Delivery of Care

The life and death of hospitals in Rhode Island

Ongoing saga of the closing down of Memorial Hospital keeps raising questions about priorities: which comes first, preserving jobs, saving residency programs, repurposing the property, or serving the patients?

Photo by Richard Asinof

The new Neighborhood Health Station facility at 1000 Broad St. in Central Falls, being built by Blackstone Valley Community Health Care, is now under construction and scheduled to open in September of 2018, with capability of providing primary care services to about 90 percent of the residents of Central Falls.

By Richard Asinof
Posted 11/27/17
As Care New England moves to close down Memorial Hospital in Pawtucket, the transfer of two medical residency programs affiliated with the Warren Alpert Medical School at Brown University from Memorial to Kent Hospital has emerged as a key issue, with Gov. Gina Raimondo, Central Falls Mayor James Diossa, Pawtucket Mayor Donald Grebien and Care New England, along with Brown University, all aligned to support the transfer. The decision, though, will be made by the Centers for Medicare and Medicaid Services, which controls the checkbook for medical education in the U.S.
At what point will Neighborhood Health Stations and health equity zones become an integral part of the discussion on the future of health care in Rhode Island? What should come first as a priority: care of the patients or preservation of jobs? Could the current campus of Memorial Hospital be reconfigured as a treatment and recovery center, including housing? How do nurses, who form the backbone of providing wrap-around services for a continuum of care, share in the rewards of accountable care? What are the future plans for Brown Physicians, Inc.?
As with the changing dynamics of the news industry, with continued consolidation of newspapers and broadcasting networks, the role of hospitals at the center of the health care delivery system is rapidly changing. The business model of hospitals does not really work any more, and no matter how much new money gets pumped to sustain the current health care delivery system, it will be unlikely to stop the inevitable financial collapse. Analogies are imperfect, but it is as if all the health care money has been invested in a chain of VCR and DVD movie rental stores, with expensive electronic record systems to track purchases, even as the technology evolves quicker than the old economic model can adapt.
Hospitals, like the state, are not going to fade away. But good health outcomes will be determined not so much by what happens in the doctor’s or nurse’s office, but what happens in the community, where access to safe, affordable housing, a clean environment, a job with livable wages, nutritious, healthy food, quality education and an engaged neighborhood are directly tied to better health outcomes.
It is also a matter of recognizing the power of public health interventions to change health outcomes, such as efforts to ban smoking in public places and holding the tobacco industry accountable.
For Rhode Island, similar to the pattern of residents given directions using places that no longer exist, there is a tendency to celebrate the prowess of its medical community and its hospitals, which are rightly recognized as being world-class. But the illusion of an independent Rhode Island hospital system is just that – an illusion. Yale New Haven owns Westerly Hospital and is in preliminary talks to acquire South County Health; Charter CARE, a for-profit California health system, owns Roger Williams and Fatima hospitals; Prime owns Landmark; and Care New England is seeking to merge with Partners in Boston. Lifespan, the largest health system in Rhode Island, still maintains its independence, but for how long?

PAWTUCKET – It should surprise no one that Care New England wants to transfer Family Medicine and Internal Medicine, two medical residency programs affiliated with Warren Alpert Medical School at Brown University, from the soon-to-be-closed Memorial Hospital to Kent Hospital in Warwick.

The recent joint news release issued on Nov. 21 from Care New England, Gov. Gina Raimondo, Central Falls Mayor James Diossa and Pawtucket Mayor Donald Grebien laid out a unified strategy, with everyone allegedly speaking from the same script. Brown University later chimed in to say they supported the planned move, based upon initial conversations with Care New England.

[Some Rhode Island news media even reported, in response to the news release, as if the transfer was already a done deal, saying that some in the medical community were “breathing a sigh of relief” that Brown medical residents would now have a place to go once Memorial closed.]

But, just to be clear here: the actual decision maker will be the federal Centers for Medicare and Medicaid Services, which controls the checkbook for medical education in the U.S.

