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Will the health care industry willingly relinquish its economic power?

The conflict between health care as a commodity and as community-driven Health Equity Zones took center stage at a meeting of stakeholders convened by the Rhode Island Foundation to develop a plan of action for its long-term statewide health plan

Photo by Richard Asinof

The view from the Rhode Island Foundation gathering of stakeholders to discuss the statewide, long-term health plan on Monday, Feb. 17, at the R.I. Convention Center.

By Richard Asinof
Posted 2/17/20
The gathering of stakeholders by the Rhode Island Foundation to discuss strategies to push ahead with its long-term statewide health plan illuminated potential directions forward at a precipitous time for public health in Rhode Island and the U.S. The session on the work being done by Health Equity Zones in Rhode Island offered a different vision about how to address upstream root causes.
Will the R.I. General Assembly include dedicated funding to support Health Equity Zones in Rhode Island, or will it fall to the Rhode Island Foundation to make that investment? Is there a need to change the focus on “waste” away from patients who are deemed “high utilizers” and instead put the focus on practices that gin up unnecessary imaging and tests? How can health systems move toward safety and quality improvements that are not conditioned on patients bringing lawsuits around legal liability? How does raising the wages of community health workers and nursing home workers increase the potential for better health outcomes?
The connection between health equity and tree canopy, particularly in the work being done in Newport by the local HEZ as a way of preventing and decreasing intimate partner violence and violent crime overall, is the kind of innovative strategy that often eludes economic development planners who see buildings and not communities as innovation hubs. It is an example of bottom-up innovation that does not seem to register as a powerful economic development tool. It shouldn’t surprise anyone who reviews the data presented in the 2020 legislative report by the R.I. Commission for Health Advocacy and Literacy that Pawtucket, Central Falls and Providence have the lowest percentage of tree canopy cover in the state, each with less than 18 percent of land with tree canopy cover.

PROVIDENCE – Everyone was there, almost. Many of the movers, shakers and decision makers in the health care industry in Rhode Island attended the confab organized by the Rhode Island Foundation to engage with “stakeholders” about its long-term strategic plan for health in Rhode Island on Monday morning, Feb. 10, at the R.I. Convention Center.

It was a standing-room-only affair, a veritable who’s who of health care delivery in Rhode Island, all crowded into the first-floor space at the Convention Center, to talk about the shifting borders where the social determinants of health and clinical health care are colliding.

“Historically, investments and interventions, incentivized by traditional payment structures, have focused on clinical care,” the long-term plan said. “But medical care determines just 20 percent of health outcomes, 80 percent are determined by the interplay of genetics and social, economic and environmental factors.” [See link below to ConvergenceRI story, “No risk, no reward.”]

As Neil Steinberg, president and CEO of the Rhode Island Foundation, said in his opening remarks, articulating the challenge: “Where do we want to be in 10 years?” The goal, he continued, was to “pivot to health, not health care.” Steinberg announced that the Foundation was committing $1 million toward its health initiative, and another $1 million toward its education initiative.

And, invoking the comic strip character Pogo’s infamous message, “We have met the enemy and he is us,” Steinberg said that there was no one to point a finger at to blame for the current health care crisis, because we are all in the room. “Them is us.”

Jane Hayward, president and CEO of the Rhode Island Health Center Association, and co-chair of the long-term plan stakeholder group, admitted that in moving forward, “We don’t know all of the how to’s; we need to be aspirational.”

The challenge was how to create a plan of action, reflecting the conflicting priorities. Steinberg was vigilant in his approach: “We’re not going to leave [the long-term health plan] on the shelf,” he promised.

Stakeholders galore
There were lots and lots of CEOs and executive directors in attendance, most of whom had served as stakeholders in preparing the long-term plan and officially signed an endorsement of the plan [although Steinberg, who insisted on the signatures, joked that he was not sure if they were legally binding].

They included: Neil Sarkar, president and CEO of the Rhode Island Quality Institute; John Keimig, president and CEO, Healthcentric Advisors; Tom Giordano, executive director of the Partnership for Rhode Island; Dr. James Fanale, president and CEO of Care New England; Dr. John Murphy, interim president of Lifespan’s Rhode Island Hospital and Hasbro Children’s Hospital; G. Alan Kurose, president and CEO of Coastal Medical; Teresa Paiva-Weed, president of the Hospital Association of Rhode Island; Samuel Salganik, executive director of the Rhode Island Parent Information Network; and Marie Ganim, R.I. Health Insurance Commissioner, among others.

Among the elected officials attending were: R.I. Attorney General Peter Neronha, State Rep. Rebecca Kislak; State Sen. Josh Miller; and State Sen. Gayle Goldin.

A photograph from the side of the podium, looking outward into the crowd, captured the moment, much like the Art Kane photo taken in 1958 for Esquire’s Golden Age of Jazz edition, in which many of the jazz luminaries had gathered in front of Harlem brownstone, a snapshot of time in a world that was about to change dramatically forever.

