Delivery of Care

What will the future of health care in RI look like?

A one-on-one interview with Dr. James Fanale, president and CEO of Care New England, on the cusp of a potential “partnership” with Partners Healthcare

Photo by Richard Asinof

Dr. James Fanale, the president and CEO of Care New England, in his office, in front of a painting by his daughter.

Photo by Richard Asinof

Center, Dr. Jim Fanale, president and CEO of Care New England, sitting next to Dr. Tim Babineau, president of and CEO of Lifespan. Immediately to Fanale's left, Teresa Paiva Weed, president of the Hospital Association of Rhode Island.

By Richard Asinof
Posted 5/13/19
A one-on-one interview with Dr. James Fanale, the president and CEO of Care New England, offers insights into his perspective why the proposed merger with Partners Healthcare will improve the delivery of care in Rhode Island.
Why is it that so many Rhode Islanders refuse to recognize that when it comes to health care systems, the state has already been colonized by large, out-of-state enterprises? Do reporters and elected officials need to attend classes to better understand the concepts of health equity zones, accountable entities, accountable care organizations, population health management and neighborhood health stations? Will the Senate take up the call to request an audit of all privatized Medicaid programs in Rhode Island? Will others attempt to replicate the new Emergency Room pod at Kent Hospital to serve elderly patients? How much money on advertising has Lifespan spent on its effort to attack the proposed deal between Partners Healthcare and Care New England?
All health care is personal; all health care is complex, all health care revolves around our own personal stories of family, work, and relationships. The relationship between the care provider – the doctor, the nurse, and the counselor – with the patient remains the crucible upon which health flows. When it becomes broken, when the trust becomes violated, when the patient has no voice or little voice in the decision-making, the entire system breaks down. There can be strong resistance encountered when trying to correct an inaccurate medical record, when the doctor makes a mistake.
Saying no to a doctor, telling the doctor that a test is unnecessary, carries with it the risk of reprisal by the doctor. Finding a new primary care physician and scheduling an appointment can take months. Listening to the patient, allowing the patients’ voices to be heard, may require a new kind of medical school education protocol. Navigating the system is difficult for a patient, even if one is knowledgeable about health care.
There is a reason why concierge practices are springing up all around the country as well as in Rhode Island, because the patient can find someone who will be his or her advocate, not an adversary.

PROVIDENCE – The war of the words launched by Lifespan against the proposed merger of Care New England with Partners Healthcare in Boston, replete with its big spend on radio and TV ads in an attempt to derail the deal, and the response by Care New England to counter Lifespan’s massive public relations with its own website and messaging campaign, has done little to illuminate the actual changes occurring in the health care landscape in Rhode Island.

What it has done, in many ways, is to reveal the dramatic inadequacies – the unmet needs for in-depth reporting – caused by the slipshod manner in which most news media in Rhode Island cover the delivery of health care services.

As part of its media blitz, Lifespan has purported to want to create a triumvirate of health care enterprises revolving around itself, Care New England and Brown University, as a kind of made-in-Rhode-Island dream team.

Such a wishful vision, along with the dire warning attached by Lifespan that the consequences of allowing the partnership with Care New England and Brigham & Women’s Hospital to move forward would be “devastating” to Rhode Island, defies common sense, the reality of the current health care map, and recent history.

For the last decade, numerous attempts have been made to “arrange a marriage” between Care New England and Lifespan, without any success, for critical reasons. While the doctors, nurses and staff workers within the two hospital systems have always played well in the sandbox together, the same cannot be said of the administrators. Call it a bad romance.

As recently as two years ago, Lifespan was attempting to build its own birthing facility on its Providence campus to compete with Women & Infants Hospital, the flagship hospital of Care New England, a mere couple of hundred yards away, saying that such a birthing facility would “complete” Lifespan’s vision of itself as a health care delivery enterprise.

Are we not colonized?
The fact is that, however much disliked, the Rhode Island health care delivery system [some would argue that it is not a system, but a market] has already been colonized by large, out-of-state health systems, in an era of consolidation and population health management.

In southern Rhode Island, Yale New Haven, which owns Westerly Hospital, is the dominant force. South County Health, the last unaligned acute care community hospital in the state, may soon succumb to the financial pressure to join the Yale New Haven network.

In northern Rhode Island, Landmark Medical Center in Woonsocket is firmly within the hands of the Prime Healthcare network, based in California.

