island health care delivery system within such a colonized map? In many ways, it resembles the peculiar Rhode Island habit of giving directions using landmarks that no longer exist, except in people’s memories.

The mapping exercise perhaps demonstrates that the idea of a Rhode Island health care delivery system is mostly an illusive creation of policy makers, a myth that does not conform to the current reality that the state’s health systems has already been colonized, with no statewide health care planning process to govern how future care is delivered.

Alternative visions, alternative maps
There are, of course, other ways to draw the current health care maps of Rhode Island, reflective of the changing dynamics of health care delivery.

Consider the follow overlays to the map: the robust system of nine community health centers in Rhode Island, delivering primary care to about one-quarter of Rhode Island’s population; the physician group practices that deliver “integrated” primary care through the concept of an accountable care organizations and the all-payer patient-centered medical home model; and the specialty group physician practices that are owned and organized outside of the hospital systems.

There are two also distinct Rhode Island innovative visions of future health care delivery that never seem to be included in the conversation: neighborhood health stations and health equity zones.

There are two neighborhood health stations operating in Rhode Island, one in Central Falls and one in Scituate, organized around the integrated delivery of primary care services according the needs as defined by the residents, not the desires of providers.

There are nine health equity zones in Rhode Island, developing community-based solutions to health disparities, recognizing that more than 75 percent of health outcomes are determined by what happens in a community, not by genetics or what occurs in a docto'rs or nurse's office.

One unifying vision, perhaps, is the connection to the academic medical enterprise that trains physicians, nurses and physician assistants that populate our health care delivery system. However, that, too, seems to have fallen victim to the competing ideologies of corporate boundaries, as if folks will somehow fall off the edge of the academic research world when crossing over the boundary of the 401 area code.

Into the fray
The decision by Care New England and Partners Healthcare in Boston to move forward with an agreement to merge in January has sharpened the war of the words around what such a strategic alliance would mean for Rhode Island for the future of its academic health enterprise system.

In a letter to the community released on Jan. 11, Brown University President Christina Paxson claimed that “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.”

However, it is unclear what evidence actually exists to support Paxson’s claims to document the threat posed by the merger of Care New England with Partners Healthcare to Brown’s hegemony to the local academic health system.

None of the corporate anchor tenants of the new Wexford Innovation Center now under construction, including Johnson & Johnson and the Cambridge Innovation Center, have threatened to withdraw, based upon the proposed merger.

The proposed new merger did not appear to have influenced the decision by Pfizer to invest in MindImmune’s drug discovery research platform at the University of Rhode Island, focused on the brain’s immune system to treat brain diseases and to become a collaborative research partner, at the same time the global Big Pharma firm decided to end its work on potential drug treatments for Alzheimer’s and Parkison’s disease.

Nor did the proposed merger appear to dissuade donors from making new, large gifts to Brown to support its future academic medical research enterprise. On Thursday, Feb. 15, Brown announced $56 million in new gifts to finance the Brown Institute of Translational Science, or BITS, a division of the Warren Alpert Medical School. The new institute, according to Brown, seeks to convert “scientific discoveries into medical breakthroughs that are tested in the clinic and brought to patients in the marketplace.” [See link to ConvergenceRI story below, “BITS and BBII: A new vision for translational research at Brown.”]

As Samuel M. Mencoff, the current Brown chancellor who made the largest share of the new gift, $50 million, with his wife, said: “What can be more exciting or important than finding cures and treatments for diseases that burden the lives of patients in Rhode Island and globally?” as reported by The Providence Journal.

[Of course, if Bruce Lamphear, professor of Health Sciences at Simon Fraser University in British Columbia, were to answer Mencoff’s rhetorical question, he might answer: the need to unleash the power of prevention and re-imagine our approach to disease. See link below to ConvergenceRI story, “Changing the way we think about disease.”]

The right questions to ask
All health care is local and personal. The reality is that approximately 75 percent of the choices that lead to better health outcomes occur not in doctors or nurses offices but in the communities and neighborhoods where we live.

What seems to be a straightforward equation about improving health outcomes becomes complex and complicated when it is addressed through the prism of the current health care delivery system and its ever escalating medical costs.

Moving forward, here are some questions to ask and answer, to better understand and make transparent the costs of delivering health care in Rhode Island.

How do we define the academic medical research enterprise in Rhode Island? What is the flow of investment into the academic medical research enterprise from both federal and corporate resources? How much actual money flows in on an annual basis? To whom does the money go? What kinds of specific research does it support? How many jobs are supported by the research, both in direct and indirect jobs? Is there an accessible, transparent database to access this information? Is the flow of research dollars tracked in a systematic fashion? What kinds of collaborative research efforts exist across the boundaries of health systems and academic health institutions?

How much does the Center for Medicare and Medicaid Services contribute to medical education programs in Rhode Island through medical residency programs? What does that money go to support?

What is the breakdown of facilities fees charged as part of emergency room care provided in Rhode Island, hospital by hospital? In a busy flu season, for instance, what are the medical costs of patients with flu seen in the emergency room that then require hospitalization? Is there a surcharge in facilities fees charged to patients to cover the costs of health IT investments?

How much does each hospital system invest in prevention activities compared with clinical care?

Similar to the way that commercial insurers are regulated in Rhode Island by the Office of the Health Insurance Commissioner, could a similar regulatory system be set up to manage and regulate increases in medical costs?

What is the ratio of salaries, comparing CEOs of health systems with nurses and community health workers?

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