Delivery of Care

Investing in Family Medicine

Dr. Jeffrey Borkan, outgoing chair of the Family Medicine Department at Brown's med school, talks about the challenges revolving around gaps in care

Photo by Richard Asinof/File photo

Dr. Jeff Borkan, chair of the Family Medicine Department at the Alpert Medical School at Brown, addresses a public hearing regarding plans whether or not to continue a maternity program at Memorial Hospital in 2016.

By Richard Asinof
Posted 7/18/22
In PART Two of his interview, Dr. Jeffrey Borkan, the outgoing chair of the Family Medicine Department at the Alpert Medical School at Brown, talks about the disincentives to creating better systems of health care.
How do the concepts of health equity zones fit into the concept of medical education programs around primary care? Was there too much investment in private business consultants during the COVID epidemic rather than direct investments for front-line care delivery? What is the schedule for the construction for the new state laboratory? What kind of research opportunities are there to study the impacts of Long COVID on schoolchildren in Rhode Island? How much would need to be invested to recruit psychiatrists to set up new practices in Rhode Island?
The world, as the over-used nugget goes, is divided into parents and non-parents. The recent birth of a child to the WPRI’s reporting couple, Ted Nesi and Kim Kalunian, brought with it a new-found reporting interest in the differences in costs of giving birth at Women & Infants Hospital, from commercial insurance compared to Medicaid insurance rates under managed care, and the low reimbursement rates that the hospital has been receiving.
In Dr. Borkan’s tale of what happened that caused financial distress at Memorial, it was the slashing of Medicaid rates beginning in 2010 that resulted in losses of $10 million a year. Despite the alleged “Reinvention of Medicaid” initiative, the state’s failure to increase Medicaid rates for providers has had a dismal impact on the entire health care infrastructure in Rhode Island – from nursing homes to Early Intervention, from community mental health providers to community recovery workers.
It is also a key point in efforts now underway by community health care activists to ensure that women who are receiving Medicaid have access to health coverage to pay for abortions, if necessary.
For those who are conducting polling in advance of the September primaries, it would be fascinating to see if there is a way to tease out how prospective voters who are receiving Medicaid – currently more than one-third of the state – are prioritizing the issues most motivating for them when they go to the ballot box.

Editor’s Note: In PART One, the first part of an in-depth interview with Dr. Jeffrey Borkan, the outgoing Chair of the Family Medicine Department at the Alpert Medical School, the conversation told the story about the evolution of the Family Medicine Department into a statewide program in Rhode Island, during a time of great disruption, when Memorial Hospital had been forced to close.

In PART Two, Borkan discusses the future challenges facing the systems of delivery of health care in Rhode Island, as the health care industry shifts away from the concept of “hospitals” to population health, as health care becomes more ambulatory and community engagement changes the metrics.

PART Two

PAWTUCKET – Call it an economic soap opera of musical chairs. In the midst of Memorial Hospital’s continuing financial difficulties, which began in the mid 2000s and escalated in 2010, following severe cuts in Medicaid rates by the state, which resulted in an immediate $10 million loss annually, it forced the acute care community hospital to seek out potential buyers.

In 2013, Care New England purchased the financially strapped hospital, but was unable to turn things around. In turn, Care New England sought to reach an agreement with Partners [now Mass General Brigham] in Boston to buy out Care New England. As an apparent condition of that acquisition, Care New England was tasked with finding a buyer for Memorial. In 2017, Prime Healthcare, which had recently purchased Landmark Medical Center in Woonsocket after a prolonged six years in receivership, had reached a tentative agreement with Care New England to buy Memorial. But then that deal fell through.

For Borkan, the purchase by Prime Healthcare of Memorial represented what he called an existential threat, one that he feared might result in the Family Medicine program disappearing.

BORKAN: We got pretty close to disappearing when Memorial was nearly sold to Prime [in 2017], it was looking like an existential crisis. But I think being under the auspices of Care New England, for all the critiques one could say to them, they have actually been very supportive of Family Medicine.

Lifespan has been, in some ways, less supportive of primary care, but their recent acquisition of Coastal Medical is important, and they have welcomed us into their hospitals’ [system].

At this point, one of the “proof of pudding” is that we graduated 16 residents just five weeks ago, and of those residents, seven are staying in Rhode Island.

Which is almost unheard of, to have so many residents stay. And, many stayed the year before and the year before and the year before that, so we are keeping our most precious “commodity” – our residents and fellows – in the state.

And, that’s been gratifying. And, it makes a huge difference, because they are smart, they are capable, and they are full of energy,

I thought that I would step down, both because I have been doing it for so long, and it was time to bring in some new blood. Also, I was expecting there would be the Lifespan-Care New England merger, and I thought the new chairperson could step right into that.

