Delivery of Care

Skirmishes on the front lines of health care

Clashes in Rhode Island illuminate how states are becoming the battleground over the future boundaries of health care delivery

Photo by Richard Asinof

An image used by Neighborhood Health Plan of Rhode Island to promote one of its health plans in 2016.

By Richard Asinof
Posted 7/24/17
The battle of words in Washington over Trumpcare vs. Obamacare tends to obscure the ongoing conflicts at the state level in Rhode Island over the future boundaries in health care delivery.
What are the benchmarks that will be used to measure quality and cost outcomes with the addition of Tufts to the managed Medicaid market? What is the status of the efforts by Rhode Island to develop accountable entities in the long-term care market? What are the actual results of Neighborhood Health Plan’s efforts under the Integrated Care Initiative to manage the Medicaid patients in nursing homes, in the effort to transition such patients back to the community? Has there ever been an independent verification of those results? How will shared savings be determined as part of the Reinvention of Medicaid? How do the current reimbursement rates being paid by Neighborhood Health Plan for behavioral and mental health services compare to other insurers? Can a Medicaid managed care insurer exclude a group practice from its primary care network because they only see women? Does the development of Neighborhood Health Stations offer an alternative model for health care delivery in Rhode Island? What is the progress of health equity zones in 10 communities in Rhode Island? What kinds of new investments should the state make in strengthening the network of community health centers?
For all the hue and cry in Washington about Trumpcare vs. Obamacare, the reality is that only about 6 percent of Americans purchase commercial health insurance through the exchanges set up under the Affordable Care Act. The other 94 percent have other methods for procuring health insurance – through employers, through Medicare and Medicaid, or through the Veterans Administration.
The fully insured commercial health insurance market in Rhode Island regulated by the R.I. Office of the Health Insurance Commissioner keeps shrinking – a total of some 215,157 Rhode Islanders, about 22 percent of the total market, are insured through small group, large group or individual market plans, according OHIC data from March of 2017.
The remaining roughly four-fifths of the market receives health insurance either through federal programs, such as Medicare and Medicaid, or through large employer self-insured plans, governed by Federal ERISA regulations.
Rhode Island is the only state with a health insurance commissioner, and its affordability standards and its all-payer patient-centered medical home model initiative are examples of innovative approaches.
But what the 2017 numbers reveal is that there is diminishing leverage at the state level to exert control over the continuing inflation of medical costs. The OHIC efforts to control such costs by limiting increases in commercial insurance rates for hospitals to 2 percent a year has been severely criticized by health systems as limiting revenues in a time of shrinking revenues.
The real battleground in the national debate over health care is over the future of Medicaid and its expansion under the Affordable Care Act. Medicaid pays for most of the 1.4 million people in nursing homes – 20 percent of all Americans and 40 percent of poor adults. Further, Medicaid covers more than 30 million children nationwide, representing about 43 percent of all Medicaid enrollees. The rhetoric being invoked by many Republicans – that those receiving Medicaid benefits are somehow undeserving and need to get a job – does that apply to children and seniors in nursing homes?

PROVIDENCE – Amidst the war of the words over health care in Washington, Trumpcare vs. Obamacare, three unrelated stories here in Rhode Island illustrate how states have become the skirmish lines in defining what is at stake in the debate over the future boundaries of health care delivery.

First, there is the story that the for-profit Neighbors Emergency Center in West Warwick, owned by a Texas-based firm, announced that it will close its doors on Aug. 4, after nine months of operation. Further, the company said that it was abandoning its plans to open a similar freestanding emergency center in Bristol.

The decision to close down its operations in Rhode Island was blamed on what Dr. Setul Patel, the CEO of the Texas-based firm, claimed was “the non-cooperation of Blue Cross [and] Blue Shield of Rhode Island,” according to a story reported by WPRI’s Susan Campbell.

Jill Flaxington, a spokeswoman for Blue Cross, responded to Patel’s claims in an email, according to Campbell’s story, by saying: “While the law requires us to reimburse out-of-network hospital emergency departments comparable to in-network emergency department rates, because Neighbors Emergency Center is not a hospital it is subject to a different reimbursement.”

Lots of states have freestanding emergency centers,” Patel told Roberts, claiming that: “It’s the wave of the future. It’s just not the wave of the future in Rhode Island.”

