PROVIDENCE – The big question is: What does health have to do with it?

The proposed move by Brown University and California health system owner of CharterCARE, announced on Thursday, Jan. 11, to acquire and then carve up Care New England, the second largest health system in Rhode Island, appears to be a last-minute attempt to break up the proposed marriage between Care New England and Partners Healthcare in Boston before they can get to altar.

Under the proposal:

• Brown University, or a nonprofit subsidiary of Brown [perhaps Brown Physicians, Inc.] would acquire Women & Infants Hospital of Rhode Island.

• Prospect Medical Holdings, the private, for-profit health system based in California that owns CharterCARE, would acquire Kent Hospital and The Providence Center.

• Either Brown or Prospect Medical Holdings would acquire Butler Hospital, with Brown having the right to decide. [No clear indication was given about how the future development rights for real estate on the Butler campus would be managed.]

• Medical school faculty at Women & Infants, Butler and Kent would be invited to join a Brown faculty group practice [once again, perhaps Brown Physicians, Inc.] or become Brown employees.

• The majority of any operating revenue margins received by Brown would be reinvested in clinical care, medical research and education. [No mention was made about how any losses in revenue would be distributed.]

Care New England immediately put out a statement rejecting the proposal, saying: “Today’s announcement by Prospect Medical Holdings and Brown University represents their intention to acquire and split up the Care New England Health System – a process undertaken of their own independent action and interests,” said Care New England spokesman Jim Beardsworth.

Beardsworth continued: “While we appreciate their interest in the future of health care in Rhode Island, we will move forward with the important process we have set upon in the best interest of both Care New England and those we care for,” saying that Care New England would proceed in its exclusive discussion with Partners Healthcare as set forth in the letter of intent.

The exclusivity of the letter of intent expires on Jan. 31, which means that if there is going to be a deal between Care New England and Partners, it is likely to happen in the next two weeks. What impact, if any, the last-minute proposal by Brown and Prospect Medical Holdings has on the ongoing negotiations remains a wild card.

Questions about the rationale
The rationale behind the move by Brown and CharterCARE, as first detailed in a letter to the community by Brown University President Christina Paxson on Jan. 11 and then in a subsequent media call with Paxson and Prospect Medical Holdings East President Tom Reardon that same day, attempted to portray the move as doing what was best for Rhode Island from an academic, health care and economic perspective.

“We believe that Rhode Islanders should have access to the best medical care in the world without having to leave the state,” Paxson wrote. “They should receive high-quality, affordable healthcare – from primary care to specialty care – from Rhode Island physicians who work at the leading edge of medical discovery. And they should benefit from the job creation, business development and economic growth that accompany a thriving local academic health system.”

Question: How does Paxson’s reasoning square with the underlying problems of size and demographics of Rhode Island? As Dr. Peter Simon, a retired pediatrician who is an associate professor of Epidemiology at the Brown University School of Public Health, asked ConvergenceRI: Is Paxson aware of the relationship between volume and outcomes for complex procedures? Does she know the history of open-heart surgery for infants with complex congenital heart disease in Rhode Island?

According to Simon, in the early 1980s, Rhode Island Hospital invested tens of millions of dollars into its open-heart surgery program. Heart surgeons began to do complex procedures on newborns and infants instead of continuing previous practice of referring these cases to Boston Children’s Hospital.

The outcomes were not good, to say the least, according to Simon, with several cases apparently ending in large judgments against the surgeons and the hospital.

As a result, the R.I. Department of Health took action and required children being seen under the Title V-supported cardiac program to go to Boston, according to Simon. [Title V of the Social Security Act supports Maternal and Child Health Services in every state.] This move reduced the number of surgical cases far below the number needed to get even close to the standard recommended by professional societies, according to Simon.

“If President Paxson is serious about all services being provided to Rhode Island residents without leaving the state, the qualities of outcomes for complex, low-prevalence conditions will suffer,” the pediatrician said.

Currently, many of the patients now receiving cardiac care from Care New England already enjoy the benefits collaborative working relationship with Partners Healthcare facilities in Boston.