We are one of those departments that span the entire health care system – and then some.

ConvergenceRI: The merger did not go through, I think Attorney General Neronha laid out some convincing reasons why it shouldn’t go through. [See ConvergenceRI story, “Getting to no.”]

I think the [rejection of the deal] caught some people by surprise, simply because most of the power brokers were behind it.

But it brings up my next question: How do you define “family medicine” moving forward? You talked about a new model. I was curious about what that model would look like – in a disrupted environment?

BORKAN: Well, I was in favor of the merger. I think that it was shortsighted by the Attorney General. Now what?

I think for Family Medicine, because our threats are somewhat different, we were some of the unsung heroes of the COVID crisis in providing care, from testing to immunizations, from triage to hospitalizations and respiratory tents, I think we showed our flexibility, which has always been there – but now it’s being seen more on a statewide level.

I think we will work with whatever organization comes in. I think the threats to us are: What happens to our training spots? What happens to the money that is needed to open more primary care facilities? You know, Rhode Island is ranked Number Four in the percentage of physicians that are primary care doctors. But we have a “doctor gap”: it’s hard to get an appointment with a good primary care doctor in the state.

As people retire or leave the field, irrespective of which [kind of practice] – internal medicine, pediatrics, or family medicine, it puts more pressure on those who stay.

Salaries are still inadequate, compared to specialists. I did an analysis where I found there are about 700 graduate medical education training “slots” in Rhode Island, and less than 100 of those produce primary care doctors.

We have a health care training enterprise that predominantly trains specialists and sub-specialists, rather than primary care doctors. We need more primary care doctors. We need other things, too. We need psychiatrists, and more general surgeons, and we are not doing that.

Whatever group comes in, will they support training? Will they support [primary care] practices? Will they make up some of the salary gaps that are present in Rhode Island, between primary care and specialty care? And then, there is the issue of what happens with team-based care?

We now train a lot of NPs [nurse practitioners] and PAs [physician assistants] in Rhode Island – but they mostly go into specialty care. They are following the money, too. But that becomes part of the question, as it becomes harder and harder to find primary care doctors, to hire predominately PAs and NPs.

And, we welcome PAs and NPs as partners. However, we favor that they should have residencies and training periods, and that there be a reasonable ratio between the number of advanced practitioners and NPs and primary care doctors.

And, I think that will depend on the systems and the availability of people to hire.

ConvergenceRI: How have things changed, since you first arrived here in 2001?
BORKAN: When I got here, most of the health centers were, for example, the federally qualified health centers, they were using a model of hiring a pediatrician, an internist and an OB.

Now, they have all pretty much moved over to the family medicine model, where all you need to do is hire a family doctor, and maybe have some consultants. So, instead of hiring three doctors to take care of a family, you only need to hire one. And, that’s their [current] economical model and, in terms of workforce, it’s easier to find family doctors than it is find obstetricians, pediatricians and general internists.

ConvergenceRI: On a broader scale, what are the investments that need to be made? One of the things that many who were proponents of the merger between Care New England and Lifespan said was that there needed to be an infusion of capital to support the consolidation, to make it sustainable. Brown said that they were willing to put in $125 million. I had always heard, in private conversations, that it would take double that amount – some $250 million – to sustain the enterprise. And, it wasn’t clear if that money would be going to support the training, recruitment and retention of the workforce, including primary care practitioners as well as nurses.
BORKAN: In Rhode Island, we have a problem with insufficient numbers of primary care doctors, psychiatrists, general surgeons and neurologists. They are all the specialties that are not procedurally based. And, that are required if we are going to have a functional health care system.

People need to stop thinking about hospitals and think [instead] about health systems.

What had been happening during the last 50 years is certainly, in terms of the medical population, fewer hospitalizations per member per year, and a greater number of ambulatory needs.

Health care is becoming much more ambulatory. That is part of the reason why we started the longitudinal integrated clerkships for third-year medical students at Brown.

And, as care becomes more ambulatory, with less conditions requiring hospitalization, when people look at the health care system and what the capital needs are, they often just think, “Well, we need to replace the labor and delivery wards at Women and Infants,” or, “We need to add another building at The Miriam,” because it’s the hospitals which are super sensitive about additions, remodeling, and renovations. But I think that there has to be a broader vision, asking: “What does the health care system require to function?”

A lot of that future is going to be ambulatory. So, where are the gaps in primary care? Where are there gaps in the general care of patients and populations that are required?