Here were most of the decision-makers in health care in Rhode Island, with recognizable faces, on the cusp of a dramatic shift, what Dr. Michael Fine has predicted will be a “health care revolt.” How will this moment be remembered?

One of the few poobahs missing from the conclave was Gov. Gina Raimondo, although the Governor had been scheduled to speak at the event at noon, according to her public schedule that had been sent out on three days earlier by the Governor’s communications team. The explanation given afterward was that she had missed her connecting flight from Washington, D.C., where she had been attending a Democratic Governors Association meeting.

Nuance and context
It would be hard to imagine such a confab occurring at a more precipitous time when it comes to health and health care: the rapid spread of the novel coronavirus was shutting down China into a county of quarantine, sending shivers through the global economy, as the biotech industry attempted to design and manufacture an effective vaccine or therapeutic. [See link below to ConvergenceRI story, “Designing a smarter vaccine for the coronavirus.”

A draft of a new economic plan for the state, “Rhode Island Innovates 2.0,” has been completed, laying out a path toward future economic prosperity, inexplicably failing to include either health or health care as a major component, except in the way that intellectual property developed through academic research could move from the bench to the bedside in the advanced industry sectors. [See link below to ConvergenceRI story, “What does public health have to do with future prosperity in RI?”]

Two days after the confab, when legislative leaders were questioned about priorities at the Greater Providence Chamber of Commerce gathering, health care was also inexplicably absent from the conversation as a “business” issue.

The artificial silos [could they be considered a quarantine?] of business and health care as legislative and economic priorities in Rhode Island, however, did not prevent the issues of the future of health care playing out in national politics, with the Presidential primary season in full force. All the polling has shown that the number-one issue that voters are most concerned about is health care. [Will any of the pollsters ask questions about health care when polling Rhode Island residents? Good question.]

One of the most contested policy issues is what will the future of health care in the U.S. become, as the existing status quo becomes more unsustainable and the single-player plans proposed by some Democratic candidates, including Sen. Bernie Sanders and Sen. Elizabeth Warren, continue to send shivers up and down Wall Street. Meanwhile, the future fate of the Affordable Care Act, also known as Obamacare, continues to be a matter to be decided in federal court cases. Last week a federal appeals court threw out efforts by states to enact work requirements for Medicaid, a change championed by the Trump administration.

Rhode Island as an innovation hub in health

The Rhode Island Foundation confab and the discussion by stakeholders about the long-term statewide plan accentuated the potential for the state to serve as an innovation hub in health and health care delivery, building upon its Health Equity Zones and Neighborhood Health Stations and integrated, all-payer primary care initiatives.

As promising as the discussion was, it could not stop the flow of news [like a glacier breaking up in Antarctica] about further consolidation and questions of financial sustainability in the current business model for health systems in Rhode Island. Lifespan and Coastal Medical announced they were engaged in aligning their operations, shying away from describing the move as a “merger.”

Meanwhile, Care New England reported that its health system had realized a $4.5 million loss in operations for its first quarter, higher than the $3 million loss that had been budgeted. Thanks to investment gains, however, the health system ended the quarter with an excess of revenue over expenses of $5.5 million. The greatest financial challenges, Care New England reported, were patient volumes at Women & Infant Hospital and Kent Hospital.

Translated, the two largest hospital-based health systems in Rhode Island are still struggling to overcome financial problems related to their current business model.

On the road to find out
The messaging articulated in the long-term vision was clear: the stakeholders were “laser focused on health equity; the efforts cannot be about health care alone, they must be focused on the significant disparities by race, ethnicity, gender and income.”

Defining the strategy for choosing the road to get there was the major focus of the first part of the confab’s discussion.

At some 25 tables, participants were led in facilitated discussions. At the table where ConvergenceRI was sitting, the topic revolved around potential solutions on how best to maximize health and reduce waste, with Neil Sarkar, the interim president and CEO of the Rhode Island Quality Institute, leading the discussion.

Much of the initial focus of the conversation at the table reflected remarks by Al Charbonneau, the executive director of the Rhode Island Business Group on Health, who spoke about the similarity of the numbers between what the average family spent on health care – 30 percent of their annual revenue, and the amount of waste in the health care system, estimated to be 29 percent, with Charbonneau emphasizing the need to distinguish between low-value care and high-value care. [Somehow, the consequences of a patient telling a doctor “no” never seem to get addressed.]

Charbonneau’s remarks, which also touted the Choosing Wisely program, had been preceded by remarks from Dr. John Murphy, the interim president of Rhode Island Hospital and Hasbro Children’s Hospital, who presented hypothetical cases involving collaboration with Coastal Medical [despite the admonition from Steinberg to have the stakeholders “leave their stripes at the door”] about the opportunities to intervene on the side of better coordination of care as a way of saving unnecessary costs.

The conversation at the table centered on the ways that data could be used to help translate better-coordinated care into monetary savings and better outcomes, with an eye to early intervention and prevention.

