Delivery of Care

When a strategy of convergence works

A new task force on primary care delivery in RI brings together key players in a collaborative approach, offering up a patient-centered vision of care

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 6/26/23
A new task force, convened by the Care Transformation Collaborative, is bringing together key stakeholders across the spectrum of the health care industry in Rhode Island to address a primary care health care crisis.
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PROVIDENCE – A remarkable new task force, convened by the Care Transformation Collaborative, focused on developing solutions to the current crises in primary care delivery in Rhode Island, demonstrates the power of convergence at work.

Three of the task force principals – R.I. Attorney General Peter Neronha, Dr. Jeff Borkan, M.D., and acting OHIC Commissioner Cory King – have all been featured in in-depth interviews with ConvergenceRI during the last year, talking about the complex, thorny issues around health care delivery in the state.

Now, they are collaborating together to find solutions, breaking down the usual silos that afflict health care delivery – a testament to the strategic power of convergence and engaged conversations.

Speaking up, being heard, taking action
For instance, Attorney General Neronha, in an interview published by ConvergenceRI on Feb. 27, 2023, “AG Neronha sounds the alarm,” shared his views of the current challenging health care landscape.

“We have a lot of people here [in Rhode Island], most of our population, who are insured,” Attorney General Neronha said. “We have high rates of people who are covered by health insurance. And, that is a good thing, I suppose.”

But, Neronha continued, “One of the underlying problems is: it’s all well and good to be insured, but if you can’t find a doctor, what good is it to have insurance? If there is an insufficient supply of primary care providers, doctors and others who provide primary care, what good is it to have insurance?”

For Neronha, the underlying problems with health care delivery in Rhode Island required a deeper analysis than just looking at who has insurance – and who doesn’t. “It’s great that everyone has insurance. But, if a hospital is financially unstable, again, what good is it to have insurance, if, in the long run, our hospitals are endangered?”

Neronha was blunt in his critical assessment: “I see at least two underlying problems in health care that we need to address: One of them is primary care – the shortage [of providers] is a problem.”

Now, Neronha is transforming those concerns into action: the Attorney General has assigned Julia Harvey, a special assistant attorney general and health care advocate, to be a key participant on the new task force.

Expanding primary care investments
Similarly, Dr. Jeffrey Borkan, M.D., who had chaired the Family Medicine program at the Alpert Medical School at Brown University for two decades, spoke at length with ConvergenceRI, in a two-part interview, “Investing in Family Medicine,” published on July 18, 2022, about the need to make better investments in primary care and family medicine.

Borkan addressed many of the shortcomings in Rhode Island around what is needed to have a functional health care system: “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?” Borkan asked.

“Part of that involves the redistribution of funds,” Borkan continued. “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?

Borkan pointed to inequities in health insurance coverage as one factor. “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.”

Borkan continued: “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.”

The interview continued, talking about the difficulty that patients often have in navigating the health care system. Borkan told ConvergenceRI: “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.”

When asked what his top priorities would be, in terms of improving the delivery of family medicine, Borkan said: “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.”

Borkan made it clear that a top priority should be to expand the reach of primary care. “I think all the health care systems have to expand their primary care base,” he said. “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. …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 population needs that we are not providing.

Now, Borkan is positioned to play a key role in helping to direct the new task force.

The high cost of caring
Following the recent public forum of the Rhode Island Health Care Spending Trends gathering, held on May 8, 2023, to discuss analyses of how the $8 billion health care industry spent its resources in 2021, ConvergenceRI spoke at length with Cory King, acting R.I. Health Insurance Commissioner, about his concerns that the state needed to spend more money on the health care workforce, on primary care, and on outpatient behavioral health. [Editor’s Note: No other news media covered the public forum, save for ConvergenceRI.]

King told ConvergenceRI that making new investments in the workforce were critical. “Workforce is critical,” King said. “I think, in tandem with this [spending trends] project, which looks at our growth in health care spending, and how we manage that growth, we also have to think about how we pay to adequately fund the workforce, and that means, in some cases, [that] we’re going to have to increase costs.”

