Delivery of Care

A strategic roadmap for primary care in RI

A task force convened by CTC-RI puts out a game plan for what is needed to address the current crisis in primary care. Will it spur the necessary political will to implement it?

Image courtesy of CTC.

The cover to the 2021 Annual Report by the Care Transformation Collaborative, which has convened a new task force on primary care in RI.

By Richard Asinof
Posted 2/19/24
The Primary Care Task Force convened by the Care Transformation Collaborative-RI has released its strategic roadmap with detailed goals and action steps, as a way to look long-term at how best to transform the crisis in primary care.
Who should be responsible for paying a bigger share of the costs of investments in improving the delivery of primary care in Rhode Island – health insurers, taxpayers, hospitals, or universities? What does “success” look like in the delivery of primary care? What happens when a community becomes empowered to support better health care for its residents? What is the connection between safe, affordable, healthy housing and better health outcomes? When will more emphasis be given to the way that endocrine disruptors have been linked to the surge in breast cancer, as researched and documented by the Silent Spring Institute?
The critical role that journalism can play in reshaping the narrative around health care – and really, all aspects of our lives – was brought home by an email from a former colleague from Environmental Action, the group that grew out of Earth Day in 1970, and where I served as an editor of Environmental Action Magazine.
The colleague attended a show of environmental posters at the Poster House entitled, “We tried to warn you! Environmental Crisis Posters, 1970-2020.” The show included a poster drawn by Ray Osrin, entitled “The Thinker,” showing an image of the sculpture by Rodin wearing a gas mask, sitting in front of a backdrop of smokestacks pouring out exhaust, in front of a pipe discharging waste into polluted waters. A description of Environmental Action was included, which said: “The radical group combined activism with lobbying…”
The descriptor “radical” touched off a lively online discussion. Were we indeed radical? Did we do enough? Could we have done more? I believe that we persevered.
We are at an inflection point where the climate crisis is converging with the health crisis, as well as a political crisis challenging the concept of democracy – all reflective of the growing corporate campaigns of disinformation being waged.

PROVIDENCE – Last week, the Primary Care Task Force convened by the Care Transformation Collaborative of RI released its comprehensive strategic roadmap, “Primary Care Access for All: A Strategic Roadmap for Patient Access and Primary Care Workforce Capacity Building.”

The succinct, 19-page document was developed under the leadership of co-chairs Dr. Jeffrey Borkan, MD, Ph.D, Assistant Dean for Primary Care/Population Medicine at the Warren Alpert Medical School of Brown University, and Dr. Denise Coppa, Ph.D., CNP, FAAN, FAANP, Program Director at the Family NP Program at the University of Rhode Island.

The project team included: Debra Hurwitz, MBA, BSN, RN, the executive director of the Care Transformation Collaborative of RI; Dr. Pat Flanagan, MD, clinical director and PCMH-Kids co-chair; Yolanda Bowes, program manager of the Care Transformation Collaborative, and Edyth Dwyer, MPA, MPH, program coordinator of the Care Transformation Collaborative.

The creation of the Task Force, which had some 40 members, was the first time that representatives from all the higher education institutions involved in the training of medical professionals in Rhode Island were included in the conversation. [In June of 2023, ConvergenceRI documented the origins of the Task Force in the story, “When a strategy of convergence works.” See link to story below.]

No one disputes that there is a crisis in primary care – in Rhode Island and across the nation. There are not enough primary care providers; there is a growing demographic of aging residents who need more care, not less, to deal with the onslaught of chronic diseases; the low pay scale for primary care providers has become a powerful disincentive for medical students when choosing an area of practice, and impoverished communities, unable to find primary care providers, have become dependent on care delivered from emergency rooms.

Here in Rhode Island, there is already a gap in primary care providers and that gap is going to get worse. The challenge, according to Dr. Borkan, is 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 on investment to their shareholders.”

What is to be done?  
The new strategic roadmap for primary care lays a series of goals and action items to take. [See link to roadmap below.]

Turning the words of the strategic roadmap into action will require political will and political leadership – and a continued willingness to collaborate across the silos within the state’s health care delivery system.

The biggest threat may come not from political inaction but from the world of private equity investments, which has sought to gobble up hospitals and nursing homes, extract the value and the cash, and hollow out the facilities, leaving them bankrupt.

