PROVIDENCE – These are the facts. All health care is personal. All health care is complex. All health care in the U.S. and Rhode Island is too expensive. And, all health care delivery systems have been disrupted by the COVID pandemic.

As a result, conversations about the future of health care delivery in Rhode Island are challenging these days, because, as Dr. Elizabeth B. Lange, MD, the new president of the R.I. Medical Society, told ConvergenceRI in a recent interview, “There is no concept of time during this pandemic.”

Lange, a pediatrician, has served as a member of the Coastal Medical board of directors, president of the R.I. Chapter of the American Academy of Pediatrics, and more importantly, the secretary of the Care Transformation Collaborative, whose mission is advancing integrated health care through a network of patient-centered medical homes.

Lange has also served as the co-chair of the PCMH-Kids Stakeholder Committee, with Dr. Patricia Flanagan. [PCMH-Kids is a division of CTC.]

Talk about transformation. The CTC was initially convened in 2008 as a pilot program, with just five practices – by the R.I. Office of the Health Insurance Commissioner and by the R.I. Executive Office of Health and Human Services. [It was originally known as the Chronic Sustainability Initiative of Rhode Island, or CSI-RI, leading to lots of bad jokes about TV crime shows.]

Today, by the numbers, the all-payer CTC currently covers:

• 128 primary care practices, including internal medicine, family medicine, and pediatric practices, with 27 primary care practices part of the integrated behavioral health initiative, with mental health professionals embedded in those practices, according to the CTC website.

• More than 700,000 Rhode Islanders receive their care from one of the patient-centered medical home practices, involving some 800 providers across both adult and pediatric practices – even if the patients may be unaware of that affiliation.

• Investment comes from every public and private health insurance plans in Rhode Island. Every federally qualified community health center in Rhode Island is a participant.

Translated, the R.I. Medical Society, a voluntary association of physicians, physician assistants and medical students which traces its history back to 1812, is now being led by a pediatrician who has been intimately involved in the transformation efforts around the delivery of primary care in Rhode Island.

[That emphasis on primary care transformation is likely to continue next year, because Dr. Thomas Bledsoe, M.D., the president-elect of the R.I. Medical Society, served as the president of the CTC.]

Does size matter?
The size of Rhode Island, with its relatively steady population of approximately 1 million residents and a statewide Department of Health, has always been a nurturing Petri dish serving as an incubator of new ideas and innovative approaches to health care delivery.

Beyond the Care Transformation Collaborative and PCMH-Kids, the last decade has seen the successful emergence of Health Equity Zones, which address finding solutions and achieving better health outcomes outside of the doctor’s or nurses’ offices through place-based community interventions. [See link below to ConvergenceRI story, “Making health equity zones part of the RI vernacular.”]

Rhode Island has also been the “home” to efforts to develop alternative payment methods for Medicaid services, through the creation of accountable entities, with private entities delivering Medicaid services through managed care organizations, with far less success to show for the social engineering involved in moving away from fee-for-service practices. [See link below to ConvergenceRI story, "Who will be accountable for accountable entities.”]

Then there is the continued evolution of the Office of the Health Insurance Commissioner to develop affordability standards and recently to consider expanding those in the face of ever-increasing costs of medical care. [See link below to ConvergenceRI story, “Ensuring acccess, affordability, and quality.”]

There is the continuing effort to expand CurrentCare, the state’s health information exchange, from an opt-in to an opt-out system for collecting and sharing of digital health records. [See link below to ConvergenceRI story, “Toward a more inclusive health information exchange.”]

There is the intervention underway by the Rhode Island Foundation to develop a statewide, 10-year plan to make Rhode Island the healthiest state in the nation. [See link below to ConvergenceRI story, “No risk, no reward.”]

There is also the effort to develop neighborhood health stations around the delivery of care, as well as efforts to develop digital connections between patients and providers.

Translated, Rhode Island has served as an incubator for many new kinds of innovation across a broad spectrum of health care initiatives – all of which were severely disrupted by the contagion of the coronavirus pandemic, which made more visible all of the racial and social inequities around health care.

Throw in the proposed merger of the two largest health systems, Care New England and Lifespan, with Brown University in the creation of a new academic medical enterprise, which would control 80 percent of the market, and the continued consolidation of insurance companies, big box pharmacies and pharmacy benefit managers, and you have a complicated system where the business model does not appear to be sustainable.

We arrive back to the beginning: all health care is personal, complex, too expensive, and disrupted – and the all different initiatives appear to be operating in their own silos, on their own mountains, without necessarily recognizing that they are all part of the same mountain range.

How to break down those silos becomes the nuance and context for the ConvergenceRI interview with Dr. Elizabeth “Beth” Lange, in her new role as president of the R.I. Medical Society, someone who is steeped in care transformation from a pediatrics perspective.

ConvergenceRI: Why did you decide to become president of the R.I. Medical Society?
LANGE: The R.I. Medical Society serves an important role, representing patients and physicians in health care. I have been given a unique place to impact how health care is delivered in this state.