King stressed the need to look at more longer-term investments rather than short-term cost increases. “And frankly, it might be a short-term increase in costs, but if you don’t have enough primary care providers, if someone can’t find a PCP, and they end up going to an emergency room, or they have a hospital admission, that is just not socially efficient. Because primary care is much cheaper than an ED visit or an admission.”

The value of the cost trends project, King emphasized, was recognizing that it was a balancing act. “I think having a program like this [cost trends project], where we are analyzing health care spending, and making sure that people understand that there are areas where we can reduce costs, we can control costs, the savings from that have to be dedicated to areas where we need to increase investment.”

King continued: “Outpatient behavioral health is one; primary care is another. And, hospitals, we need to have enough nurses working in our hospitals in order to staff beds safely and meet quality standards. It’s all part of the balancing act at the end of the day.”

King, like Borkan, like Neronha, will be playing a critical role in shaping the directions of the new task force, which is being organized under the auspices of the Care Transformation Collaborative.

Converging strategies
Here is the ConvergenceRI interview with Debra Hurwitz, executive director of the Care Transformation Collaborative, talking about the auspicious goals of the new primary care task force.

[Editor’s Note: As ConvergenceRI readers may recall, the Care Transformation Collaborative began as a pilot program in 2008, with five initial practices participating in an experimental, all-payer, patient-centered medical home model of care, under the direction of then-R.I. Health Commissioner Christopher Koller.

Today, 15 years later, CTC, working in partnership with PCMH Kids, includes 128 primary practices, involving some 800 providers across both adult and pediatric practices. Perhaps equally impressive, approximately 700,000 Rhode Islanders are receiving care from one of the practices – roughly two-thirds of the entire state’s population, even if the patients may not be aware that they belong to a patient-centered medical home.]

ConvergenceRI: First, how would you describe the current landscape for the delivery of primary care in Rhode Island? And, what are the forces that are creating the problems related to there being not enough primary care providers in Rhode Island? What led to the creation of the new task force to develop solutions?
HURWITZ: Data show that Rhode Island is expected to have a deficit of almost 100 primary care providers [PCPs] by 2030. This number may be an underestimate, since as we emerge from the pandemic, the situation has grown much worse.

• A number of primary care practices did not survive the pandemic shutdown.

• Primary care providers are burning out and retiring early – and many more are approaching retirement age.

• A number of PCPs are leaving to join for-profit entities with significant venture capital funding.

• In addition, the “great resignation” has made it increasingly difficult for primary care practices to hire nurses, medical assistants, behavioral health clinicians and other key staff, which is leading to even higher [rate of] burn out among primary care providers.

• Finally, since 2019, our population has increased by 35,576 residents in need of primary care, further exacerbating the situation.

• This post-pandemic crisis in primary care is gaining recognition nationally and regionally. [Recent articles in The Boston Globe and The Providence Journal have reported on the enormous difficulty for people to get an appointment with a primary care doctor.]

In short, all of these factors and more have created a primary care crisis in Rhode Island.

ConvergenceRI: What roles are Dr. Jeff Borkan, MD and Dr. Denise Coppa, Ph.D., playing on the new Primary Care Provider Task Force?
HURWITZ: Care Transformation Collaborative board members Dr. Jeffrey Borkan, MD, PhD, Assistant Dean of Primary Care-Population Medicine at the Alpert School of Medicine at Brown University, and Dr. Denise Coppa, Ph.D., APRN-CNP, FAAN, coordinator of the Family Nurse Practitioner program at University of Rhode Island, are providing leadership for the Task Force and serve as co-chairs.

This is the first time that all the medical and advanced practitioner leadership are coming together to take on this thorny issue.

ConvergenceRI: What are the goals of the new Primary Care Provider Task Force?
HURWITZ: We want to recruit, train, retain and sustain a primary care workforce [MDs, NPs, and PAs] required to meet the needs of all Rhode Islanders.

