PROVIDENCE – Many of the titans of the health care industry in Rhode Island gathered on Tuesday morning, May 28, in the House of Representatives chambers for what was billed as a “Healthcare Summit,” organized by House Speaker Joseph Shekarchi. Can you spell “clout?”

Give credit to the Speaker – and to the Senate President, who because of his current health condition was unable to attend in person, but his presence behind the scenes was clearly felt. [Editor’s Note: The Senate President returned to work in person on June 6.]

Speaker Shekarchi had assembled the powers that be to talk about the future of health care in Rhode Island. For sure, there were lots of powerful folks talking at each other from the podium about what they thought the state should do to solve the problems besetting the delivery of health care in the state. There were a lot of important folks attempting to score points in a public airing of problems and solutions.

How much listening was being done?  Well, that was much more difficult to discern. There were lots and lots of competing agendas at play in the room.

The indefatigable reporter Steve Ahlquist provided a complete four-hour video of the session, along with partial transcriptions of both Sen. Sheldon Whitehouse and R.I. Attorney General Peter Neronha. [See link below to the Ahlquist post.]

Now, some two weeks later, ConvergenceRI is still wrestling with how best to put together a story about what was articulated at the health summit – and what wasn’t said out loud at the gathering.

Because the world spins so quickly these days, particularly around the moving targets of health care and innovation and budgets – the stories tend to blur together.

[Editor’s Note: The result is that rather than a “he says this, she says that” reporting of the summit, ConvergenceRI found himself, much like the oral historian Studs Terkel, posing what Terkel often called “the impertinent question.”]

There was a great deal of what is known as the “pressing of the flesh” – ConvergenceRI spoke briefly with John Tassoni, Jr., SUMHLC president and CEO, Debra Hurwitz, executive director of the Care Transformation Collaborative, Michael Souza, president and CEO of Landmark Medical Center, M. Teresa Paiva Weed, president of the Hospital Association of Rhode Island, Neil Steinberg, chair of the RI Life Science Hub, House Speaker Joseph Shekarchi, Martha Wofford, president and CEO of Blue Cross and Blue Shield of RI, and OHIC Commissioner Cory King, among the numerous folks in attendance.

There were also nods, waves and hellos from Peter Marino, President and CEO at from Neighborhood Health Plan of RI, Sen. Josh Miller, and Rhode Island Foundation President and CEO David Cicilline.

One important factoid that did not seem to earn any mention in the more than four hours of talking about the future of health care in Rhode Island was the continuing crucial role that Optum, a for-profit division of UnitedHealth, is now playing in Rhode Island as the manager of behavioral health contracts for the private health insurer Managed Care Organizations of Neighborhood Health Plan of Rhode Island and UnitedHealthcare of New England. [An impertinent question to ask: Was UnitedHealth in attendance? Were they invited and declined to attend?]

By the numbers, there are roughly 1.1 million residents of Rhode Island. Some 325,000 Rhode Island residents – children and families and single adults living at the stipulated federal poverty levels – are receiving their health benefits through Medicaid. As of April 30, 2024, there were 329,760 Rhode Islanders enrolled in Medicaid, according to R.I. EOHHS. There is always a monthly churn when it comes to Medicaid numbers. A month later, as of May 31, 2024, R.I. EOHHS reported that there were 320,884 Rhode Islanders enrolled on Medicaid. 

Translated, the lion’s share – some 90 percent, or about 290,000 Rhode Islanders – receive their health benefits though three private managed care organizations, or MCOs. They are: Neighborhood Health Plan of RI [some 64 percent, or 181,000 members]; UnitedHealthcare of New England[some 30 percent, or 83,000 members] and Tufts Health Plan [Point32 Health] [some 5.7 percent, or nearly 16,000 members].

What that means is that there are roughly some 265,000 Rhode Islanders on Medicaid – approximately one-quarter of the state’s population – whose behavioral health services are managed by Optum, the for-profit division of UnitedHealth.