And so, I look forward to the opportunity to advocate for positions of health care at the Legislature, with the insurers, and for the needs of individual physicians in society.

For me, it is an opportunity to serve and to try and make the whole health care system better for everybody in the state.

ConvergenceRI: What is your vision for the current landscape health care delivery system in Rhode Island?
LANGE: Rhode Island is a unique place. And, with our small size, we are able to be an incubator for new ideas of innovation, in terms of delivery systems, rebuilding the health care system as a whole, the ability to pay for outcomes that we are looking for, and the ability to enhance relationships that will enhance care and collaboration.

And so, my goal in this term, this year, will be to continue to move forward on the great work that Rhode Island has already done in this realm, recognizing that the pandemic has changed a lot of our emphases and changed a lot of our directions, just by necessity.

I think that this is a unique time to continue to improve health care and lives for Rhode Island citizens.

ConvergenceRI: One of the common descriptors that I have heard about what has happened in response to the pandemic is that the health care delivery system has been disrupted. Is that an accurate phrase?
LANGE: I think the pandemic has disrupted everybody, every system across all sectors. And, as we emerge, with a better vaccinated population, and a hopefully decreasing disease burden, hopefully all sectors of this state can look at the lessons we learned during the pandemic, look at the challenges that were made raw in the pandemic, and continue to improve. Health care is no exception to any other system in the state.

ConvergenceRI: Being more specific, what do you think the takeaways have been about public health from the pandemic?
LANGE: I hope everybody has realized how important a strong health care system is when, all of a sudden, every citizen needs access to health care.

It is nice to have a strong system to help with that. Whether that be clinicians who are available to see patients, whether that is access through in-office visits or through telehealth – we quickly stood up a robust telehealth system in this state. And, working collaboratively with the insurance companies to pay for that.

Whether that has been setting up the inoculation clinics and the testing sites, we have learned quickly that there are parts of the state that have had less access to health care. And, the R.I. Department of Health has done a great job at being aware of those sites, learning more about those places and their needs, and delivering pandemic-specific care in those cities and town and neighborhoods.

I think in terms of primary care access, we have learned that having a robust primary care system so that everybody has access to a primary care clinician is important, and that is something we need to work on going forward.

And, I think [the needs of] behavioral health have really been laid bare in this pandemic, as all of us have had various feelings, feelings of isolation and loneliness, anxiety and depression. Having access to mental health resources has proven to be very important. And, we need to work on building up those resources as well.

And then, going the next level out, looking at childcare. People can’t go back to work if they don’t have access to healthy childcare. People can’t go back to work if schools are not safe for students to learn, and safe for both students as well as faculty.

I think the things that we limp along with, and knew that we needed to pay attention to and fix along the way, were highlighted during the pandemic. And, thankfully, people are aware of those and are starting to put some focus and some energy to that.

We saw that in the Governor’s supplemental budget proposal yesterday [Thursday, Oct. 7] about [how to spend] the rescue dollars, to really start applying them to places that need rescue in this time of pandemic.

ConvergenceRI: Can you talk a little bit about the evolution of PCMH-Kids and the way that it has changed the way that pediatricians are delivering care in Rhode Island?
LANGE: Pediatricians are the original founders of the patient-centered medical home concept. Since the late 1960s, pediatricians have been trained to work in a collaborative way to care for our patients and to work with specialists in taking care of our patients and their families.

One of the changes with PCMH-Kids is that with monthly financial support from the insurers, we have been able to get the data that we need to show what our work is [accomplishing], and to highlight areas where we might need improvement. Without data it is hard to know about the success of the work that we are doing.

The other piece of PCMH-Kids, going back to the mental health needs, we have had the opportunity to have behavioral health specialists integrated into the medical home, and we have proven at those sites that have social workers embedded in the practice what an incredible difference that makes for the care of children and families.

To be able to have access to mental health services [on the] same day and often times in the same office, as the family’s need, or the child’s need, [is identified]..

ConvergenceRI: You talked about data. One of the more interesting datapoints that have emerged from the recent data analyses of health care costs in Rhode Island has been the role of prescription drugs in driving those cost increases. Has also been your experience? Does that provide an opportunity for the R.I. Medical Society to weigh in?
LANGE: As a pediatrician, we don’t prescribe a lot of medications. So, the driver of prescription costs is not as big in pediatric care as it is with adult medicine care.

This is a place where I look forward to learning more in my role as president of the R.I. Medical Society, and to see if there is a place where we can make a difference.

Certainly, Medicare is a big insurer related to medication costs. And, I know from the headlines, that valiant work is being done on this in Washington, D.C.

That also highlights another linkage, one that makes Rhode Island be as successful as we can be with health care, is that we have had tremendous advocacy and support from our national delegation in Washington. D.C., where the decisions are made about funding and policies that affect what we are able to do in Rhode Island.

One of the things I plan to work on this year as Rhode Island Medical Society president will be to look into prescription costs and how it affects all patients.