The other reality, which Patel did not mention but Campbell did, is that the federal government does not recognize freestanding emergency departments and will not reimburse costs for Medicare and Medicaid patients.

Missing factors
In his effort to find a convenient punching bag in Blue Cross to blame for the failure of his company’s expansion into Rhode Island, other factors not addressed by Patel include:

The way that big pharmacy chains and big box stores have expanded into the urgent care business, such as CVS with its MinuteClinics, providing strong marketplace competition.

The expansion of hospital-linked urgent care centers, including four such centers by Southcoast Health in shopping center plazas in Seekonk, Fairhaven, Darmouth and Wareham, Mass., catering to the need for immediate, non-emergency care, with a coordinated, online presence, linked to Southcoast’s network of care providers.

The expansion in 2016 by South County Health to grow its footprint by creating a new urgent care medical facility in Westerly, broadening the definition of the community it serves, offering 24/7 urgent care, lab and imaging services, including ultrasound and 3-D mammography, as well as primary care, orthopedics, physical therapy, dermatology and OB-GYN services.

The trend is that hospitals in Rhode Island and throughout the region are moving away from inpatient care settings to outpatient care settings, as a way to cut costs and increase market share, catering to convenience.

The importance of having strong state regulators at the R.I. Department of Health to review the operations of health systems to protect the health and well-being of consumers – including access and affordability to health care.

Unlike in Texas, where state regulation of health care is more lax, the folks at the R.I. Department of Health have been rigorous in exploring licensing issues. In fact, the director, Dr. Nicole Alexander-Scott, overruled the recommendation of the R.I. Health Services Council in allowing the Neighbors Emergency Center to open – but attached some consumer safeguards as a condition of the license.

Border disputes
Which gets us to the second story – the effort by Lifespan’s Rhode Island Hospital to curtail its long-standing collaborative agreement with Care New England’s Women & Infants Hospital for the treatment of cardiac and stroke patients.

As reported by WPRI’s Ted Nesi, the policy for what’s known as “adult code” incidents, when an adult shows cardiac or stroke-like symptoms, enabled Women & Infants doctors to call for help from physicians at Lifespan.

Rhode Island Hospital, expressing concerns about patient safety and physician liability, moved to end the policy effective June 26 at 8 a.m., according to Nesi’s story. But R.I. Department of Health Director Dr. Nicole Alexander-Scott stepped in, ordering the backup coverage to continue.

Negotiations to resolve the issue are still ongoing, according to R.I. Health Department spokesman Joseph Wendelken.

In 2016, according to Women & Infants, there were some 14 incidents when the 30-year-old policy came into play.

Of course, the context to this flare up of a “border dispute” between Lifespan and Care New England are two broader conflicts:

The decision by Care New England to seek a merger with Partners Healthcare in Boston, rejecting the bid by Lifespan.

The effort by Lifespan’s Rhode Island Hospital to build a $43 million obstetrics facility a few hundred yards from Women & Infants is a move that many have seen as duplicative of existing services.

Dr. Timothy Babineau, the president and CEO of Lifespan, positioned the move to build a new obstetrics facility as a way to fill “a missing piece” in the health system’s portfolio of care, in a recent interview with Ted Nesi on WPRI’s Executive Suite.

“I feel more strongly than ever, when care is delivered within a completely integrated health system,” Babineau said, it drives quality up, improves outcomes and controls costs.

A big missing piece of Lifespan’s portfolio, Babineau continued, “is obstetrical services in downtown Providence.” [Lifespan does provide obstetrical services at Newport Hospital.]

Babineau added: The move to create the new birthing facility was “not an attack on Women & Infants.”

When Lifespan filed a revised Certificate of Need with the R.I. Department of Health for its new obstetrical facility in January of this year, Lifespan spokesman David Levesque specifically tied the need for the new obstetrics facility to the fact that Rhode Island Hospital provides care for patients that Women & Infants does not provide.

“Rhode Island Hospital already cares for about 500 patients each year who are transferred from Women & Infants because they experience complications and require care not available at that hospital,” Levesque said, as quoted by The Providence Journal.

As reported by ConvergenceRI: That number seemed overly large. To double-check, ConvergenceRI reached out to Levesque, asking for a breakdown of the clinical diagnoses of those 500 cases, to better understand what precipitated the need for transfers.