As Lisa Peterson, the COO of VICTA, wrote in a story in ConvergenceRI published on Dec. 5, 2022, “The state’s co-dependence upon Optum is not optimal.” [See link below to the story.]

Those numbers may change, pending the outcome of the upcoming decision by the state to renew the contract for selecting the future Managed Care Organizations. Bidders include the three current health insurers as well as a fourth bidder, Blue Cross and Blue Shield of Rhode Island. Only three will be chosen, according to state officials.

Optum is also one of the largest owners of physicians’ practices in the U.S., and if the expedited sale of the physician practices by Steward Health Care goes through under the bankruptcy, that number will increase.

A story last week in The Boston Globe described the urgency attached by Steward Health Care’s attorney for selling the physicians’ groups to Optum before the U.S. Federal Trade Commission can investigate potential anti-competitive practices.

The quote, which could be found at the bottom of the story, was easily missed; it may have relevance to future health care developments in Rhode Island and what happens as state regulators decide about the proposed sale of Roger Williams Medical Center and Our Lady of Fatima hospitals to the Centurion Foundation: “It will be up to the bankruptcy court to decide who gets paid, and how much, from Steward’s asset sales. Much of the jockeying over financing terms Monday [June 3] was driven by worries that whoever provides financing will be first in line to receive proceeds, elbowing out others owed money.” 

“Steward’s lawyers insisted there’s substantial buyer interest in its hospitals and especially its doctors network. ‘This physicians group is very sought after,’ said Ray Schrock, an attorney for the law firm Weil, Gotshal & Manges, who represents Steward. ‘It’s very valuable.’”

“But he said it was important to move quickly with a sale, citing the Justice Department’s ongoing antitrust review of a proposal to sell the network, called Stewardship, to the Optum division of UnitedHealth [enphasis added]. ‘Keeping physicians motivated is of paramount importance,’ Schrock said, warning that ‘competitors are circling’ to poach doctors.”

Optum has also been linked to the fallout from the recent large cyber attack and data breach, forcing Optum to shut down UnitedHealth’s Change data clearinghouse that serves many U.S. medical providers, 131 million patients and 676,000 pharmacies, according to an April 30, 2024, story by Forbes.

An impertinent question to ask: Why was any discussion of Optum’s role in Rhode Island’s management of health care in Rhode Island absent from the discussion at the May 28 health care summit? Another impertinent question to ask: When will Rhode Island’s news media – the Boston Globe, The Public’s Radio/PBS, the Providence Journal, Providence Business News, WPRO, WJAR, WPRI, and WLNE – begin to report on why Optum’s current role may not be “optimal” for the future of Rhode Island’s health care?

What many Rhode Islanders do know is that the current way that behavioral health care is managed in Rhode Island, particularly for women and children and for the elderly, has been proven to be problematic. All patients are now being removed from the St. Mary’s Home for Children after the facility has been swept up in scandal. The recent murder allegedly committed by a nursing home resident – he reportedly suffocated his roommate – has demonstrated some of the vulnerabilities in the delivery of care in nursing homes. Another impertinent question to ask: Did you know that the person accused of allegedly committing the murder is a veteran who served in Vietnam?

week, a number of community agencies voiced renewed concern to ConvergenceRI about the forces of entropy afflicting the care for those at risk of homelessness, including the alleged discharge by hospitals of medically fragile homeless persons back onto the streets. The fear is that such individuals were likely to end up dying on the streets without further investment in a coordinated system of intervention.

The good news – call it the forces of synergy to counter the entropy – is that after years of neglect and avoidance, the R.I. General Assembly enacted a FY 2025 budget that made dramatic increases in how Medicaid providers are being paid – increases recommended by OHIC in September of 2023. [See link below to ConvergenceRI story, “Big budget victory on raising Medicaid rates.”]

In further good news, the federal agency SAMHSA announced last week that Rhode Island would be one of 10 states, receiving an additional $40 million in federal funds to support the work of Certified Community Behavioral Health Clinic Medicaid Demonstration Projects [CCBHC].