In the role of both a participant and an observer, ConvergenceRI raised the need to capture the patients’ voices, and the barriers inherent in the cultural differences in patient populations. ConvergenceRI also talked about how health care outcomes reflected the relationship of trust between the patient and the provider – and the community.

Later, when asked about the remarks around waste in health care, a physician attending the confab responded with particular vehemence, saying that “25 percent of all the costs in health care could be eliminated by removing insurance companies from the equation,” endorsing a single-payer system. It was a strong undercurrent that was not necessarily captured in the facilitated discussions, for sure.

A Chautauqua on health equity
The second part of the confab was a panel discussion on health equity in action in Rhode Island, led by Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health. As part of the presentation, the 2020 legislative report by the Rhode Island Commission for Health Advocacy and Equity, an impressive document that connected data and health equity measures around five specific policy agendas: Integrated health care, community resilience, physical environment, socio-economics and community trauma. [See link below to the 2020 legislative report.]

The panel featured: Womazetta Jones, the secretary of the R.I. Executive Office of Health and Human Services; Jennifer Hawkins, the executive director of ONE Neighborhood Builders; Cynthia Roberts, the empowerment evaluator for all programs at the R.I. Coalition Against Domestic Violence, and empowerment evaluation support for the Newport Health Equity Zone, and Shaun O’Rourke, director of Stormwater and Resiliency at the R.I. Infrastructure Bank, responsible for developing Resilient Rhody, the state’s first climate resilience action strategy.

Here are some excerpts from what was said as part of the panel, which held the audience of stakeholders in rapt attention.

JONES: I have been very direct, with the state as a whole, as it relates to [the focus] that I am bringing to the Executive Office of Health and Human Services. Our work needs to be grounded in three simple roles: community engagement, racial equity, and ensuring that in our work with our residents, [we] are working with the whole person, not just the identified need that has brought them to the attention [to one of our departments].

[In our work, we need] to ask: How have we engaged the community? Did we use a racial equity lens? And, are we focused on ensuring whatever [services] we deliver help the whole person?

When we look at the services that we are offering an individual, we need to look at [that person] not just as an individual, but as a human being, a human being who could be our neighbor, our family, our friend.

At the discussion [at my table this morning], one of the questions I asked was: Do people really recognize that child welfare is a public health issue? But, sometimes, we literally keep those [issues] in two different buckets.

It’s about our community, what they need, what they like, and what they want. We have to relinquish our power, to take a step back.

HAWKINS: The long-term health plan identifies upstream root causes. It correlates with our work with the Central Providence Health Equity Zone, which serves four neighborhoods – Hartford, Elmwood, Olneyville and Federal Hill.

In those four neighborhoods, the life expectancy rate is eight years less than if you live in the East Side neighborhoods.

When we looked at the social determinants of health, we honed in on economic stability and economic opportunity. What we mean is: Can you afford base, stable housing? Do you have the opportunity to [find] sustainable employment?

When we look at it from that direction, [we recognized] that we needed to pivot away from addressing social needs, and truly look at upstream social determinants.

One way that we have changed our model and reframed the way we are thinking about this is, for example: A social need addressing one individual’s circumstance, in which a community health worker may assist them in completing an application for affordable housing.

Pivoting to social determinants means launching [an internship program] to develop core competencies for community health workers, at the end of which [they] have credentials and you have professionalized the position, so [they] can demand higher wages because of the [training] and the professionalism.

It is moving from acknowledging the importance of addressing social needs, and going deeper to the root cause and upstream work to really get at the core of uplifting economic development for workforce development and advocating for housing production.

O’ROURKE: This is exactly the room and the audience that we need to be engaging with on linking public health and health equity and climate change. [In developing our initial plan], we held 10 workshops across the state. We expected to hear about the needs around roads and bridges; what we heard was about how people [were] at the core of bulding healthy, strong and resilient communities.

As a result, we shifted the way we framed our strategy.

Climate change is a threat multiplier, [creating] stresses to already vulnerable systems and communities.

[Increasing] tree and canopy covers is one of the tangible ways that we are linking [lack of] wealth and lack of access to public, open spaces.

Tree coverage is a proxy for wealth and communities of color. Trees grow on money. Open space and parks are really a tier one climate change and public health investment.

ROBERTS: The greening urban strategy that the Newport Health Equity Zone is engaged in, in partnership with R.I. Coalition Against Domestic Violence and the Women’s Resource Center, which is the backbone agency of the Newport HEZ, reflects long-standing work on primary partners violence for the last 16 years.

Open space had been a big priority identified [in the community needs assessment] but there was no funding. When the federal Centers for Disease Control and Prevention came out with new funding and said that we’re moving upstream, it created an opportunity for the work involved with preventing intimate partner violence by greening urban spaces.

Because Newport was ready to do this work, because of all of the [community] infrastructure that has been developed through the Newport Health Equity Zone.

[The research shows] that greening urban spaces is so important in preventing violence and decreasing violent crimes.

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