Delivery of Care

RI health care landscape redefined

First-ever detailed statewide health inventory reveals significant gaps

Courtesy of the R.I. Department of Health

Sandra Powell, left, and Dr. Theodore Long, discussing the new statewide healthcare inventory that was released on Nov. 17. Powell and Long were the key staff at the R.I. Department of Health in conducting the inventory.

By Richard Asinof
Posted 11/30/15
The new statewide health inventory provides a comprehensive, evidence-based look at the health care delivery landscape in Rhode Island, identifying significant gaps.
How will the gaps in access and in equity be incorporated into the planning around the State Innovation Model? Will the identified shortage of primary care doctors in Rhode Island force a re-evaluation of current strategies, making it a priority to investment in recruiting and retaining primary care physicians – and paying them more money? How will the “unpacking” of racial disparities in health Rhode Island lead change the equation?
The first four applicants have been selected by the state to undertake a pilot program to develop accountable care entities for some 25,000 members in the state’s managed Medicaid program: two hospital systems, and two community health centers – Blackstone Valley Community Health Care, Providence Community Health Centers, Care New England, and Prospect Medical, the parent of CharterCARE. At the crux of this effort are the sophisticated population health management analytical tools required to do this work.
In a separate but related matter, a more detailed report will be forthcoming in January on the health IT infrastructure in Rhode Island. Stay tuned.

PROVIDENCE – The results of the first comprehensive statewide health inventory ever conducted in Rhode Island were released on Nov. 17, and with it, some glaring gaps have been identified within the state’s health care delivery system.

The 176-page comprehensive survey, conducted by the R.I. Department of Health, provides detailed data, methodology and analysis to support its findings. The question is: how will the findings have consequences in reshaping the system?

Nearly one-third of Rhode Islanders – 31 percent – delayed or put off medical care because of cost, and almost half of those who delayed care – 47 percent – became sicker before they received care. The inventory found that cost barriers to care, including high deductibles and co-pays, often prevent patients from accessing needed care in a timely manner.

A precise counting of the number of primary care physicians in Rhode Island revealed that there are about 603 full-time equivalents of primary care physicians in the state, a figure substantially lower than other previous estimates – by as much as 40 percent. That translates into a 10 percent shortage of primary care physicians in Rhode Island, according to national standards.

One consequence of the documented shortfall in the number of primary care physicians could be a change in strategy by the R.I. Office of the Health Insurance Commissioner, recognizing that more investment is needed in primary care – beyond the current 10 percent rate of medical costs under its affordability standards, in order to attract and retain more primary care physicians.

There are significant gaps in the ability of primary care, behavioral health and outpatient specialty practices to identify and respond to patient needs for language and interpreter services, a barrier to quality health care. In addition, a significant gap was identified in the collection of information on race/ethnicity reporting in outpatient care.

Another consequence could be to invest in the concept of neighborhood health stations where the delivery of services reflects the needs of the community being served, such as the one now under development in Central Falls.

Rhode Islanders who are poor and/or elderly and have health insurance plans through Medicare and Medicaid are unlikely to be treated by either psychiatrists or psychologists. Psychiatrists reported that only 5.2 percent and 3.9 percent of their patient profile were Medicaid and Medicare members, respectively. The corresponding data for psychologists was 5.3 percent and 5.1 percent. Those numbers seem to indicate that there are economic and racial disparities in the delivery of behavioral and mental health, despite parity laws with physical health.

The inventory found that there was “limited integration” between primary care and behavioral health. The survey, using the same electronic medical record for behavioral health and primary care providers as an indicator of integration, found that no integration was reported by 75 percent, 89.1 percent, and 100 percent of licensed behavioral health clinics, psychology practices and psychiatry practices, respectively.

Shortcomings in long-term care
The comprehensive statewide health inventory also looked at long-term care facilities, including nursing homes, assisted living residences, adult day care programs and home health agencies. In long-term care delivery, the health identified a number of shortcomings:

The majority of assisted living residences, some 51 percent, are not accepting new additional Medicaid beneficiaries, undercutting plans under the state’s Reinventing Medicaid initiative to transfer residents out of institutional and into community-based settings.

The survey data also revealed that 60 percent of nursing homes and 52 percent of assisted living facilities do not have dementia care units.

Similar to the findings with outpatient care, the health inventory found that there were demonstrated gaps in reporting and collecting information about race and ethnicity, and that there were significant gaps in the ability to identify patient needs for language and interpreter services.

Be careful what you wish for
The release of the health inventory comes at a time when the entire state health care delivery system is in flux: hospital systems are consolidating; a major transition in business models for reimbursement is underway, moving away from fee-for-service to accountable care entities; the state’s Medicaid program is attempting to reinvent itself; and health IT systems are changing the way information is shared and analytics are performed to measure and manage population health across a continuum of care.

Amidst the turmoil, there are strong undercurrent emerging, promoting investments in health equity that address the social and economic determinants of health, and not just the health care delivery industry.

Digital devices are also redefining the flow of communication as being a two-way street that is more than patient-centric but patient directed.

The vision of the R.I. Department of Health is that the new statewide health inventory “will drive the statewide plan to build a healthier Rhode Island,” according to the news release accompanying the inventory. The inventory is envisioned as a critical tool as the state looks “to shift our entire health care industry toward a structure that rewards better outcomes and coordination, and healthier communities,” according to Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services.