Payment reform to increase salaries of primary care providers to make them competitive with our neighboring states is our number-one goal.

In addition, we need payment for preceptors [physicians/clinicians] in the community who provide the clinical training for medical students and residents, NP and PA students during their clinical rotations in the field.

The PCP Task Force, convened by CTC-RI, will meet monthly to develop a “Primary Care” workforce strategic plan for the state.

The plan will include recommendations and action plans for increasing the number of clinical training sites for physicians, nurse practitioners, and physician assistants. It will also develop a training curriculum that will include the critical components of the PCMH model, such as:

• Interdisciplinary care management

• Team-based care

• Integrated behavioral health in primary care, and

• Coordination with community-based organizations to address health-related social needs.

Other issues to be addressed include: recruitment and retention of primary care providers, such as scholarships, loan repayment programs, competitive salaries, work/life balance, and administrative burden.

ConvergenceRI: How did the idea of a task force come about?
HURWITZ: As part of ongoing CTC strategic board discussions that we have on a monthly basis, Jeff Borkan gave a talk about the state of primary care, coming out of the public health emergency. The board recognized the seriousness of the situation and asked CTC to convene a task force to build the case for a call to action.

ConvergenceRI: How is the Attorney General’s office participating in the process?
HURWITZ: As you know, Richard, Attorney General Nerohna is very interested in primary care. Your interview with him in ConvergenceRI was one of several where he has spoken about this concern.

CTC met with AG Neronha and his team to discuss the state of primary care in Rhode Island. As a result of that meeting, one of his staff members, Julia Harvey [a special assistant attorney general and health care advocate] has joined the Task Force meetings.

In addition, Cory King, Acting Health Insurance Commissioner and co-convener of CTC, attends the meetings and is very focused on the health and stability of our primary care providers.

ConvergenceRI: What is the timeline for implementing any action items?
HURWITZ: We are developing a comprehensive strategic plan for the primary care workforce development, which we hope to have completed by fall of this year.

The Task Force has defined the goals of the strategic plan that address the recruitment of individuals interested in becoming a primary care provider (MD, NP, or PA); enhanced training at the clinical practice sites; retention of trainees to stay in the state after graduation, and to create a pipeline that is sufficient to produce the number of new PCPs needed for Rhode Island.

ConvergenceRI: How much is “burnout” a factor?
HURWITZ: It is a big factor, as noted in our discussion about the post-pandemic fallout.

ConvergenceRI: How much are increasing data demands – and things such as chasing prior authorization for insurance – contributing factors?
HURWITZ: Yes, this is another project that we are working on. The work is being co-chaired by Dr. Peter Hollmann, M.D., and Karen Labbe, utilization manager at Blue Cross and Blue Shield of Rhode Island. Prior authorization is a definite contributor to provider burnout; we have heard this loud and clear.

We hope our work will inform policy makers around regulation needed to reduce the burden of prior authorization on providers and patients.

ConvergenceRI: How does this new task force illustrate the valuable role that CTC is playing?
HURWITZ: CTC has the valuable position of being an impartial transformation initiator and convener. We have been able to convene the program directors of all the colleges and universities that train MDs, Nurse Practitioners and Physician Assistants, in addition to other key stakeholders, to discuss the current state, challenges and potential solutions.

CTC can leverage its board of directors, state agency co-conveners, and our well-established learning collaborative framework to convene the right parties needed to address this primary care crisis.

Given the post-pandemic crisis in primary care, the CTC board directed management to convene a Task Force of all the program directors of primary care training programs in the state, including physicians, nurse practitioners, and physician assistants. The Primary Care Provider Task Force on workforce development convened in February 2023.

It was the first time ever that the program directors of colleges and universities, such as Brown University, University of Rhode Island, Salve Regina, and Johnson & Wales University met to discuss the current state of primary care in Rhode Island, their program capacity, challenges and potential solutions. This represents an opportunity to build academic clinical partnerships.

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