Delivery of Care

Surviving in a time of uncertainty in health care

That was the week that was: grants announced in physical therapy room at R.I. Free Clinic; Memorial Hospital withdraws its physical therapy, x-ray and lab facilities from Central Falls; and Lifespan and Care New England are joined in battle over future obstetric facilities

Photo by Richard Asinof

Neil Steinberg, left, president and CEO of The Rhode Island Foundation, Ana Morquecho, a R.I. Free Clinic patient, Marie Ghazal, CEO of the Rhode Island Free Clinic, Mark Gim, chair of the R.I. Free Clinic, Karen Voci, executive director at the Harvard Pilgrim Health Care Foundation, and Sandra Powell, associate director at the R.I. Department of Health, at the May 2 news conference, at which the Rhode Island Foundation announced more than $270,000 in grants.

By Richard Asinof
Posted 5/8/17
The awards of more than $270,000 in health care grants by the Rhode Island Foundation to providers on the front lines to expand their reach got swallowed up by the bigger picture stories, as health systems collided over competing obstetrical facilities and Congress moved Trumpcare along to the next step.
How will insurance companies in Rhode Island define what a pre-existing condition is, if Trumpcare is enacted? Is there a major problem brewing with the low rates of reimbursement by Neighborhood Health Plan of Rhode Island? Will Blue Cross & Blue Shield of Rhode Island become a potential target for consolidation? How will the planned innovation center by Wexford be impacted by reduced federal funding for university research and potential cuts in reimbursements for hospitals under Medicaid? When will the House Committee on Oversight hold a hearing on the Reinvention of Medicaid and the development of accountable entities?
All health care is personal. Yet patients are often pawns caught in the larger struggles between clashing economic behemoths. As with the medieval struggles between Florence, Siena and Rome, it is often the peasants caught in the middle between the warring city-states that suffered the dire consequences.
The new Trumpcare proposal that the House of Representatives passed is not so much a health care bill but an attempt to redistribute the wealth of the nation, taking benefits away from the “undeserving” poor and frail and delivering tax breaks to the wealthy.
For all the political rhetoric, the proposed new law does nothing to address the escalating costs of medical care and drug prices, even as the nation is caught up in a wave of peaking chronic diseases – including diabetes and obesity that are taxing the resources of the health care delivery system. Dementia, Alzheimer’s and Parkinson’s disease afflict an increasing percentage of our aging population, driving up care-giving costs. The ever-increasing death toll from opioids and prescription painkillers has become a modern plague.
The patients are the ones with their noses pressed against the glass, looking in, at the mesmerizing ballet, a cartoonish “Dance of the Hours” between the crocodiles and the hippos in health care. The news media needs to do more than serve as a blow-by-blow commentator at the fight, or to deliver fashion critiques of the tutus. And patients – as customers, as clients, as advocates – need to learn to act together as an engaged community.

PROVIDENCE – The setting for the news conference held on May 2 by the Rhode Island Foundation to announce more than $270,000 in health care grants was at the Rhode Island Free Clinic at 655 Broad St.

The Clinic serves as an oasis for uninsured, low-income working adults who cannot afford or do not have access to health insurance in Rhode Island. Stephanie Chafee, the former First Lady and a nurse by profession, founded the Clinic in 1999, nearly two decades ago.

In 2016, the Clinic served nearly 2,000 uninsured low-income adults, providing some 7,000 patient visits, mobilizing 550 volunteer doctors, nurses and medical support staff statewide, including 26 medical specialties. The volunteer medical contribution was valued at $814,000.

Overall, the Clinic said it diverted approximately 600 uncompensated ER visits last year at cost savings of about $3.9 million.

Translated, the Clinic depends on the kindness of strangers, medical volunteers and the generosity of corporate philanthropy to provide health care to those left out in the cold by the current health care delivery system – what some have described not so much as a system of health care but a system of wealth extraction.

The demand for services at the Clinic is a constant flood, though it often occurs out of sight and off the radar screen. Karen Voci, executive director at the Harvard Pilgrim Health Care Foundation, in her remarks at the news conference, candidly admitted that she “had never been here before.”

[For sure, the diverse neighborhood along Broad Street near where the Clinic is located, with its plethora of fast food joints and bodegas and ah, vibrant street commerce, is not necessarily where Gov. Gina Raimondo would choose to take visiting executives from prospective companies considering relocating to Rhode Island for lunch or a walking tour.]