CharterCARE, which operates Roger Williams Medical Center and Our Lady of Fatima Hospital, is a division of the for-profit Prospect Medical Holdings in California. [At one point, CharterCARE was floated as an alternative purchaser of Care New England by Brown University.]

No one, including Lifespan, cried “devastation” when these acquisitions occurred.

One-on-one with Fanale
That preamble provides the context for the one-on-one interview that ConvergenceRi conducted recently with Dr. James Fanale, the president and CEO of Care New England, in his offices.

[For the record, ConvergenceRI would be delighted to interview Dr. Tim Babineau, the president and CEO of Lifespan, if and when the communications folks at Lifespan would be willing to permit it.]

The conversation began with a reminiscence that the last time ConvergenceRI had seen Dr. Fanale in person was three months ago, at the Wednesday, Feb. 6, gathering at the Brown University School of Public Health, where an array of Rhode Island leaders from government, health insurers and health systems came together to announce a voluntary 3.2 percent annual cap on the growth of health care costs in Rhode Island. [See link below to story, “Annual cap of 3.2 percent put on health care costs in RI.”]

At the event, which included Gov. Gina Raimondo signing an executive order in support of the voluntary cap on spending, Dr. Fanale had sat next to Dr. Babineau in the audience, where they appeared to chat amicably. [See second image above.] In the group photo at the event, they stood adjacent to each other.

However, the recent attack by Lifespan on the proposed partnership with Brigham & Women’s Hospital, a division of Partners Healthcare, has apparently altered the personal relationship between the two CEOs..

“I think it would be fair to say, when things like this occur, relationships become a little more challenged,” Dr. Fanale said, in response to a question by ConvergenceRI.

Lost in translation as a result of the dispute, and mostly unreported by the news media in Rhode Island, are the efforts being undertaken by Care New England to develop a new approach to its care for its oldest, sickest patients at Kent Hospital, including a dedicated Acute Care for the Elderly inpatient unit, with 12 beds, which was launched in February, and a soon-to-be-launched ED unit to care for elderly patients, the first of its kind in Rhode Island.

[The need for such an ED unit was exposed in a recent article in ConvergenceRI about a 92-year-old woman who spent seven hours in the emergency room at Rhode Island Hospital, only to receive a band-aid for her cut. See link below to story, “If it takes a village, what happens when the village is too small.”]

“At Kent, we’ve just opened the first Acute Care for the Elderly [ACE] unit,” Dr. Fanale said. “We have a 12-bed unit that is dedicated to sickest of old folks. We are marching vigorously down the age-friendly campaign, starting at Kent, because that is where the highest proportion of older folks are.”

Dr. Fanale continued: “We’re beginning to work with the ER to make it age-friendly. We hope to be able to develop a pod in the ED, focused on just older folks who come into the emergency room. It’s the demographic that’s growing; it’s also the people we need to do a better job taking care of.”

Dr. Fanale shied away from describing the new developments as “innovative,” explaining that such work had been the focus of much of his clinical life, and it was something that, as he put it, “We should have been doing for the last 10 or 20 years.”

Exactly when the new pod at the ED will open is unclear, Dr. Fanale said, saying that they were working through the details. What he could share was the results to date from the new inpatient ACE unit, which treats the frailest of older patients. “It’s full, there are less falls, the length of stay is lower, and the outcomes are better.”

Financially, it has worked well, Dr. Fanale continued. “This is a different model of care; in medicine and hospital work, we’ve got to look at different models of care to decrease the costs of care. We’ve done it with this unit. It’s exciting. It’s invigorating. And, we need to take that to the ED.”

Here is the ConvergenceRI interview with Dr. James Fanale, president and CEO of Care New England, on the cusp of the potential partnership with Brigham & Women’s Hospital, a division of Partners Healthcare in Boston, talking about the changing business model for delivering health care in Rhode Island. Jim Beardsworth, Care New England’s communications director, sat in on the interview.

ConvergenceRI: Some observers have said that the media campaign by Lifespan to attack the pending deal between Care New England and Partners Healthcare has a tone of “desperation” about it. Do you think that is an accurate description?
I can’t answer what they are thinking, Richard. You know that.

I think that they have their reasons for doing things. But what exactly is their theory, their goal, their thoughts on this, I couldn’t say.

They say that it is meant to inform; I just think [it is] meant to inform – with lots of ads and lots of radio advertisements.