ConvergenceRI reached out to Debra Hurwitz, the executive director of the Care Transformation Collaborative, to ask a series of questions to frame the important work of the Task Force.

ConvergenceRI: OHIC has recommended a $45 million increase in provider rates for fee-for-service Medicaid rates, for the current budget year. Where does this initiative fit within the strategic roadmap? Without such an increase in provider rates for Medicaid providers, it is unclear how the goals of the strategic roadmap can be accomplished.  
HURWITZ: The OHIC rate review is related to community-based services, which is long overdue and indirectly helps primary care providers who make referrals to these services.

The CTC Road Map relates to improving patient access by focusing on primary care workforce capacity. We need to recruit, train and retain primary care providers [MD, NP, PA] in Rhode Island. We need to sustain a pipeline of providers to meet the population health needs of Rhode Islanders.

I believe that there was an article that stated that OHIC will be looking at primary care rates. This is consistent with our first goal around adequate compensation for primary care.

ConvergenceRI: How does the strategic roadmap respond to the reality that roughly 50 percent of the 2,500 primary care practices within 30 miles of Providence listed on the Blue Cross and Blue Shield of Rhode Island provider list are not accepting new patients, according to the data research by the Attorney General?  
HURWITZ: I have not seen this report. But the findings are not surprising. We hear from people regularly that they can’t find a primary care provider, or that wait time to get an appointment is months.

[Editor’s Note: The documentation was provided in an in-depth interview by ConvergenceRI with R.I. Attorney General Peter Neronha, “AG Neronha weighs in on future of health care,” published on Monday, Jan. 29. The information was also talked about in a recent WPRI “Newsmakers” interview with Attorney General Neronha. See link to story below.]

ConvergenceRI: When it comes to issues of equity and primary care, the issue is often related to the way that models of care are perceived by the community being served. In Central Falls, for instance, Jenks Park Pediatrics has created an innovative, bilingual pediatrics practice that has been broadening mental health and women’s health coverage, expanding outreach through programs like Cover All Kids.

How do they fit within an alternative payment model structure? How does the community get to voice what it needs in terms of health care under the strategic roadmap?  
HURWITZ: Dr. Nelken's passion to provide access to underserved children and families is amazing. Unfortunately, the American health care system does not adequately support providers and community-based organizations that are working hard to meet the needs of people who need more resources.

Providers can’t rely on philanthropic funding for sustainability. There is increasing recognition that public health and primary care are converging, but payment models that support medical and social needs aren’t there yet.

Unfortunately, small practices are at a disadvantage because they don’t have the number of patients to participate in alternative payment models.

We welcome the patient voice. Many task force members were also experiencing the primary care access problem personally.

ConvergenceRI: There seems to be competing datasets being developed around primary care inputs: one by the Rhode Island Foundation; another by the Attorney General; and a third by OHIC and Brown. Which will have precedence?  
HURWITZ: As a state we lack data on our primary care workforce. Studies show that Rhode Island has one of the highest number of primary care providers per capita in the country. So why do we have an access problem?

We have many questions and different datasets may help us answer different questions. Such as: How many primary care providers – seeing patients – do we have? Are they full-time or part-time? The Brown analysis is hoping to answer these questions.

What is their average age of our primary care workforce? Race? Ethnicity? 

The EOHHS Ecosystem has linked licensure data for NPs and will soon add MDs and PA’s – this will help to answer age, race and ethnicity.

In addition, CTC-RI is finalizing a primary care dashboard that looks at a range of indicators from already existing data – we want to measure the health of our primary care delivery system/network of providers. As a state, we have a lot of work to do in this area.

ConvergenceRI: Is it possible to set up a time for an interview about the strategic roadmap with say you, Dr. Borkan, and Dr. Flanagan?  
HURWITZ: Happy to do a Zoom interview.

ConvergenceRI: Finally, it’s a small point, but why does the strategic roadmap cite articles in the Boston Globe and the Providence Journal but not ConvergenceRI?  
HURWITZ: Thank you, Richard, for the hard work you have done to provide a spotlight on the primary care provider workforce crisis. Your journalism is much appreciated. We have added ConvergenceRI to our reference list.


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