At present, there are some 50,000 Rhode Islanders living outside the health insurance safety net, according to Mark Gim, board chair of the R.I. Free Clinic and executive vice president of Wealth Management at Washington Trust.

That number in Rhode Island, or course, may triple or quadruple if the new Trumpcare bill passed by House Republicans becomes law.

Vulnerable populations
Neil Steinberg, president and CEO of The Rhode Island Foundation, who served as emcee at the news conference, set the stage by acknowledging that uncertainty grips the future of health care, both in Washington, D.C., and here in Rhode Island, lending more import of the foundation’s philanthropic efforts to support a “more inclusive primary care system that promotes healthy lives.”

Many of the grant recipients – made through the Rhode Island Foundation’s RIGHA Foundation Fund it now manages – targeted service providers working with vulnerable populations, such as the R.I. Free Clinic.

[For history buffs and transparency purposes, the RIGHA Foundation Fund was created after Harvard Pilgrim Health Care acquired the former Rhode Island Group Health Association. In 2010, Harvard Pilgrim Health Care and the RIGHA Foundation transferred its $1.6 million endowment to the Rhode Island Foundation.]

The R.I. Free Clinic received a $25,000 grant to launch a Healthcare for Hispanic Women program, hiring a bilingual medical assistant, enabling the Clinic to expand services to an estimated 600 low-income, uninsured Hispanic women who are ineligible for coverage under Obamacare and cannot afford health insurance though HealthSourceRI.

Clinica Esperanza was awarded $50,000 to support its bridging the gap program, targeted at improving the health of uninsured, low-income, limited English-speaking patients who have diabetes, hypertension or other chronic diseases.

Thundermist Health Center received a $61,875 grant to hire a pharmacist to provide chronic disease management, medication assessment and advanced patient education.

Crossroads Rhode Island received $70,000 to support its Mental Health Navigation and Housing Stability project, targeted at assisting homeless adults transitioning to permanent housing.

South County Hospital Health Care was awarded $64,347 to work with the Washington County Behavioral Health Collaborative, The Providence Center and Butler Hospital to reduce the number of behavioral health-related visits to emergency rooms at South County Hospital and Westerly Hospital.

Sandra Powell, associate director of Health at the R.I. Department of Health, framed the grants in terms of the effort to help achieve “health equity,” to extend the reach of quality health care into every community, regardless of zip code.

Despite the advocacy for health equity by Powell, Ana Novais and Dr. Nicole Alexander-Scott at the R.I. Department of Health, the promise of equal access to health care often takes on the appearance of a brass ring beyond the grasp of many, a dream deferred.

In turn, the flexible, innovative approaches developed on the front lines of health care, many examples of which were provided in the new grants, more often than not get lost in the conversation and receive few if any headlines.

Working it out
Working space at the Clinic is at a premium. In real life, the impromptu room in which the news conference was held serves as a physical therapy facility for the Clinic.

As Marie Ghazal, CEO at the R.I. Free Clinic pointed out, there were tape marks on the floor to show where to put back the PT equipment once the new conference was over. A row of brightly colored exercise balls lined one of the walls.

The R.I. Free Clinic patient who spoke at the news conference, Ana Morquecho, who uses a walker, praised the physical therapy she had received to help her maintain her recovery.

Physical therapy often serves as the therapeutic link – the connective tissue, as it were – to help patients in their transition from acute health care treatments in hospitals back to the community as well as to better maintain their own health in battling chronic diseases.

Physical therapy has also emerged as one of the effective tools to combat the epidemic in prescription painkillers. Instead of prescribing addictive opioids, many physicians are instead referring patients to physical therapy to deal with chronic pain. The likelihood that a patient will keep that appointment improves if the location of the physical therapy is in the same facility, according to one physician.

Physical therapy, in turn, has become one of the fastest growing professions in the U.S. The average annual salary for a physical therapist in the U.S. is $86,520, which is 103 percent higher than the average income of Americans, according to the website physicaltherapysalary.org.

Access to physical therapy is not a problem for patients of sports medicine and orthopedic groups, where companion gym sites predominate – and a steady stream of patients, beginning early in the morning, keeps flowing through the doors.

But that is not the case in Central Falls, where access to a physical therapy site in the square-mile city is limited to one site – and that existing location has, for the moment, become caught up in the ongoing musical chairs of hospital consolidation.