ConvergenceRI: You talked a little bit about telehealth, and I was wondering if you could dive into that a little more deeply. What is the future of telehealth in Rhode Island and the ways in which it can be improved?
LANGE: Telemedicine had a role in Rhode Island, we had a nascent program already on the books before the pandemic hit, [with] telemedicine services being a covered service.

In the pandemic, when medical offices had to severely limit the patient traffic due to the risk of infection from COVID, telemedicine services tremendously increased in our state.

It has allowed us the ability, in that quick ramp up, to look at exactly what is working and what could be working better. The Office of the Health Insurance Commissioner convened a task force last year that produced a very thorough and balanced report of all of the experiences.

There are definitely conditions and situations where telemedicine is a tremendous support to medical care, especially for families that do not have access to transportation to get to a medical office. We also learned that there are limitations as to what telemedicine can do, especially where a hands-on exam is actually helpful to continue that health care,

We are also learning about what is best for telemedicine, working with the insurers about properly paying for telemedicine services, because the care that is delivered over audio-visual [links] or telephone can be very challenging, based on technology needs and the distance of that care, but cognitively, the skills of that medical person doing that service is all hands on deck.

So, having parity in payment for telemedicine services equal to in-office services is also important to make it sustainable.

ConvergenceRI: Quick follow up question. Healthcentric Advisors has been working in creating digital platforms to better connect providers with patients. Are you familiar with the work that they are doing on those digital platforms?
LANGE: At this time I am actually not aware of that.

ConverenceRI: I will make the connection then. It is all about convergence. You should talk with them about what they’ve done in terms of remote blood pressure readings and remote screenings, under their platform known as PRiSM.
LANGE: I have heard about [remote digital connections] under other umbrellas, not from Healthcentric – but indeed, the blood pressure monitoring, the diabetes monitoring, the data has been [important] for maintaining chronic health conditions and a stable life, so patients do not have to keep coming to the office for further check-ins.

ConvergenceRI: How have not only the behavioral health of patients, but behavioral health needs of doctors and nurses changed as a result of the pandemic, as health care workers are coping with a sense of burnout?
LANGE: The data for telemedicine for behavioral health is tremendous. That is a place where telemedicine has been a tremendous addition to the health care of people in the state.

Behavioral health colleagues will say that their no-show rates plummeted when patients had access to care through telemedicine and did not have to come into an office.

That is important because the pandemic has been very challenging on everybody’s mental health, as a baseline in terms of disruption in our home and our families.

But for mental health providers, this is something else that will be important to me in this next year of leadership.

Health care providers have had an incredibly stressful pandemic, working on the front lines, trying to save lives, not only the lives of people who are sick, but the lives of people coming into our offices and talking to them about the importance of the COVID vaccination. It has been a very trying and stressful 20 months. And so, I do worry about the mental health of our health care workers .

The vaccine mandate has put stresses on people in different directions as well, and so, I think, as a state, we need to be aware, and acknowledge the stresses, of working in medicine during the pandemic, and see what we can do to make sure that all health care providers feel supported, and have a safe place to work through their own mental health.

ConvegenceRI: Where should the conversations around health care be taking place? I know that the Rhode Island Foundation has convened a meeting of stakeholders to come up with a 10-year plan, but do the conversations around health care need to being taking place in a different format?
Sometimes it seems the conversations are taking place high up on the mountain, where not everyone can participate. Is there a better place for those conversations to happen?
LANGE: I would turn that around a little bit and say any place a discussion about health care delivery and the future is important, in every setting. The important thing is to stitch those discussions together, so that they are not occurring on individual “mountains,” but [recognizing] they are all happening in a mountain range together, so we are able to talk about our ideas share our experiences.

Health care delivery and the health of Rhode Islanders is so multi-faceted, it is not just about the chronic disease management and mental health and preventative vaccines and [office] visits, it is housing, it is substance abuse, it is schooling, it is anti-poverty, it is anti-racism, there are so many pieces under the bucket of social determinants of health. And, I think that state leaders are realizing how inter-connected health is with every other aspect of our society.

It is important that in each place, where these conversations are happening, that we continue to link them together. I don’t think that one group has the perfect answer. I don’t think that there is one perfect answer. But I do think that having ongoing discussion collaboratively is important.

Knowing that the Rhode Island Foundation is having discussions is great; let’s see them get together with the legislative discussions; let’s link it together with what is happening at Dorcas Place or at RI Kids Count.

Let’s link these conversations together, so we make sure we hear everybody’s needs, and we can put together a system that can address everything.

ConvergenceRI: What haven’t I asked, should I have asked, that you would like to talk about?
LANGE: [long pause] I think my overarching theme is that we need to be patient with each other. The pandemic has put us all on a journey, both individually and collectively. We need to be patient with each other’s pace on this journey.

And, we need to continue to work collaboratively. We can continue to do the good things that Rhode Island has always done. We are poised for good stuff, building on the foundation of the good stuff we already have. So I am excited to spend this year as president of the Rhode Island Medical Society, and I will try to keep things moving along.