Levesque did not respond to the email. Then, in a follow-up phone call, Levesque told ConvergenceRI that he did not have the information available regarding the clinical conditions, and doubted that he would be able to get it before ConvergenceRI’s deadline.

ConvergenceRI also reached out to Amy Blustein, spokeswoman for Women & Infants Hospital, to see if she could verify the numbers claimed by Levesque and provide details of the clinical conditions that caused the need for transfers.

Here are the questions and Blustein’s reponses:
ConvergenceRI: Was the figure cited by David Levesque, 500 transfers a year from Women & Infants to Rhode Island Hospital, an accurate number regarding transfers?
No, this number is not accurate. The incidence of transferring obstetric patients to Rhode Island Hospital is fewer than one per week. We are working internally to provide a more accurate number.

ConvergenceRI: Can you provide clinical details why they were transferred, i.e., what complications were there that Women & Infants would not be able to provide care for?
Only obstetric patients requiring trauma care or ICU level of care would be transferred to Rhode Island Hospital.

Translated, the attempt by Rhode Island Hospital to curtail its collaborative agreement with Women & Infants to have its physicians treat potential stroke and cardiac patients appears to be linked directly to efforts to establish a rationale for the new obstetrics facility, according to the past statement by a Lifespan spokesman.

Across the borderline of health care
Beginning on July 22, there are now three managed care organizations that are available as health plan choices for managed Medicaid recipients in Rhode Island: Neighborhood Health Plan of Rhode Island, Tufts Health Plan, and UnitedHealthcare.

Yet, even with the expansion of insurer choices, there is apparently still limited regulatory oversight about how these insurers manage the determination of who’s in and who’s out in their health care networks.

A woman of a certain age – too young for Medicare and insured under Medicaid – uncovered the problem when she attempted to schedule a physical with a primary care physician at a physicians’ group practice.

Under Medicaid, the woman explained to ConvergenceRI, “It is difficult to find a doctor that is available to new patients, especially if you are a woman and prefer to see a woman physician or be seen by a female-oriented practice. There are many nurse practitioners and physician assistants listed but few doctors.”

After waiting about 10 weeks to schedule an appointment, given a long waiting list, the woman was able to schedule with a primary care physician, who had been recently recruited from Delaware to practice in Rhode Island, she was informed by the physician group practice that her Medicaid insurance, which was through Neighborhood Health Plan of Rhode Island, would not cover the visit.

The problem, the woman discovered, is that apparently Neighborhood Health Plan did not include primary care providers in its network from that physicians group practice, allegedly because the practice was specialized for women.

ConvergenceRI reached out to Tom Boucher, the spokesman at Neighborhood Health Plan, who responded by saying that it was the insurer’s policy not to respond to questions from ConvergenceRI. [Call it a badge of honor that I ask difficult questions, that I do not reprint news releases, and that I am not a mouthpiece.]

ConvergenceRI also reached out to the R.I. Executive Office of Health and Human Services, to ask if it was legal to deny primary care participation in a health insurer’s network allegedly because the practice only saw women, and not men.

The questions that were asked: Is it legal, if the woman’s story is accurate, for Neighborhood to deny a Medicaid patient the ability to see a primary care practitioner of her choosing because the practice does not treat men? What recourse is there for the woman?

Meghan Connelly, a spokeswoman for R.I. EOHHS, responded by email: “Our Medicaid unit is looking into the situation you presented, and the guidelines surrounding a primary care services that might not be classified as such by Neighborhood.” She promised to circle back on Monday, July 24, with a more complete answer.

A long-time family medicine physician in Rhode Island suggested that it was perfectly legal for Medicaid insurers to make whatever determinations they wanted to regarding inclusion of providers in their networks. The physician explained, in a sarcastic tone: they could say that the provider had to take a rocket and travel three times around Mars and return to Earth as a condition to be included in their network, and it would be legal.

Framing the issues
Dr. Michael Fine, the former director at the R.I. Department of Health, when asked about the ongoing conflicts around access to coverage, competing health systems and efforts to enter the Rhode Island health care market, reiterated his often-expressed view: “We have a market, not a health care system. The market is there to extract as much wealth as it can. There is no illusion that anyone is responsible for providing equal access to medical services for Rhode Islanders. This is a market, not a health care system.”


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