Further questions about Brown’s rationale
In her arguments for opposing the merger between Care New England and Partners Healthcare in Boston, Paxson attempted to stoke fears that such a merger would lead to specialty health care shifting to Massachusetts, that the state’s underserved communities would suffer as a result, that it would lead to increased costs and that it would reduce the ability of Rhode Islanders to have a voice in how the state’s health care delivery system works.

Question: Would the proposed move by Brown and Prospect Health undercut the savings and outcomes achieved by Integra, the Care New England system-wide accountable care organization, with its emphasis on the coordination of a continuum of care between primary care providers and specialists?

In October of 2017, the Centers for Medicare and Medicaid Services found that in 2016, Integra had achieved nearly $9 million in Medicare savings and received a patient satisfaction score of 95 percent.

Brown currently appears to have little, if any, experience in creating and/or managing an accountable care organization or an accountable entity, serving different demographic population groups and health plans, and integrating the delivery of primary care with specialty care.

That management experience cannot easily be bought or replicated without some kind of boots-on-the-ground experience. While Prospect Medical Holdings does have experience in managing numerous hospital systems, it is unclear how involved the local CharterCARE division would be with Brown-owned hospitals.

In April of 2017, Care New England received a $3.9 million federal grant from CMS to establish an Accountable Health Community model delivery program, one of only three such awards in New Englandnad 32 nationwide. Under the new program, the accountable entity will screen and connect high-risk Medicaid and Medicare patients with services, including navigators, to help them access resources, addressing issues of health equity and social and health disparities.

Almost by definition, the Brown/Prospect Health proposal, by creating separate fiefdoms, would appear to undo the capabilities to function as a system-wide accountable care organization.

In contrast, the Partners merger appears better positioned to accept and to endorse the current Care New England efforts under accountable care management.

Question: How will the Brown/Prospect Health proposal solve one of the biggest failings of the current health care delivery system in Rhode Island: the lack of a comprehensive statewide health planning mechanism?

One fundamental question is how, moving forward, the current health care delivery system in Rhode Island can reduce the number of inpatient hospital beds or reduce the continuing rise in medical costs.

Questions about economic benefits
In her letter, 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.”

Her rhetorical argument seems to fly in the face of the current reality in Rhode Island, where there is greater recognition that collaboration, rather than competition, between the innovation ecosystems in Boston and Cambridge and Rhode Island can be the source of a much more fruitful economic relationship.

Question: What is the evidence to support such claims? The Wexford Innovation Center has, as one of its anchor tenants, the Cambridge Innovation Center. Semma Therapeutics has invested in significant operations in both Cambridge and Providence. IlluminOss in East Providence just received the first ever de novo marketing OK for an orthopedic medical device. MindImmune, a for-profit drug research development firm, has developed an MOU with the University of Rhode Island to embed itself as part of the university.

In addition, the state is now seeking corporate partners to invest in the creation of two or more innovation campuses in partnership with URI, under a $20 million investment approved by the voters.

The potential merger between Care New England and Partners Healthcare does not appear to preclude or prevent any of the aforementioned developments. Nor does it appear to interfere with the active efforts to secure federal grants for translational research being championed as part of the academic research enterprise as championed by the Warren Alpert Medical School or the School of Public Health at Brown University.

What it does push to the forefront is how Brown University and the Warren Alpert Medical School will redefine itself in the changing, challenging landscape of health care delivery. In 2017, Brown made a strong move in creating its own Brown Physicians, Inc., as a way to preserve its position as a secure home for its academic medical faculty.

Future musical chairs
The evolution of the health care delivery system in Rhode Island is not yet finished. There remains only one acute care community hospital that is unaligned and unaffiliated with a health system: South County Health in Wakefield. However, they are in preliminary talks with Yale New Haven Hospital about a potential partnership.

Underneath the currents of health system acquisitions are two trends in which Rhode Island is a national leader: the establishment of health equity zones and the establishment of neighborhood health stations. So far, neither has been included in the health care delivery system conversations.