ConvergenceRI: How do you counter Lifespan’s message of foreboding, that the future will be terrible if this happens?
Obviously, we don’t feel the future is terrible for Rhode Island. We have remained steadfast that we are following our goals to make sure that we that we can take better care of our patients. This transaction really helps us do that.

We are under-capitalized. We have a unique group of staff members who really do a great job of taking care of patients. We need to expand our ability to do a better job. And that’s what this is all about. We’ve gotten through some tough times.

We will continue to perform. But, we really want to be able to do a better job, and we need a strong partner in terms of quality services and capital.

And, the one [phrase] that I think is probably mischaracterized is: this [will be] “devastating” to Rhode Island.

I believe it is exactly the opposite. It’s exciting for Rhode Island [to be] affiliating, partnering with one of the most accomplished health care systems in the world.

When you look at potential partners – with a small “p” – you look at whether they are financially stable, check the box; are they high quality, check the box; are they world-class, check the box. Having them come down to work with us, I don’t see how that could ever be characterized as “devastating.”

BEARDSWORTH: Richard, we’ve been doing it for almost 10 years.

We’ve been working through Kent and the Brigham for 10 years [with our angioplasty program].

ConvergenceRI: Who is the target audience for what Lifespan is doing? Do they have a particular audience for whom they are trying to sway public opinion? Is it a targeted audience at the State House?
You’d have to talk to them.

ConvergenceRI: One of the interesting changes in the equation has been the role of President Christina Paxson at Brown University, who has moved from being a doubter, initially, toward a full-throated endorsement of Partners coming into the market and really cementing the relationship around academic research moving forward.
A couple of things. One is that we’ve always had a terrific working relationship with Brown. Our board has always said that Brown works right alongside us, and we would never walk away from Brown. I think we were able to reassure Brown and President Paxson and Dean [Jack] Elias that we were all in, in a relationship with them.

We have begun to work on an academic research infrastructure together, which has sort of stalled a little bit as we go through the transaction.

But, we’ve always believed that we could strengthen our teaching programs and research programs through Brown as a partner.

ConvergenceRI: Can you talk a bit about that research infrastructure? I did an interview with Dr. Jim Padbury about a year ago, where he talked about his work and what he was doing, and his sense that we needed to think differently about what our relationship was with the Boston research ecosystem, and the role that Rhode Island could play as a partner, once again, with a small “p,” rather than believing that the world ended when the 401 area code ended. [See link below to ConvergenceRI story, “RI as a scalable research lab in a regional universe.”]
FANALE: I think on the research side, I think it’s always been our interest to expand our research programs. As we reviewed our research support, at CNE, we know we are not providing the support that is necessary to expand our portfolio, if you will.

So we spent some time, even prior to my tenure, working with Brown, to see how do we assess the academic [research] infrastructure, and how do we do it together better.

With the Partners/Brighams arrangement, they are obviously doing a lot of research, the Mass General and the Brigham are the two highest funded NIH organizations in the country. They bring in about $700 million a year in NIH grant funding.

So we have asked: How do the Brigham, Care New England and Brown come together to do it in the most efficient manner?

We think that Brown is integral to that, and we think that by working together, we can advance both of our positions, and I think we see things in the same light.

ConvergenceRI: Perhaps one of the “understated” gems of Care New England is the nurse midwife program, which is one of the national leaders, they have strong relationship with Brown, they train all the residents in deliveries…
They participate in the training of the residents. The way you said, it sounded like they trained the residents; they participate in the training of the residents.

ConvergenceRI: What they provide is a very different approach than many other hospitals. It’s that type of excellence, if that’s the right word, I don’t want to oversell it, that often gets lost in the conversation when you look at the things that Care New England does extraordinarily well. How does that plays out in your messaging?
In true Belichick-ian fashion [Bill Belichick the head coach of the New England Patriots], I would say that they are one of many members of the team that do lots of good stuff here.

I mean, there are profoundly positive programs that are nationally [recognized], at Butler at Kent, at Women & Infants, with Integra.

At Integra, we have the highest performing ACO in the state.

But, getting back to the midwife program, yes, it’s a national model. I don’t think it’s affected by this deal.

ConvergenceRI: Some people have expressed worries, however unfounded, that people are going to deliver their babies in Boston.
Does that make any sense? No. It never did.

ConvergenceRI: I’m asking you to tell me why it doesn’t make any sense.
I don’t even think I have to answer that.

ConvergenceRI: OK
So, 8,000 women are going to go to Boston to get delivered. Really? How long have you been living in this state?