“It is my belief,” said Benedict Lessing, Jr., the president and CEO of Community Care Alliance of RI, framing the importance of the collaborative advocacy by community agencies, “that the multiple CCBHC SAMHSA grants that CCA, Newport Mental Health and Thrive Behavioral Health were awarded and successfully implemented were instrumental in getting Rhode Island to this point.” Lessing continued: “What we are seeing, in my opinion, reinforces the power of collective advocacy, collaboration and vision.”

Who’s on first?    
Back to the health care summit. The good news is that there was a conversation about the future of health care, held in a public forum, where people had the opportunity to speak and to ask questions.

There was lots of talk and lots of ideas presented and an avalanche of words and ideas delivered to a captive audience – even if there was not much agreement about what to do to solve the ongoing health care crisis that is rocking Rhode Island.

The first speaker of the day was U.S. Senator Sheldon Whitehouse, providing a federal perspective, and as he stood at the podium and adjusted the microphone to his height, he noticed the gavel before him, and with a big grin on his face, much as a kid in the candy shop offered the opportunity to choose a handful of sweets, Sen. Whitehouse seized the gavel and gave it a good, hard bang of the desk before him. Call it an exercise of power.

Sen. Whitehouse began by lamenting the failure of the two largest hospital systems in Rhode Island, Lifespan and Care New England, to merge. “I have long worked towards the goal of trying to make Rhode Island's health care system a model for health care delivery around the country,” Sen. Whitehouse began. “I had hoped that the Lifespan/Care New England merger would be the vehicle for moving forward and completing that work, but that was not to be.”

The anti-competitive legal problems posed by the proposed merger were made perfectly clear by R.I. Attorney General Peter Neronha, at his Feb. 17, 2022, news conference announcing the rejection of the proposed merger. [See link below to ConvergenceRI story, “Getting to no.”]

[Editor’s Note: At the summit, directly behind ConvergenceRI’s seat in what is known as the pit, Dr. Michael Wagner, president and CEO of Care New England, and Dr. John Fernandez, president and CEO of Lifespan, sat side-by-side together, often kibitzing.

Dr. Wagner recently sat down for an in-depth, one-on-one conversation with ConvergenceRI. See link below, “When convergence works, and silos get broken down.” During a break at the summit, ConvergenceRI introduced himself, and asked for a similar opportunity with Dr. Fernandez.

The Lifespan leader said he would be happy to be interviewed by ConvergenceRI, apparently breaking a 10-year corporate policy of not talking to ConvergenceRI. Stay tuned.]

In his address, Sen. Whitehouse then gave a full-throated endorsement to the idea that the state apply for what is known as the federal AHEAD Program, or “All-Payer Health Equity Approaches and Development,” with the goal of improving the delivery of health care services through what is known as a “total cost of care” approach.

On the Centers for Medicare and Medicaid Services website, the AHEAD model is described as follows: “AHEAD is a state total cost of care (TCOC) model that seeks to drive state and regional health care transformation and multi-payer alignment, with the goal of improving the total health of a state population and lowering costs.”

The description continues: “Under a TCOC approach, a participating state uses its authority to assume responsibility for managing health care quality and costs across all payers, including Medicare, Medicaid, and private coverage. States also assume responsibility for ensuring health providers in their state deliver high-quality care, improve population health, offer greater care coordination, and advance health equity by supporting underserved patients. The AHEAD Model will provide participating states with funding and other tools to address rising health care costs and support health equity.”

The apparent linchpin of the AHEAD model, according to CMS, is primary care:  “Primary care is the foundation of a high-performing health system and is essential to improving health outcomes for patients and lowering costs,” the description continued. “Through AHEAD, CMS aims to strengthen primary care, improve care coordination, and increase screening and referrals to community resources like housing and transportation to address social drivers of health. AHEAD aims to increase resources available to participating states to improve the overall health of their population, support primary care, and transform health care in their communities. Improving health care outcomes and health equity for all residents within a participating state or region is a primary goal of the AHEAD Model.”