As Care New England wrote in its most recent correspondence with the R.I. Department of Health, the final staffing for the medical residency programs "will be dependent on CMS's allocation of slots and the [Accreditation Council for Graduate Medical Education] approval of our programmatic changes."

And, Seema Verma, the new administrator at CMS under the Trump administration, may not prove be a good friend to Rhode Island, given her policy agenda. For instance, Verma recently promoted the policy of giving states authority to impose work requirements on Medicaid recipients, calling the prohibition of such work requirements under the policies of President Barack Obama “soft bigotry.”

For those who want to look on the brighter side of hospital life at Care New England, CMS’s analysis of 2016 Medicare Shared Savings Program data showed that Care New England’s Integra Community Care Network achieved $8.3 million in savings while receiving a 95 percent quality score, according to an Oct. 26 news release. A portion of the savings, some $3.85 million, was to be reinvested back in Integra as well as shared with primary care practices, [although no breakdown was given by Care New England about how the money would be divvied up, when asked by ConvergenceRI.]

Always part of the plan?
The proposed transfer of the residency programs to Kent was always apparently part of future plans, when the sale of Memorial to Prime Healthcare was still on the table and being negotiated, according to several sources.

Now that the deal with Prime has gone south and Care New England is moving to close down Memorial to staunch the flow of red ink, that transfer strategy does not appear to have changed all that much – except to make it part of a broader statewide public policy discussion, with buy-in from state and local elected officials and Brown University.

Despite the altruistic messaging in the news release about meeting community needs, protecting jobs and ensuring high-quality patient care, the bottom line has always been, in large part, about following the money: between the two, three-year residency programs affiliated with Brown that had been located at Memorial, some 25 Brown medical residents a year were supported by medical education funds provided by the Centers for Medicare and Medicaid Services, a steady revenue stream worth more than $7 million annually, according to several sources.

Translated, the legitimate fear is that Brown University and Care New England [and the state of Rhode Island] could lose the steady flow of income – more than $7 million a year – and the jobs, services and benefits that go with it, as well as losing a dedicated pipeline of new medical residents that often opt to pursue their medical careers in Rhode Island.

Public hearing
On Monday evening, Nov. 27, the R.I. Department of Health will hold a public hearing at Lyman B. Goff Middle School from 5 p.m. to 7 p.m. at 974 Newport Ave in Pawtucket.

The purpose of the meeting is to allow the public to provide input on the potential effects of the proposed closing of Memorial Hospital, including plans to close the emergency department and to transfer the primary care services to Kent Hospital’s license. [No doubt there may be some discussion about the recent shootings that occurred near Memorial Hospital and the resulting transfer of patients to Rhode Island Hospital.]

The format will be that residents talk, and health department officials listen, without responding to specific questions about the applications.

The hearing promises to be cathartic in nature, with emotional testimony, similar to what happened during public hearings held in 2016 when Care New England closed down Memorial’s birthing center, helping to move the stages of grief about Memorial’s closing from denial to anger, bargaining and depression toward acceptance.

Slithy toves do the gyre and gimble
With the Governor, two mayors, and a health system executive speaking together in the Nov. 21 news release, there appeared to be a bit of the jabberwocky at play in the messaging, with slithy toves doing the gyre and gimble in the wabe [with apologies to Lewis Carroll].

Witness the statement attributed to Dr. James Fanale, Care New England’s executive vice president, chief operating office, and chief clinical officer, who will become the interim CEO upon Dennis Keefe’s retirement in December.

“Care New England is dedicated to meeting the needs of the population that have historically been served by Memorial Hospital in a way that honors and continues the legacy of this institution, while acknowledging the industry-changing dynamics and future of health care,” Fanale was quoted as saying in the news release.

What does that actually mean? Good question. Here’s a brief attempt to break down a very complex sentence.