It is an embarrassment that you can’t find a psychiatrist in Rhode Island. Shouldn’t we fix that if we are going to have a functional health care system?

Part of that involves the redistribution of funds. Why are certain specialties – I always use the example of pediatric oncology and orthopedics – paid differently. One is lowest paid in medicine; the other is just about the highest paid, and they both require the same number of years of training. Is it too harsh to say that society doesn’t care enough about cancer in children?

It often comes down to health insurance. Kids with cancer often have Medicaid, and people with orthopedic problems are often patients with good health insurance. But that is no way to run population health. It is not just; it is not equitable.

I think the health care system needs to be more [focused] around centralized planning of investment. Somehow, we have to be able to raise capital without selling out to for-profits.

In order to keep, somehow, a system where hospitals and health care systems are there to improve the health of the community, not to improve the return investment to their shareholders. That is a broader view.

I think the good news is that the health systems, compared to when I came here, seem to value Family Medicine.

ConvergenceRI: Where does the patient fit into all of this? The difficulty of navigating the health system is often a mess for patients.
BORKAN: It is crazy that we have things like the prior authorization system, which is not there for the benefit of patients and is not there for the benefit of providers. The only people who seem to benefit are the insurance companies. And, it is one of the top burnout items for physicians,

It creates havoc for patients. But, we need to design a health care system that meets the needs of patients, not the needs of specialty [practices], and part of that is, like in Britain, where every person has a primary care doctor, and there might be a patient navigator to assist, community health workers to assist.

But you shouldn’t require advanced degrees to be able to work your way through the health care system. It should be accessible, affordable, equitable, and just. It should be easy to navigate. If there is anything that I am saddest about that hasn’t happened, it is that we continue to have this fragmented health care system that is difficult to navigate.

I think that we have made some progress with electronic health care records. And, with the opening of records to patients, and with patient portals, people are getting the results more quickly; they are more connected.

But, if you have a complex issue, and it’s expensive, you can get blocked at multiple places.

ConvergenceRI: If you had a magic wand and you could wave it now, and say, we are going to address these three things as the top priorities, in terms of family medicine, of what we need to do in the next six months, what would they be?
BORKAN: Number one would be to reduce the administrative load and the administrative burden. It’s gone from every four hours of care that might take you a half-hour to do the paperwork, to more than two plus hours. That includes the prior authorization. It is not just killing family medicine, but it’s killing off doctors. The administrative burden is outrageous. And it is totally non-productive.

ConvergenceRI: So, how do you reduce the administrative burden? Is it changing the health insurance processes? Is it changing how data is recorded? Is it expanding the team? A lot of doctors now have scribes that record what happens in an appointment.
BORKAN: It is all of the above. But, I am sure that you’ve heard that the electronic health record, which has some advantages, has made the life of doctors much worse. So, rather than fixing it, what we’ve done is to create workarounds. Scribes are workarounds.

Electronic health records are time consuming, bulky; they reconstruct the visit with a physician to be more about the electronic health record and less about the patient.

They have added innumerable hours, unproductive hours, to doctors’ lives. They have been made worse by the third-party payers. It has to go away.

Prior authorizations are a crude instrument. Let’s say you go through the process, which always requires paper, you fill out the forms, and then you have to get on the phone. Let’s say that you do that, and 100 percent of the time, the insurance company agrees with you. They don’t give you a golden pass; they don’t say, OK.

They don’t say, “You seem to be making good decisions; we’re going to give you a pass for the year. Instead, they penalize everyone. If we save money for the system, it doesn’t come back to us. It only goes back to the insurance companies. So, it’s an unjust, unfair, in many ways a punitive system, which is killing off medicine.

ConvergenceRI: That is two things, what is the third?
BORKAN: I think all the health care systems have to expand their primary care base.

So that we are present where the patients are. We have to figure out where there is a primary care need. And the systems need to invest in creating primary care centers that serve them. I’m sure you are familiar with Mike Fine’s idea of Neighborhood Health Centers. It is not quite that, but we have communities of color that do not have adequate primary care. We need to provide it. We need to look at the whole state, and figure out where there is need, and put money into creating solutions.

And not just for primary care, but also for the other specialties that the populations needs that we are not providing.

ConvergenceRI: Where does value-based care fit into the equation?
BORKAN: Number four is payment reform. Fee for service systems create the wrong incentives, as we saw with COVID. The hospitals got slaughtered financially when they were providing care, because all of the care for elective surgeries, that are high fee-for-service, were not being done. But the hospitals and their staffs were working beyond their capacity. The current system has perverse incentives and it doesn’t work. We need to align incentives, health care, and health.

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