PART One

PAWTUCKET – The major highway system running down the spine of Rhode Island, I-95, is changing its exit numbers on July 31.The new directional guideposts for those traveling up and down the Ocean State has attracted its disproportionate fair share of Twitter news distraction.

Which is not surprising, given the avalanche of serious news stories crashing down in our lives – the war in Ukraine, the ongoing hearings about the Jan. 6 coup to overthrow the U.S. government, the health disruptions caused by the Supreme Court ruling overturning Roe v. Wade, the sweltering heat crises around the globe linked to climate threats, and even the appearance of virulent white supremacy leaflets in Rhode Island. Who could ask for anything more?

The actual disruption to the accustomed Rhode Island tradition of giving directions using landmarks that no longer exist should be minimal, it seems.

But, a larger, more important question, not being asked, is this: How is the state dealing with changes within its health care delivery system, changes that promise to reshape the future of medical education and the expansion of primary care in Rhode Island?

On Aug. 1, Dr. Jeffrey Borkan, M.D., Ph.D., chair of Family Medicine at Alpert Medical School at Brown University, is stepping down from his role, after 21 years on the job. [Borkan will continue to see patients, teach residents, and conduct research, while continuing to serve as Assistant Dean for the Primary Care Population Medicine program.]

Borkan will be replaced Dr. Caroline Richardson, who has been serving as the Associate Chair for Research in the Department of Family Medicine at the University of Michigan. Richardson also serves as editor-in-chief of the Annals of Family Medicine.

Borkan has been at the helm of the state’s proving ground for medical education for family medicine and primary care, during a time of great disruption and consolidation within state’s the health care delivery system.

When Borkan arrived in 2001, the Family Medicine Department was, for the most part, self-contained at Memorial Hospital. Today, the Department has evolved into a statewide program, which is ranked No. 14 for primary care by the U.S. News and World Report, a remarkable achievement, given that the program is relatively new – and that its ranking was higher than that of the medical school.

“We are actually known for primary care,” Borkan told ConvergenceRI, in a recent interview conducted at his office on the former Pawtucket campus of Memorial Hospital. “We have this relatively new – you have reported about it in the past – our primary care population health program,” Borkan continued. The program admits 16 students a year at the medical school and they earn a master’s in population medicine and an MD degree, with about 60 percent of the students going into primary care, according to Borkan. “It is a signature program at the medical school, and it also creating a lot of buzz about primary care.”

Here is the ConvergenceRI interview with Dr. Jeffrey Borkan, talking about the ongoing evolution in health care delivery – one that is not being televised – and the challenges facing Rhode Island during a time of extreme financial disruption, consolidation, and health workplace crises.

ConvergenceRI: After all this time, you’re leaving? Why?
BORKAN: I’m not leaving. I’m stepping down as Chair. I announced it last March. And, they have found a great candidate who is taking on the job, starting on Aug. 1 – Dr. Caroline Richardson from the University of Michigan in Ann Arbor. She is a premier researcher and the editor of the leading Family Medicine journal, Annals of Family Medicine.

I will no longer be the chair of the Department, but I will still be serving as the Assistant Dean for the Primary Care Population Medicine program. And, I will continue to teach residents and see patients – and do research.

It seemed more than enough years [for me] to be Chair. The Department is in a good place; the Department has totally changed from what I inherited; it’s a new model, and it’s set up [to prosper] in the future.

ConvergenceRI: You’ve been the chair for how many years?
BORKAN: For 21 years, since 2001.

When I came here, the Family Medicine program was, basically with [a few] exceptions, self-contained at Memorial Hospital. We delivered babies. We helped with surgery. We had inpatient services – in Pediatrics, in Rehab, and in Adult Medicine.

We had an outpatient facility. That’s where we are now. It was built in 1999-2000. And, basically, you could see a panel of patients, you could deliver a baby; you could check on your in-[hospital] patients – and still make it to lunch on time. The cafeteria was very good; it was staffed with trainees from Johnson & Wales University.

But the days of the all-inclusive general hospital, especially one treating the underserved, is long over. And, Memorial, probably beginning about five years after I got here, began to really not be able to afford [to pay for] the new technology and services. For a long time, we had gotten a very good Medicaid rate, then that changed. Between the costs of technology, workforce, and the Medicaid rate change…

ConvergenceRI: When did the Medicaid rate change take place?
BORKAN: I would have to look up the exact year, but it was around 2010 -2011. It caused a $10 million [annual] loss to the hospital, immediately. The hospital’s budget at that time was around $120 million, and we couldn’t sustain that [kind of loss].