ConvergenceRI: About 30 years.
Women are going to drive 50 miles to deliver kids?

ConvergenceRI: I’ve never thought that it was a realistic argument.
I agree. It’s hard to even grace the question with an answer. Because it’s absurd to think that everyone is going to go to Boston for their health care. That’s ridiculous. We’ve never done it. We haven’t transferred more people to Boston. It’s been the same forever.

Here’s the kernel of truth, and people need to understand and believe this: We take care of patients and we do the right thing for every patient. And that doesn’t include sending them all to Boston.

We have to keep our patients local, so we [improve] financially and quality wise our own bottom line.

We’re not sending patients away. Sending all the women to Boston to get delivered makes no sense.

We have a larger OB program; we have a larger NICU program, than the Brigham. We do about 2,000 more deliveries. Our NICU is 30 percent bigger.

I don’t see anything changing across Care New England as part of the transaction. I just think we will get stronger and it will expand our ability to take care of folks.

ConvergenceRI: Can you talk about the growth of Integra?
Integra is all about delivering better-coordinated care for patients. And, if you do that well, costs go down.

Our program is based on a very strong base of primary care practices, with primary care being the center of the universe in terms of Integra. Coupled with a strong behavioral health partner, we can take better care of people.

Through multiple programs of complex care management and behavioral health integration, we have demonstrated that we can reduce the cost of care for Medicare patients, commercial [insurance] patients, Medicaid patients, while at the same time improving quality.

Financially, we had the highest performing ACO in the state. We have risk contracts, which heretofore, no one would go at-risk; sometimes it is scary.

It’s really about the whole interdependence of taking better care of people; it doesn’t mean that you all need to get admitted, or that you all need to get every test in the world.

It’s, let’s be efficient, follow guidelines, coordinate, collaborate with the hospitals, collaborate with the specialists, collaborate with primary care providers, and collaborate with a tertiary partner.

So, if you keep communication going, you take care of people better and reduce redundancy.

ConvergenceRI: How data driven is all this work?
I think data drives everything we do.

Data drives all the programs at Integra. Data drives our business decisions at Care New England.

They drive our quality programs; they drive our protocols.

We’re about to look at the “care path” at Women & Infants and at Kent, and go to the evidence and use the evidence to say: this is what the [best] care path is.

We’ll be able to look at the variability in the delivery of care from provider to provider. So, if we’re not performing, we can dig down and say, [for example], “Hey, look at this, the treatment variability is very wide on the treatment of sepsis.”

If we reduce the variability, we improve safety. And we reduce costs. So, data drives everything that we do. And, our data systems are pretty good.

We have systems now [in place] that can get down to the provider level to see how they are providing care, and work them to modulate that if it is required.

ConvergenceRI: How about interoperability? There are still parts of your system that are on Cerner, rather than Epic. With Partners coming in, will that shift be made entirely to Epic?
Our IT infrastructure is complex. We have Cerner as the inpatient backbone, we have Epic as the ambulatory backbone, and we have lots of other stuff.

The goal, obviously, is to get it to one platform, which really decreases all the other steps in terms of IT interoperability. But it takes a lot of work and it takes capital, because it’s not cheap. That is in the planning and discussion stages now, asking: How do we afford to do it, and when can we do it?

ConvergenceRI: One of the questions about rising costs has been about utilization. And it has always struck me that that some questions don’t get asked about utilization. One is: is more utilization a good thing when it comes to better preventive care, if you are getting people seen on a more regular basis?
I think, on a global perspective, more is usually never better, except, for prenatal care and those things. I’m firm believer in that you follow the guidelines.

There was one proponent, regionally, that said, we need to have annual physicals for everybody, every year.

No. All the guidelines say: you don’t need to have a 25-year-old person to get a physical every year. The yield is minimal.

The utilization rates in this region are pretty high. We’ve been successful, as has Coastal Medical, in reducing the Medicare inpatient utilization significantly. And it is sustained, and that’s one of the reasons why we have been successful.

We’ve been able to reduce the use of skilled nursing facility beds. We probably reduced that by a third since we started.

Quality has improved. You have got to do the right thing, at the right time, for the right person.

Doing more testing when the evidence says it doesn’t have any yield, really doesn’t work.

The “Choosing Wisely” program, which the RI Business Group on Health proposes, we’re a piece of that now, we’ve signed on to that, if you look at those guidelines, there are a lot of things we do every day that we should stop doing.