No doubt few in the room attending the summit were familiar with the explicit details of the AHEAD Model that Sen. Whitehouse was endorsing when he said: “The AHEAD Program moves participants more clearly to full value-based, annualized payment with little pressure,” Sen. Whitehouse said. “It also allows us to set that value-based reimbursement commensurate with our neighboring states in our regional market – not based on past rates held back by the unfair fee-for-service system – but on regional rates. I know that the delegation will gladly put our shoulders on the wheel to use the AHEAD plan to get out of that funding reimbursement hole. I don't see any other escape vehicle from the fee-for-service hole anywhere on the horizon. This is an opportunity, and I want to submit to something other than decades more unfair Rhode Island payment levels.”

In Sen. Whitehouse’s opinion, better health hospital cooperation regulation and an AHEAD reimbursement success will only come with a “consensus [emphasis added].”

“The Rhode Island Foundation has been a particular force for good in this area as have Integra and Coastal, our high-performing ACOs [Accountable Care Organizations,” Sen. Whitehouse continued. “Our unions are at the table with expertise and experience to bring to bear. The bad old days of warfare among hospitals and insurers are behind us and we have leaders in those organizations who well understand the triple aim.”

The problem with the endorsement of ACOs is that the past performance in Rhode Island has often proven to be very uneven. One prominent Rhode Island doctor once said to ConvergenceRI that “Accountable Care Organizations give clusterf*** a bad name.”

The two ACOs mentioned by name by Sen. Whitehouse were those run by Lifespan [Coastal Medical] and Care New England [Integra]. The best person in Rhode Island who might be able to give an overview of the difficulties of creating and maintaining an Accountable Care Organization is Dr. Al Kurose, the former president and CEO of Coastal Medical and, when it was acquired by Lifespan, an executive vice president at Lifespan. He currently serves as chair of the board at the Rhode Island Foundation. At the end July of 2023, Dr. Kurose quietly left Lifespan. ConvergenceRI respects the right to privacy that Dr. Kurose deserves but would welcome his insights.

Scarcity versus abundance, in the search for sustainability    
The model of health care being endorsed by Sen. Whitehouse is what could be described as hospital-centric. The success of OrthoRI as a non-hospital-centric model of care, however, offers a different perspective of how health care in Rhode Island could be organized. [See link below to ConvergenceRI story, “Ortho RI emerges as innovation hub.”]

Similarly, the model of health care delivered at the community level by practitioners such Dr. Beata Nelken, founder of Jenks Parks Pediatrics in Central Falls, combining health care with affordable housing, is non- hospital-centric. [See link below to ConvergenceRI, “Changing the lives of women and children in real time.”]

A third model of health care delivery that is independent of hospitals is the ongoing work in Rhode Island to develop health equity zones and public participation in budgeting of health priorities. Research has shown that only 10 percent of health outcomes in population health are determined by what happens in a doctor’s office. [See links to ConvergenceRI story, “In search of a common language about disruptive health innovation in RI,” and “Changing life trajectories in Providence.”]

Much of the work with Accountable Entities has been done through the R.I. EOHHS, working with community health centers, with uneven results, in ConvergenceRI’s opinion, focused on health services to Medicaid patients delivered through the privatized Managed Care Organizations as part of Rhode Island’s attempt to “re-invent” Medicaid ushered in under the leadership of Gov. Gina Raimondo and then-EOHHS Secretary Elizabeth Roberts.

At issue is the way that the way that the “money saved” by the improved performances under accountable care at community health centers are shared with community health centers, differentiated from the slices of the pie received by the MCOs involved, such as Neighborhood Health Plan of RI, and also the state, which receives a direct claw back of revenues achieved by “better management” through liability contracts with the health centers. At some point, someone in the General Assembly may want to conduct a comprehensive audit of the flow of money through Accountable Entities and Accountable Care Organizations, particularly in light of what occurred during the COVID 19 pandemic and what is occurring now with the ongoing health conditions known as “Long COVID.”