You probably know this: 20 percent of rural hospitals today are threatened with closure, and many urban hospitals, particularly those treating the underserved, are really having a difficult time surviving financially.

ConvergenceRI: I remember you getting up, there was a big meeting that was held in Central Falls in 2016, at which you essentially said that the community hospital in a urban setting no longer worked financially. [See link below to ConvergenceRI story, “Life cycle of health care in RI: busy being born, busy living, busy dying.”] This was probably a year or two before Memorial closed. Do you remember the story? I believe it featured a photo of you.
BORKAN: Yes, I do remember that. There were actually two sets of public testimony. One was over closing the obstetrics unit. The other was the closure of the emergency room. I think, at the time, there wasn’t a group that was willing to step in to cover the losses. Care New England tried, unsuccessfully, but the losses were just too big.

The age of the independent – or the age of the general hospital, doing everything, in an urban setting for the underserved, basically had ended. We were [surviving] on the fumes for a great deal of the time.

The hospital had eaten through what had been a nearly $60 to $70 million endowment, and then it ate through all the money that Care New England threw at it.

But, I think that there were multiple factors, including the ones that I mentioned – the technology costs, the personnel costs, the cuts in Medicaid rates. But also I think the community stopped seeing this as their hospital; more and more people went to neighboring hospitals, particularly The Miriam.

And, they couldn’t keep the emergency room open; according to state law, unless they had [a certain number of] inpatient beds. And, the cost of that was prohibitive. I think that there was a good-will effort to try to keep the hospital open, but it wasn’t possible.

ConvergenceRI: What is the model that we are now entering for hospitals, if the concept of a general hospital doesn’t really work anymore? The business model for hospitals doesn’t work any more, [in my opinion].

Part of it is the failure to increase Medicaid rates across the board. Part of it is the workforce crisis, where too much is being asked of people who are getting paid too little. All of this has been exacerbated by COVID. And, the growing dependence on for-profit private equity; hospitals are being bought up.

My questions are: What happens with Family Medicine? What is the role of primary care? And, what needs to happen?
BORKAN: That’s a good question. So, I think I can give an answer, one that is spurred by the fact that we [at Family Medicine] have been around for 40 years. We have trained somewhere between one-half and two-thirds of all the family doctors in the state.

Family doctors are present in state government; they are in the insurance companies, they are at the medical school, they are in all of the physician groups, and they are running hospitals. So, it is a different [concept of] family medicine than when we were just starting the discipline.

[After Memorial closed], what we decided to do was to say: we are going to continue to provide care to the communities in need where we are located – but we are going to be a statewide department. I think three things contributed to that.

One was that there were more family doctors. If you go around to whatever primary care [practice], you are going to meet family doctors who are young, where many of our colleagues in internal medicine and pediatrics, they are “graying” out.

The other part is that there are more places with multiple generations of family doctors. With Memorial closing, we had to find new sites. So, we moved our adult inpatient continuity service to The Miriam, and that has been kind of a love fest – and it turns out it is only two miles away from our Pawtucket training site, where we have been for years.

And, we worked with Kent Hospital, which became our sponsoring institution for our Family Medicine residency. And, 2.5 miles away was a brand new community health center facility that was opening, which was empty; it didn’t have doctors or providers…

ConvergenceRI: Which one was that?
BORKAN: Thundermist West Warwick. So, we did a match making, even before we were officially part of Kent, with Thundermist West Warwick.

We took it under our wing; we helped them to attract more faculty, we helped them to build osteopathic and allopathic certification for their residents. And, then we merged the residency sites together, so that we had a two-site residency, one in southern central Rhode Island, and the other here in Northern Rhode Island. And, we opened up an adult medicine service at Kent.

And then, we couldn’t’ deliver babies here anymore at Memorial, so we created, actually, two-and-a-half services, one at Women & Infants, that has really expanded its service for pregnant women and newborns. We also deliver babies at Kent, and we have a Family Medicine service once again, taking care of pregnant women and newborns.

And, although it is not officially connected to our Department, we have a fellowship program that we now call, instead of Maternal Child Health, we call it Family Medicine Obstetrics [FMOB], at Thundermist Woonsocket and at Landmark Medical Center.

So, we went from having everything in Pawtucket and Central Falls, to still being present, but to having two adult residency services, three OB services, two-to-three newborn services. And, we grew, from having about 150 faculty, to having about 240 faculty that teach medical students, residents, and fellows.

I think it changed our vision, to think of ourselves as a statewide player, working closely with our colleagues in the other primary care fields, and in taking kind of an activist role in everything from the Care Transformation Collaborative-RI to the Physician Advisory Committee at the R.I. Department of Health, and encouraging the multiple generations to get engaged and involved.