PROVIDENCE – The news that Dr. Michael Fine, the director of the R.I. Department of Health since 2011, was resigning as of March 27, apparently means that Gov. Gina Raimondo has allegedly kept her promise to a number of special interest groups to remove Fine.

In late December, as Governor-elect, Raimondo met privately with members of the association representing Rhode Island dentists. At that meeting, Raimondo assured the dentists she would take action to remove both Dr. James McDonald and Fine.

The two public health agency officials had angered dentists by proposing new regulations that would prevent them from prescribing prescription painkillers to family members as part of the effort to change prescription behaviors around addictive painkillers, in the face of a continuing epidemic of accidental overdose deaths in Rhode Island.

At a Dec. 15, 2014, hearing on new proposed regulations, the dentists and their lawyers had objected vehemently to what they saw as an infringement of their rights to practice the way they had always done in the past, i.e., treat family members and prescribe them painkillers after procedures. [See link to ConvergenceRI article below.]

The dentists did not share Fine’s public health concerns about how important it was to try and tighten the control over the flow of addictive prescription drugs in Rhode Island. Translated, self-interest trumped public health, in the dentists’ view of the world.

The facts, however, appear to support Fine. As the latest statistics reveal, there is still a flood of addictive drugs entering the market being legally prescribed: in January of 2015, 113,986 individuals – 11 percent of the state’s population – filled a prescription for a Schedule 2, 3 or 4 drugs in Rhode Island.

And, in terms of volume, there were, in January of 2015 alone, 1.2 million doses of stimulants, 2.7 million doses of Schedule 2 pain medicines, and 5.5 million doses of benzodiazepines [addictive anti-anxiety drugs such as Valium] prescribed.

“When you really begin to understand the [scientific] mechanism of action, opioids used for more than a few days at a time actually make pain worse, not better. All they do is breed addiction,” Fine told ConvergenceRI in an interview following his resignation.

Changes in attitude
The new Raimondo administration does not appear to share Fine’s urgency and willingness to challenge the status quo in addressing the addiction crisis.

Maria Montanaro, the Raimondo nominee to become the new director of the R.I. Department of Behavioral Healthcare, Development Disabilities and Hospitals, suggested the solution that perhaps the state could offer “better training” for doctors prescribing painkillers as a way to stem the tide.

Montanaro made that recommendation after listening to recovery community member Abbie Stenberg describe her descent into drug hell as a result of a prescription of Vicodin from her doctor for a gymnastics injury, at a recent community gathering at Anchor Community Recovery Center hosted by Sen. Sheldon Whitehouse. Montanaro likened the approach to her own regiment regarding the use of painkillers following her child’s broken ankle.

Step right up, everybody’s a winner
Of course, the dentists were not the only ones who had been angered by Fine’s aggressive public health advocacy and who had put a target on his back. Add CVS Health to the list of the usual suspects.

The retail pharmacy chain had been upset by the conditions imposed by Dr. Michael Fine, the director of the R.I. Department of Health, in a May 14 decision approving the licensing of seven MinuteClinics in Rhode Island, following an involved, lengthy public process before the R.I. Health Services Council. [See link to ConvergenceRI article below.]

In response, the Woonsocket-based corporate behemoth, which earned $126 billion in revenue and $8 billion in operating profits in FY 2013, went straight to the offices of Rep. Nicholas Mattiello, the R.I. Speaker of the House, to get the conditions watered down.

Mattiello, in turn, called then Gov. Lincoln Chafee. Behind closed doors, in private, in a meeting that included Richard Licht, then head of the R.I. Department of Administration, and Peter Marino, then director of the R.I. Office of Management and Budget [and now president and CEO of Neighborhood Health Plan of Rhode Island], as well as CVS Health, MinuteClinic officials, and lobbyists, discussions were held on how to cut out conditions that CVS didn’t like.

In doing so, CVS chose to bypass direct engagement with Fine, creating what Dr. Elizabeth Lange, a pediatrician, called “unfortunate precedent,” one based upon political leverage and not on public health.

“I don’t know exactly what happened; what I do know is that a very public process became a private negotiation,” she told ConvergenceRI. [The final revised version apparently did involve some further discussion and some back-and-forth negotiations with Fine.]



The outcome is problematic, Lange continued. “The decisions made by Rhode Island’s senior health care official about state public health needs were circumvented,” Lange said. 



Steven DeToy, spokesman for the R.I. Medical Association, was more blunt in his assessment. “It’s the story of a disparate group of individuals, primary care providers, [fighting] against one big-ass corporation – life as it is in Rhode Island.”



Mattiello, for his part, was more than happy to carry the water for CVS, because he believed that “CVS was being unfairly treated, and that Rhode Island needed to be more business friendly,” Larry Berman, Mattiello’s spokesman, told ConvergenceRI. 



Mattiello proudly championed his successful intervention. “Speaker Mattiello met with CVS, MinuteClinic and state officials to express his concerns regarding burdensome regulations and conditions that were initially put into place by the Department of Health,” according to a statement issued by Berman, as reported by The Providence Journal.