The agenda of presenters included: Dr. Howard Schulman, speaking about the primary care provider crisis; Mary Marran, president of Butler Hospital and the Providence Center, talking about behavioral health care, Dr. Frank Paletta and Dr. John Kiang, talking about the shortfalls in dental health services. There was Blue Cross’s Martha Wofford and Joseph Perroni, president and CEO of Delta Dental. Richard Charest, Secretary of R.I. EOHHS, Care New England’s Dr. Wagnerand Lifespan’s Dr. Fernandez, were also on the agenda.

Where do we go from here?    
The last featured speaker was R.I. Attorney General Peter Neronha. In his talk, the Attorney General responds to what many of the other speakers had to say. Here is an excerpt, taken from Steve Ahlquist’s excellent reporting. Attorney General Neronha’s concluding words spoke of the urgency facing Rhode Island. “There are moments in our history that require urgency, direct speaking, and not being afraid to rock the boat,” he said. “As a state, we can't afford to hold back. We are on the precipice of a disaster and the beginnings are there.”

ATTORNEY GENERAL NERONHA: But make no mistake, we need change. Why do I say this? Do you know that right now we are in Superior Court in a closed hearing fighting to keep Roger Williams and Fatima Hospitals open? The courtroom is sealed. I hear a lot in this job about the need for transparency, but where is the outcry from the media about why that courtroom is sealed? I take no issue with Judge Stern sealing it, but where is the media that criticizes my office repeatedly for not being transparent when there is nothing more important than what's going on in that courtroom?

In that courtroom is the future of Roger Williams and Fatima Hospitals, make no mistake. They’re $24 million behind in their payments. Why? They don’t care about those hospitals. If they could, they would close them. Had we not forced them to put $80 million in escrow four years ago, they'd be closed today. They’re closing hospitals all over this country and the only difference is we have money in escrow to prevent them from doing that.

That is the definition of a crisis, folks. One of my six lawyers is a bankruptcy lawyer. Do you think that's a coincidence? I hired a bankruptcy lawyer because I see insolvency events on our horizon and they can't wait for a report in December. By the way, if that report in December recommends doing the AHEAD program, that ship will have sailed before the report’s done. That report’s not going to be all that helpful, to the extent it recommends the AHEAD program.

Why are Roger Williams and Fatima in crisis? It's not just because they have a lousy owner - and they do. It’s because structurally, in this state, we don't bring enough revenue into the system to allow hospitals like that to function and be in the black and invest back into the health care systems.

I jumped up when Dr. John Fernandez, President and CEO of Lifespan, said he’s operating a public hospital because I wanted to bring attention to the point that in any other state, his hospital and probably every hospital in this state would be supported by public funds. And what is the appetite for public funds for these hospitals? Zero.

We want a health care system. We want bright, shiny new hospitals. We want to get a doctor tomorrow if we don't feel well or if we need a neurologist. [You want to] see a neurologist? See you in six months.

I think Dr. Michael Wagner [president and CEO of Care New England] said, “If you don’t know anybody, you’re not getting an appointment.”

Why can't Roger Williams and Fatima Hospitals make it? It's because they are a 70-30 Medicare and Medicaid payer versus 30 percent commercial. Now, Martha Wofford is right. Commercial payments are the train that is trying to pull Rhode Island into the 21st century when it comes to our medical system. 

I remember going on Newsmakers, and Ted Nesiand Tim White asked me, “How do we get more revenue into the system?”

I said, “Grow the economy” and they scoffed at me. Make no mistake, getting people out of Medicaid and onto commercial insurance is the vehicle by which we can begin to solve this problem – in part.

But do we ever talk about the economy in the context of urgency and what it means for health care? Not until today. We’ve got a lot of people on Medicaid and Medicare. We’re old and we are economically challenged.