In preserving the two medical medical residency programs by moving them to Kent Hospital, Care New England’s rationale, according to Fanale, was this: Care New England is dedicated to meeting the needs of the population that have historically been served by Memorial Hospital. But what are those needs? How have they been determined? What are the unmet needs, by comparison? How do those “needs” match up with the community needs assessment done by the Pawtucket/Central Falls Health Equity Zone? When exactly did those historical needs for a hospital that began operation in 1901 stop being relevant to the community being served? Who speaks for the community?

[There were results from the community health needs assessment conducted by Memorial in 2016, based on data from The Nielson Company, that compared Memorial’s services for traditionally underserved populations to the rest of Rhode Island, which were cited in the eight-page, Nov. 2 memo sent to Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, detailing plans surrounding the closing of Memorial. But the data only provided a snapshot in time, not necessarily a longitudinal analysis of how the community and its needs have changed. Kind of like pointing at a tree and saying, this is a tree.]

Meeting the needs of the population was then further parsed by Fanale’s next modifying clause: …in a way that honors and continues the legacy of this institution, while acknowledging the industry-changing dynamics and future of health care. First, how do you honor the legacy of a closed hospital? What are those industry-changing dynamics? What does Care New England see as the future of health care?

Not to pick on Fanale and his quotation, but hidden inside the verbiage is a disliked fact, a hard truth not often voiced in public: The business model for acute care community hospitals does not work anymore. The future of health care is population health management, as practiced by accountable care entities, with the risk [and hopefully rewards] being spread to providers, with a focus on primary care as a preventive way to keep folks out of hospitals.

To survive in the future health care delivery service “wealth extraction” market, health systems will need to bring in more than $1 billion in revenue a year, according to some health system executives in Rhode Island. That is what the proposed consolidation of Care New England and Partners Healthcare in Boston appears to be all about.

Included in the news release but attributed to no one is a statement that attempts to provide a positive reframe for the changes precipitated by the closing down of Memorial: “It is important to note that [these changes] include the positive shift from volume-based to value-based reimbursement. This simply means ensuring that patients receive the right care at the right time in the right place while reimbursing providers for the quality of care rather than the quantity.”

There is an alternative model, growing up in the shadows of Memorial, the new Neighborhood Health Station facility in Central Falls, owned by Blackstone Valley Community Health Care, with the promise of providing primary care to about 90 percent of the residents in Central Falls. And with that, Blackstone Valley will have a more complete electronic patient record for most of the residents of the city, allowing the health center to identify and reach out to those with health needs.

Translated, while Memorial dies and is mourned, a symptom of the business failure of hospital-based health care delivery, a new model of health is being born in Rhode Island. Combined with health equity zones, neighborhood health stations present a different kind of strategy based upon community needs, not providers’ desires.

But first, there is still some muck in the news release to try and clean up.

More slithy toves
Equally filled with its quota of slithy toves was the statement attributed to Gov. Gina Raimondo: “As soon as Care New England announced it would be closing Pawtucket Memorial [sic – the official name is Memorial Hospital of Rhode Island], I said clearly that no one should lose their job and Care New England could not just walk away from the property,” said Raimondo in the news release.

As expressed in the news release, Raimondo’s list of priorities appears to be: jobs, property, and then patients, in that order.

Raimondo continued: “I am pleased that Care New England will continue to provide primary care services on the Memorial campus to ensure that Pawtucket residents still have access to the care and services they need. I look forward to working with their leadership team to identify a long-term use for the hospital building.”

Amend the priorities list to: jobs, property, patients, then buildings.

Reading the fine print
As much as Care New England is promising to maintain primary care services for patients, the fine print accompanying its Nov. 2 letter to the R.I. Department offered a qualification to that promise. The delivery of primary care services would be done with clinics, “if deemed feasible [emphasis added], located in the outpatient area of the [Memorial] campus,” according to Care New England officials.

The reality is that many of those patients may be transitioned to community health centers, mostly likely Blackstone Valley Community Health Care, which serves Pawtucket and Central Falls.