Slip sliding away
In Central Falls, the ongoing collaboration between Memorial Hospital and Blackstone Valley Community Health Care at the former Notre Dame urgent care center on Broad Street, now a Neighborhood Health Station, hit a pothole last week, apparently a victim of the ongoing financial struggles at Memorial and the pending sale of the hospital to Prime Healthcare, owners of Landmark Medical Center in Woonsocket.

Blackstone Valley received word that Memorial intended to pull its physical therapy from the facility as of Friday, May 5. That will be followed by the elimination of its x-ray services at the end of May and its lab facilities at the end of June, consolidating those services back on the main campus of Memorial.

“Businesses have to make decisions to survive, you can’t fault them for it,” said Ray Lavoie, executive director of Blackstone Valley Community Health Care, saying that he believed the move was prompted by efforts being put in place to prepare Memorial to be sold to Prime.

Translated, Memorial’s removal of physical therapy from the facility, along with its withdrawal of laboratory and x-ray services, places an additional burden upon Blackstone Valley and its neighborhood health station to provide comprehensive care in one setting within its city borders.

The silver lining, Lavoie continued, is that now Blackstone Valley can shop for a new partner to deliver the services being withdrawn by Memorial. Those conversations are in the works, he said.

Who’s in charge?
The move also raised questions about who is making the decisions at Care New England and how are they being reviewed by the R.I. Department of Health.

The Rhode Island Department of Health said it had not been notified of the changes.

“We have not been notified,” said Joseph Wendelken, communications spokesman at the agency, in response to a question from ConvergenceRI. “In terms of a review,” Wendelken continued, “I can’t say if one would be required without having the details in front of us.”

ConvergenceRI also queried Care New England about the changes and, in particular, who had been responsible for making the decision to withdraw services. No response has been received to date, although Care New England spokesman James Beardsworth told ConvergenceRI that he was working on it.

Among the questions ConvergenceRI asked were:

Were these changes that Dr. Michael Dacey, president and CEO of Memorial Hospital, approved?

Had the R.I. Department of Health been notified of the changes?

Shrinking coverage
Last week, there were new numerous stories about the first-quarter financial results for Care New England, said to be more than $40 million, ramping up concerns about the financial stability of the health system as it moves forward with its intention to merge with Partners Healthcare in Boston and sell Memorial to Prime Healthcare, owners of Landmark Medical Center in Woonsocket.

First WPRI, then the Providence Business News, then the Providence Journal, all joined in the chorus, much like a wave of cascading cortisol in the brain, triggering a stress response.

Whether or not the losses in the first quarter have changed the financial prognosis for Care New England remains unclear, but the stress level has been pumped up.

[Beardsworth, in a statement reported by The Providence Journal, described the losses in the first quarter as further telling the story “we have been very candid about – decreases in patient volume, a worsening payer mix, changing health care needs of the population, and extremely restrictive reimbursement caps” put in place by the R.I. Office of the Health Insurance Commissioner. “While we continue to make important progress,” Beardswoth continued, “it takes time for such results to ultimately be seen on the bottom line.”]

Later in the afternoon on May 2, a public hearing was held before the R.I. Health Services Council in the basement of the R.I. Department of Health on two different Certificate of Need proposals, one by Lifespan’s Rhode Island Hospital to build a new Obstetrics facility, the other by Care New England to renovate its existing facilities at Women & Infants, in a clash of money, politics and health systems. [See link to ConvergenceRI story in this week’s edition.]

Also last week, on May 4, the U.S. House of Representatives voted in favor of a revised version Trumpcare, in a close, 217-214 vote, moving the process to the Senate.

Even as health care becomes the center of an existential debate about the future direction of American democracy and, for that matter, the American economy, here in Rhode Island, the number of full-time health care reporters keeps shrinking.

Former Providence Journal reporter Richard Salit is now working for Lifespan in its communications department, and reporter Kristin Gourlay has departed Rhode Island Public Radio and has yet to be replaced.

At best, there are only two or three full-time health care reporters left in Rhode Island: ConvergenceRI, Lynn Arditi at The Providence Journal, and Barbara Morse-Silva at Channel 10.

More often than not, health care stories are complex, connected across the silos that predominate in local news coverage. Attempting to squeeze them into 500-word reports or 60-second segments, whether in print, on radio or TV, renders most news coverage into easy-to-swallow placebos or anxiety-creating click bait.

Everyday consumers of health care are being left in the lurch.

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