That said, the origins and legislative intent of the inventory were quite different. The health inventory had been mandated by the R.I. General Assembly as part of the Rhode Island Access To Medical Technology Act, passed in 2014 by the R.I. General Assembly and signed into law by then Gov. Lincoln Chafee.

The inventory, however, had not been the primary intent of the new law. Rather, the push for the new law had been to promote the concept of “domestic medical tourism,” which was defined in the statute as “the practice of patients traveling to states other than his or her residence for the provision of health care services.”

The bill had been sponsored Rep. Joseph M. McNamara, D-Warwick, chair of the R.I. House Health, Education and Welfare Committee, in order to help national firms such as the Florida-based Laser Spine Institute open a new ambulatory surgical facility in Warwick, according to reports in The Providence Journal.

The inventory was seen as a way to help reform the process around the certificate of need to build new facilities in Rhode Island. As the old adage goes, be careful what you wish for.

Behind the inventory
ConvergenceRI recently spoke with Sandra Powell, director of the Division of Policy, Information & Communications at the R.I. Department of Health, and her colleague, Dr. Theodore Long, medical director of that division, who were responsible for coordinating the surveys and analysis for the statewide health inventory.

ConvergenceRI: I was impressed by the comprehensive nature of the statewide health inventory. Can you talk about the process behind the product?
POWELL:
Ted and I are both recent entrants to the public health department. Ted is a graduate of the Robert Wood Johnson clinical scholars program [at Yale University]. It was a convergence of both interest and resources, at a certain time.

Ted was not engaged at the time the legislation was passed. He has come in and really moved that work along.

We worked closely with some other folks from EOHHS and OHIC who were members of our team. We think that it has a tremendous amount of value for policy leaders and decision makers who are deeply invested in the work of public health.

ConvergenceRI: What is the take-away that you want people to draw from the inventory?
LONG:
It is a comprehensive look at access to care and health service capacity. It offers a detailed view of what we have currently, and it also provides a baseline so that we can track improvement over time.

It offers [a view of the landscape that is compiled from] more than just one perspective – from primary care practices, specialty practices, long-term care, hospitals. In terms of access to care, we surveyed more than 400 Rhode Islanders.

It is an evidence-base look at health care planning around access and the needs and barriers to access in Rhode Island.

ConvergenceRI: Is there anything missing from the conversation?
LONG:
A lot of the findings point out areas point out areas where we could do things differently, or better. It shows the baseline. It is evidence-based, academic, and comprehensive. It allows us to know how we’re doing.

It is an inventory; inventory is not a word we really use in the academic world.

The reason we chose the word is that we have a 92 percent average response rate to our surveys – from long-term facilities, primary care practices, specialists, and hospitals.

We really pushed to create an inventory that was comprehensive. We used a very systematic approach, wanting to hear from all the relevant stakeholders.

We also wanted to make sure that the issues identified by stakeholders were mirrored and reflected in the surveys.

For instance, in assisted living, the people living there are not called clients, or patients; they are called residents. You want to achieve a certain resonance, to reflect the situations, to get the levels of response [desired].

There are a few areas that were challenging. For outpatient specialists, the response rate was 55 percent.

POWELL: As Ted said, the overall average response rate to our surveys was 92 percent or above, a reflection of the amount of outreach and engagement with stakeholders before the surveys.

Ted is the mastermind behind the inventory.

ConvergenceRI: How do you see the integration of the data in the inventory influencing the development of population health goals and outcomes?
LONG:
I’ll give a global answer. Our survey does give us [a snapshot] of the landscape at a point in time, to help us understand what is really going on [regarding] access and capacity.

We hope that our reports and our data can then be used to inform the State Innovation Model in development of population health and behavioral health plans for Rhode Island.

POWELL: For instance, we tracked the issue of community health workers and community health teams, and we were able to discern how many practices actually have community health workers as part of their health team, connecting patients to the other services that they need.

The data from this report details the ways and opportunities and avenues for better utilization of community workers.

LONG: Population health encompasses the divide between health care and health. Population health is where we are looking at the different determinants of health outcomes, and what those outcomes should be.

Population health inequities are relevant and important to reducing chronic illness.

ConvergenceRI: Are you considering breaking down the information into specific data stories, similar to the work done by The Providence Plan and its DataSparkRI division?
LONG:
There is a lot of variation across practices and facilities geographically, so we included a lot of maps in the report. We are putting all of this data online, with click-throughs for the first edition.

The Providence Plan does a phenomenal job and is an inspiration. We have every intention of putting this together in way that is more understandable.

ConvergenceRI: What are the next areas you would like to explore in terms of data and surveys?
LONG:
I would like to look at the financial access picture, and with respect to financial access, Medicaid. There are a lot of variations across practices; perhaps looking at the population of Medicaid patients in any one practice, whether the practices and facilities are taking Medicaid patients, and how the rate of which new Medicaid patients compares with other patients.

And for assisted living, what access was like for a new Medicaid patient.

We don’t need to collect this data every week. Rather, the question is: how can we continue in a non-resource intensive way to leverage [the information we have].

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