ConvergenceRI: As a patient, it is sometimes difficult to tell a doctor no. And if you say no, that test is not necessary, the doctor often does not respond very well to a challenge to his or her authority.
That’s on the doctor.

ConvergenceRI: But the patient suffers the consequences.
Then the patient needs to come to one of our doctors.

That’s why we need to shift the curve to a value-based equation.

A physician has a machine in their office to do a certain whatever. There’s a problem with that, because if you’ve got [that machine], you might want to use it.

I’m not saying, categorically, that’s a bad thing. But, if you look at EKGs, I will tell you that the vast majority of EKGs we do in offices are totally useless.

Not to try and state something that’s controversial, but if you go to your primary care physician, and every year they do an EKG, there’s no indication for that. Look at the guidelines.

There’s no indication for it. If you go to your cardiologist twice a year, which you should wonder why you’re going twice a year, they might do an EKG every time you walk in. Why?

There’s no need for it. What I’m saying is: challenging and having a dialogue with physicians to talk about what you need and what you don’t need, I think we should have [that conversation].

ConvergenceRI: Moving forward, do you have a message that you’d like to communicate about what the potential is for Care New England, if and when the merger is completed?
The message has been the same all along, Richard. It will allow us to take care of patients better.

And, I mean that sincerely; it will allow us to do better care for patients, that’s what our staff is dedicated to, that is what our providers are dedicated to, that is what management is dedicated to.

How does this transaction help [us] do that?

Our quality of service and access platform gets up-ticked, by adopting some of the protocols and programs that the Brigham has in place, number one. Day one, go.

Number two: we’re looking to expand the programs and services that we are able to provide our patients at Kent, Butler, VNA, and Women & Infants.

Number three: The access to capital; we have been poorly capitalized for a decade or two. [This partnership] allows us access to capital to begin to fix our buildings.

People talk about how much? A lot is needed to get us to where we need to be. It is going to take us 10 years to get there. But have to start on that path.

ConvergenceRI: What are the types of innovations that you see moving, forward, beyond the ACO, looking at the business model for hospitals?
[Following a discussion of the new ACE unit at Kent and the plans to introduce a pod at the emergency room there, catering to the older patients]

When we first started to propose this [age-friendly] work, Dr. Ana Fulton, the chief of geriatrics at Care New England, and I, we knew we had naysayers, [who would say to us]: “Those people will stay in the hospital too long, we will lose money on them.” And, we said: “If we take better care of them, the outcomes will be better, the length of stay will go down.” It’s a different model. The outcomes will be better and the costs [will be reduced].

Because we have the expertise, we have built up geriatric services at Care New England. We have four-plus physicians, four nurse practitioners; it’s a huge team. We work at Butler, we work at Kent; we work at Women & Infants, taking care of the older folks, focusing on the sickest of the sick.

The “innovative” stuff will be part of the relationship with Partners – or really, the commercialization of some of the research we do. Partners has done exceedingly well with their commercialization efforts, with some 200-plus spin-off companies [based upon] the good work their research is doing.

That is something we will be able to lock into as part of this deal.

ConvergenceRI: Another big demand that is out there in Rhode Island is the increasing number of unmet needs for people with mental health and behavioral health issues. What are the kinds of programs that you would like to see addressing such increasing demand for services?
It’s all about access. If you look at child mental health issues and the availability of resources and people to deliver that care, it is challenging, especially given the fact that, in this state, 35-to-40 percent of the kids are covered by Medicaid.

Where do you find a Medicaid child provider [for mental health and behavioral health issues]? Now, we do that work. We do that work because we take care of everybody at the Providence Center and Butler Hospital.

But we have to figure out how to do a better job in terms of access.

We have certainly [begun] to have done it with substance abuse, in terms of some of centers of excellence and having our staffing at emergency rooms trying to get people into therapy early.

It’s really about the prevalence of behavioral health needs that are rising, and how do we provide better access to those services. Again, you have to provide access to all.

Even among our employees, it’s one of the biggest drivers of cost. How do we make sure we provide access to them for what they need?

ConvergenceRI: What do you see as the importance of the effort now underway with Health Equity Zones in Rhode Island, in order to develop a community-based approach to achieve better health outcomes?
It is all helpful. All of these things are different – I’m not an expert on this. But all these initiatives are meant to deliver better local care for the community, and I think they all have their strong points, and interoperability points that are challenging.


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