Again, reading the fine print, among the community health centers mentioned by Care New England in its Nov. 2 memo to Alexander-Scott that are likely to see increased utilization of primary care are: Blackstone Valley, Providence Community Health Centers, and The Providence Center [owned by Care New England.] Thundermist was also mentioned as part of the mix, with its offices in West Warwick, Wakefield and Woonsocket.

The latest iterations of Care New England’s Reverse Certificate of Need application for primary care services at Memorial provide some intriguing new details.

They are contained in a letter that was submitted on Nov. 22 to the R.I. Department of Health and then amended in a hand-delivered, emailed response on Nov. 24, with Care New England’s responses to questions raised by the R.I. Department of Health regarding the Nov. 22 letter.

Under the plan, Internal Medicine, Family Medicine and pediatric services will continue to be provided in Pawtucket by Kent Hospital.

Services will be provided at the current locations for all of these primary care services in the outpatient area of the Memorial campus, although Care New England said that a potential future site is being evaluated.

The provision of clinical services with a community-based primary care focus comes with a caveat: if they are “deemed clinically and financially feasible.”

In addition to the family care and internal medicine services, the intended services will include behavioral health and nutritional counseling and perhaps diabetic counseling.

The planned hours of operation for Internal Medicine, Family Medicine and pediatric clinics will follow a Monday-Friday schedule, from 8:30 p.m. to 5 p.m., with extended hours until 7 p.m. on Wednesdays for Family Medicine.

As for repurposing the current Memorial Hospital facility and surrounding property, the question is: who besides the Governor and Care New England get to participate in the conversation?

Not part of the conversation
Surprisingly, what has not yet become part of the conversation is the development of Neighborhood Health Stations. Rhode Island currently has two now in operation, one in Central Falls, the second in Scituate.

As reported by ConvergenceRI, with the impending demise of Memorial Hospital, one of the largest remaining provider of health care services for residents of Pawtucket and Central Falls is Blackstone Valley Community Health Care, a community health center. [See link below to ConvergenceRI story, “As Memorial Hospital dies, officials appear to be in denial.”]

“My priority is to reassure people that good quality health care is still accessible here in Pawtucket and Central Falls,” said Ray Lavoie, the executive director of Blackstone Valley Community Health Care, as reported by ConvergenceRI in its Oct. 23 edition.

“We’re expanding,” Lavoie continued. “Ours is a community health care system, not a sick care system.”

The manifestation of that approach, Lavoie explained, is the new 47,000-square-foot facility being built at 1000 Broad St. in Central Falls, a Neighborhood Health Station, with the goal of increasing primary care and preventative care. The new facility is scheduled to open in September of 2018.

Prime motivation
Speaking of following the money, the recent decision of the R.I. Health Services Council to approve the transfer the ownership of Landmark Medical Center in Woonsocket and the Rehabilitation Hospital of Rhode Island in North Smithfield from the for-profit Prime Healthcare division to the not-for-profit revealed some of the financial facts in the tangled web of the property transfer.

Prime was fined $1 million for allegedly lying about its illegal transfer of Landmark from its for-profit division to its not-for-profit foundation. [See link below to ConvergenceRI story, “Prime fined $1 million for hiding its transfer of Landmark.”]

The corporate strategy of “donating” for-profit hospitals to Prime’s non-for-profit foundation is a common practice by the California-based health system.

According to the for-profit division’s latest audited financial statements, Prime paid $15.4 million in 2014 to purchase Landmark and its sister facility, Rehabilitation Hospital of Rhode Island, as reported by WPRI’s Ted Nesi.

However, the assets transferred in the switch from for-profit to not-for-profit were valued at some $65 million, as reported by Nesi.

Translated, as a result of the transfer, Prime’s for-profit division apparently received a potential tax write-off worth nearly $50 million.

In that light, the $1 million fine could be seen as the cost of doing business.

A final decision to approve the transfer is still pending, with Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, responsible for making that decision.

A separate decision, whether or not to approve Landmark’s application to establish a Level Three trauma center, is still pending.

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