And then, our rates are lower than our neighboring states so we’ve got a double whammy and we need to fix that problem. We need to grow our economy and we need to increase our rates, folks.

The AHEAD program may well be a means to increase our Medicare rates, but if we can’t get our application in on time and the ship sails for some period of years, how are we going to do that?

What is our plan to leverage our Medicaid dollars? These are things we can do if we recognize the scope of the problem, and if you’re not in the game, you don't see the scope of the problem.

Somebody said to me that maybe it wouldn't be the worst thing if Roger Williams and Fatima closed. This is somebody who is involved in government at a high level. We know that we can't close those hospitals. It’s not just about the jobs. I know you guys care about your jobs, it’s about the patients first. And John Fernandez and Mike Wagner have both told me they can't take the overflow so we have to fight and save those hospitals and how do we fight and save them? We get those Medicaid rates up, we get those Medicare rates up if we can. 

The federal delegation needs to fight for that and I know that they will. We need to leverage our Medicaid dollars to every last dollar. And if we're not doing it, we need to know why.

Prospect, Roger Williams, and Fatima have been going on for three years now. It’s why the $80 million is in escrow. If it wasn't, they’d be closed and the day of reckoning would already be here. We can’t wait until the end of the year.

I spoke to some emergency room doctors not long ago and we were talking about private equity in health care and of course that has driven this crisis when it comes to Roger Williams and Fatima, no question about it. I said to them, “It’s going to take spectacular failure for people to wake up.” And, I would argue, given the state of oral health with children, we are in a state of spectacular failure [now].

We wonder why Providence School children don’t perform the way we'd like. Well, if you can’t eat and you can't think clearly because your teeth hurt, is it any wonder? We need to fix those three components of our health care system and we need to do it now because if we don’t, we are going to have a more spectacular failure.

We are too fractured in our thinking. We are too siloed in our thinking and we don’t sit around the table and talk to one another enough directly and honestly, even though that’s a hard conversation.

You know what I said to Martha Wofford? I said, “Don't spend more money on health care when it comes to providers. Just reallocate it. Make Rhode Island a magnet for primary care doctors. Take a little from the specialists, and give more to the primary care providers. Rebalance how we pay.”

I don’t know if we can do that or not. Martha would probably tell me 10 reasons we can’t. But it's that kind of thinking that I believe can move us forward. What I know won’t work is continuing to do what we do today.

So what can we do? Well, for one thing, the governor's group that is talking about planning our health care can invite my office to participate, because I would argue no one has done more in this state, in the last three years, in defense of health care than my office.

I'm going to leave you with one thing. The beginnings of the correction are reworking our state regulatory bodies. We’ve got OHIC in one corner doing great work, but it’s over there. We've got the Medicaid office doing great work, but they're over there.

You're trying to move this ship and you don't have enough people and you need a champion to get those people because there’s nobody more important than the Medicaid office and leveraging our federal dollars. So if you take the Medicaid office and you put it with OHIC… I know you want to be independent [but] we'll figure that out.

This is just my plan. Take the Department of Health and bring them to the table as a true regulator empowered and funded and built to do real health care policy so we're not always relying on the Rhode Island Foundation to give us the data. The state ought to have that data... How can we analyze these issues if we don't have the data? Let's figure out how to get the data. Let's get in the room and figure this out.

The Lifespan/Care New England merger wasn’t good for Rhode Island. It was putting two weak places together, which never would’ve worked, particularly with leadership that didn't have a vision as to how it would work. But we are now in a place where we have great leadership in this state with Dr. Wagner and Dr. Fernandez and others. We have a great labor perspective... that can inform the policy decisions we need to make right now to get this done.

Roger Williams and Fatima are there but you can't find a doctor there. The children can't get their teeth treated. We can fix it, but we need a state of urgency. We need to understand what's real and we need to get in a room, not a room where we talk at each other like I'm doing to you frankly, but where we talk together. …Let's fix this. We can do it.