Mattiello, Berman continued, “was pleased to have been able to facilitate a positive result for one of the state’s largest businesses that will be adding jobs through seven MinuteClinics. He will continue to oppose overbearing regulations that hamper the growth of Rhode Island’s economy.”



But, were the conditions really that overbearing? How exactly would they truly have hampered the growth of Rhode Island’s economy – beyond CVS’s own self-interest?

Instead of an engaged, transparent, public conversation, it ended up being a backroom deal – an outcome tinged with irony, given the current cathartic debate about whether or not to repay the debt caused by the failed investment in 38 Studios, the result of a previous backroom deal.

So, add CVS Health to the list of suspects that were pleased to see Fine gone.

The story of who gets what, and when
Within the state’s health care bureaucracies, Fine had also run up against entrenched interests regarding his advocacy for the concept of neighborhood health stations, a proposal to create community-based primary care facilities that directly addressed the needs of community residents, looking at the health care delivery system from the bottom up.

In particular, those who championed the State Health Innovation Plan, and then the State Innovation Model, which led to the recent $20 million grant from the Centers for Medicare and Medicaid Services, successfully fought tooth-and-nail to prevent the concept of neighborhood health stations from being included as one of the innovative models that Rhode Island would explore as part of its innovative effort to transform the state’s health care delivery system. [See links below to the ConvergenceRI stories.]

Those entrenched interests won.

Left out of the equation was any support and funding for Fine’s proposed Neighborhood Health Stations, despite the collaborative work being done to create a school-based high school health clinic in Central Falls.

As the actual budget breakdown and project narrative for the $20 million SIM grant showed, the way that the money will be invested is revealing in its endorsement of a top-down approach, rather than a bottom-up investment in placed-based health.

One-quarter of the SIM grant will go to six new high-level bureaucratic positions in state government. Those six new employees, with salaries and fringe benefits of $3 million, will have a total of $1.55 million in their budget to hire expert consultants to develop and manage their work plans.

That’s a total of $4.55 million – 23 percent of the grant – to pay for six new hires to manage the project and to develop, monitor and report on the work plans.

None of those jobs and none of those consulting contracts are necessarily guaranteed to go to Rhode Island residents or firms.

Another $6.5 million of the SIM money is targeted for contractual work for health IT, the bulk of which appears to be dedicated for investment in the Rhode Island Quality Institute, a quasi-public created by Sen. Sheldon Whitehouse when he served as R.I. Attorney General.

The Institute has been responsible for the development and implementation of Currentcare, the state’s health information exchange, with mediocre results to date.

A recent 2014 survey of Rhode Island physicians, for instance, found that 72 percent said that their practice was not signed up to view or receive data from Currentcare. Of the 28 percent that were able to view or receive data, more than half said that they were not using it. In other words, some 86 percent of physicians in Rhode Island were not signed up or were not using Currentcare, a clear lack of participation.

Within the SIM project narrative, it include targeted investments in the creation of a statewide common provider directory, budgeted at $1.5 million. The R.I. Quality Institute had already been tasked with developing such a provider directory as part of its existing contractual obligations, but it has not yet completed the task. The new money will be used to “leverage the federal investment to date” from the 2010 Beacon grant, according the project narrative.

Investments in transformation
The SIM project seeks to build upon existing structures to transform Rhode Island’s health care delivery system – including the all-payer R.I. Chronic Care Sustainability Initiative, or CSI-RI, a patient-centered medical home model of care that has expanded to provide primary care to about one-third of Rhode Island’s population, even if the patients may be unaware that they are part of a PCMH.

The Rhode Island Foundation serves as the Initiative’s fiduciary parent, which recently officially changed its name to Care Transformation Collaborative of Rhode Island, or CTC.



About $4.5 million of the SIM award’s financial resources – broken down into $1.14 million a year budgets over four years – are targeted for health care delivery “transformation” contractual investments.

The bulk of those investments, some $3 million, appear to be dedicated to future Care Transformation Collaborative plans to move beyond its current adult primary care focus, with new programs for pediatric care, behavioral health, and community health teams to reach high-risk patients.

Risk-taking
Long before the epidemic of accidental drug overdoses became front-page news in Rhode Island, Fine, responding to an article written in July of 2011 by this reporter, took action to change the public health priorities in Rhode Island to build a collaborative coalition to address the issues of substance and addiction. [See link below to ConvergenceRI article.]

The willingness to work in a collaborative framework – involving the recovery community, law enforcement, emergency room physicians and behavioral health practitioners – was very much the hallmark of Fine’s leadership.

The innovative approaches – having recovery coaches at emergency rooms, expanding the use of naloxone and training law enforcement on its use, extensive community meetings, and even developing a media campaign funded by private sources to encourage recovery – were all products of this approach.

The kind of leadership displayed by Fine will be hard to replicate.