WAKEFIELD – With the selection of Aaron Robinson to replace him beginning on April 1, Lou Giancola has begun the process of saying goodbye as the president and CEO of South County Health, which stands as the last unaligned acute care community hospital in Rhode Island, a hard-earned distinction in an era of consolidation and colonization of health systems in the Ocean State.

The mantra of Giancola has been to put community first as an organizing principle for the hospital’s survival, under a vision of neighbors taking care of neighbors, both at the hospital and in the community.

At 73, about to turn 74 in a few weeks, with a career spanning 50 years in health care, 22 of them that have been spent in Rhode Island, Giancola is someone who has earned respect as an elder statesman within Rhode Island’s health care delivery system.

“I’m old,” he said. “I would say I am elderly, but I am not necessarily a statesman.”

At this point in his career, Giancola doesn’t mince words when he looks out on the current landscape of health care delivery. When asked to share his views, he said bluntly: “I would describe it the same way I would describe the U.S. landscape in health care. We have a non-system of care. We have no plan for how health care can and should be delivered in a more efficient and effective way.”

Giancola continued: “We have no strong policy arm, although OHIC has done some positive things. The Rhode Island Foundation is trying to pull some strings together, I mean that in a positive way, to bring some currents together.”

Further, Giancola added: “I think probably we are having less inflation than other places, largely because of OHIC’s policy of limiting hospitals increases to, give or take, around 3 percent.”

And, if hospital payments for both inpatient and outpatient care are now about 40 percent of the health care spend, you have some control over inflation, Giancola said.

“I haven’t seen the exact figures for Rhode Island, but that is generally the percentage of hospital payments, as a percent of total dollars spent on health care,” he said.

Despite those numbers, Giancola continued, “We seem to be seeing increases in insurance premiums that don’t reflect the lack of underlying inflation in health care prices.”

According to Giancola, there are only a few explanations for that. “One is greater utilization, and the other, I guess is greater administrative costs. That’s a question that needs to be answered.”

In the weeds on health care policy
As a health system executive, Giancola pays great attention to number crunching. When it comes to understanding what is driving health care costs, he has a number of potential working theories.

One theory, he explained, is that we have gotten many more people insured, and that’s driving costs up because of greater utilization. “But I have no evidence of that,” he said.

South County Health is a member of the accountable care organization, Integra, operated in partnership with Care New England. Through the accountable entity concept, Giancola said, “We’re going to see what the per capita costs are for people that are newly insured, because they will be coming under [the auspices] of the accountable entities.”

One of the things that has proven instructive for Giancola has been South County’s experience as part of Integra. “It’s only Blue Cross & Blue Shield of Rhode Island commercial, Blue Cross & Blue Shield of Rhode Island Medicare Advantage, and traditional Medicare,” he said. “But, you can see where we’ve made progress, and where it has been difficult to control utilization.”

Giancola offered some specifics: Emergency department utilization was not under control, despite the fact, that in South County’s case, they’ve seen year over year declines.

“There are modest declines in emergency visits, but we’ve seen a growth in express care,” he said. “From an insurer’s perspective, that’s less expensive.”

Giancola added the caveat: We’re so small, you can’t extrapolate that to the larger state situation.

Weighing in on a national health plan
On the morning of the interview with Giancola in his office, ConvergenceRI had published an exclusive op-ed by Sen. Sheldon Whitehouse, explaining his support for the Medicare For All Act in the Senate.

Giancola had not yet read the piece, but he found it interesting that Whitehouse wrote about Medicare For All. “Did he talk about the fear of the providers?”

The reason he asked, Giancola explained, is that many health providers have come out against it, because Medicare now pays 80-90 percent on the dollar. “The fear is that they’ll extend that pricing to everyone through Medicare,” he said. “I think it is an irrational fear, because they put everyone out of business if they did that.”

From Giancola’s perspective, “I’m waiting for someone to talk about that, because pricing would have to reflect an amalgamation of the current commercial pricing and the pricing for Medicare.”

Maybe, Giancola continued, behind that sort of fear is concern that the government would control pricing and that we would suffer under that. Still, Giancola welcomed the beginning of the conversation.

One of the problems, Giancola said, is that the national debate around health care now is not about the facts; it’s about ideology. “We need to be able to talk about the issues,” he said.

A community voice
Giancola admitted that he was of two minds when discussing the future business model for hospitals, and where to draw the line between parochialism and community control.

“I don’t think we need to have one of everything in Rhode Island,” he said. “And, I don’t think it’s a disaster if you had to go to Boston for some kinds of care. I don’t know where that line is.”

Giancola continued: “I am not impressed that large systems have produced economies of scale. Some of the studies suggest that savings are about 2.5 percent. It’s nothing to sneeze at, but it is not the be-all and end-all.”

Giancola voiced a belief about the importance of care being local. “I’m not taking a position on Partners that their owning Care New England will lead to economies of scale, that some studies have suggested.”

His experience at South County, Giancola continued, “leads me to believe that you have to be really careful about not undermining community health and local decision-making around priorities.”

Giancola said he also worried about the impact of large organizations where the priorities start at the top and get pushed down, as opposed to small organizations, where you have community members making policy.

“If I do something stupid, people are going to write editorials in the local newspaper, or they are going to be in my office, or they’re going to email me, because we have that kind of connection.”

He continued: “I wouldn’t want to ignore them, but I can’t. It’s my job.”

It sounded as if Giancola was going to miss his job as much as people in the community were going to miss him in that job.