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In R.I., successfully mixing liberal, conservative healthcare reform

Rhode Island State House after a post 9/11 ceremony.

David Leonhardt, writing in The New York Times, presents Rhode Island as a state that is successfully combining liberal and conservative ideas about healthcare reform.

He writes:

“Conservative health reform is not an oxymoron. Nor is bipartisan health reform. It’s possible to combine conservative and liberal ideas to cover more people while holding down costs.”

“You can find a real-world case study  in Rhode Island.”

Gov. Gina Raimondo’s “strategy has been based on the most important — and, in a strange way, most promising — fact about American health care: Much of our spending doesn’t make us healthier.”

To read the article, please hit this link.

Smooth care transitions a point of pride for this small R.I. hospital


South County Health, a small nonprofit system in bucolic southern Rhode Island, owes a large part of its success to its ability to manage transitions of care – an increasingly urgent imperative as healthcare moves from fee-for-service to value-based reimbursement.
The system’s flagship is South County Hospital, a 100-bed community hospital. The system also includes South County Home Health Services (a home health agency); South County Surgical Supply (home medical supplies); South County Medical Group, with 65 physicians and advanced-practice providers, and two Medical and Wellness Centers, one in Westerly and the other in East Greenwich, with urgent-care facilities and an array of primary-care and specialist physicians.

South County Hospital has long had very high marks for quality and patient satisfaction. Indeed, surveys have often called it the best hospital in its state and one of the best in New England. It was recently awarded a five-star rating by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), putting it in the top 2 percent of those surveyed nationwide.

Louis R. Giancola, the system’s president and chief executive, attributes much of the hospital’s success in patient satisfaction — and fiscal stability — to the strong engagement of its staff, which “we keep in the know’’; a “supportive board’’; the long-term loyalty of people in the service area, and the “nimbleness of a community hospital’’. Having a relatively affluent market with many well-insured people hasn’t hurt either, he acknowledged.


Mr. Giancola.

A particular point of pride is: “We’re good at transitions of care. Maybe that’s a result of our being small.’’

South County Hospital, like virtually all health systems these days, faces many challenges in dealing with the rewards and penalties involved in the forced-march transition to value-based reimbursement. Mr. Giancola notes:

“Medicare incents us to improve patient satisfaction, reduce hospital infections and avoid various patient injuries.  Most commercial payers (insurers) have followed suit. I believe the threat of reduced payments has focused our attention on these measures even though we sometimes complain that the measures are not always fair.’’ (See below.)’’
“It’s all about blocking and tackling. The biggest issue is readmissions within 30 days. {South County has long had lower readmission rates than most hospitals.} We’ve really focused on managing the transition from the hospital to another level of care. The important element is good communication between the hospital providers and the skilled-nursing facility, home health and the doctors caring for the patients in the community.’’

Part of South County’s recognized success in overseeing clinically successful and financially efficient transitions – and, in so doing, reducing costly readmissions — has been its emphasis on using, when possible, home health care instead of nursing centers to save money and improve care, Mr. Giancola said.

The Centers for Medicare & Medicaid Services and other regulators and payers have been pushing hard for better patient-care management, especially since the Affordable Care Act took full effect. Much of South County Health’s work in this area involves helping primary-care physicians to be better traffic managers of their patients’ care.

Another transition success story he cites is medication reconciliation. “Often patients are confused about their drugs and that can lead to readmission because they take drugs that are contra-indicated or they take two meds designed to address the same problem. We’ve hired pharmacists that review meds in the hospital to ensure they are reconciled and the patients get clear advice on discharge.’’

He notes as an example of what might sometimes be unfair pressure from the Feds: CMS’s making hospitals put many patients who have to stay in the hospital for a night or two into “observation’’ status instead of as inpatients, thus slashing potential hospital reimbursement.

Bundled payments, Medicaid and an ACO

An increasingly important strategy for controlling costs and improving care is bundled payments.

South County Health participates in a bundled-payment program for joint-replacement patients with Blue Cross for their Medicare Advantage and commercial-insurance members. (Cambridge Management Group has been doing a lot of work in bundled-payment programs and so this particularly caught our eyes.)

With older-than-average market demographics, the joint-replacement business is a major contributor to the system’s bottom line. (However, while the system is financially stable, its operating margin is only about 2 percent; the system is closely managed.)

Mr. Giancola said that, as with many things in the brave new world of value-based medicine, it’s unclear what sort of savings may come out of the move to bundled payments. However, he thinks that the clinical benefits are clear:

“The bundling process helps us to get a better handle on the clinical process. Having to report quality throughout the entire episode of care makes for better transitions and final outcomes.’’

South County Hospital’s leaders are happy that the Affordable Care Act has put so many uninsured people into Medicaid. While Medicaid reimbursements lag those of Medicare it’s a lot better than no insurance for low-income people. Many of those people, of course, have long used the emergency room as their major source of “free’’ (to them) medical care.

But, perhaps surprisingly, Mr. Giancola told us, Medicaid expansion has not yet cut the flow of people into South County Hospital’s ER, despite efforts encouraged by public and private insurers to promote more and better preventive care to keep people out of the ER. “ERs are too handy for lots of people,’’ he observed.

South County Hospital has had to deal with many other changes, whose long-term fiscal effects are difficult to predict. One is the rising number of employed physicians, hired, Mr. Giancola says, to ensure that the hospital can maintain the range of services that patients want and need in an acute-care facility, such as obstetrics.

Mr. Giancola notes that’s expensive. “Hiring doctors away from private practices to be based in the hospital puts them in more expensive places, with expensive support staffs, equipment and technology. The jury is out on whether the increase in hospital-employed physicians will save money in the long run.’’

Also unknowable at this point is whether South County’s participation in an Accountable Care Organization with Blue Cross & Blue Shield of Rhode Island (BCBSRI) and Integra Community Care Network will ultimately save money. Integra is a partnership of Care New England Health System and its network physicians, Rhode Island Primary Care Physicians Corporation and South County Health and its network physicians. Focused on population-health management, the ACO provides incentives for Integra’s providers to proactively manage patient health, with a heavy emphasis on prevention of illness, while trying to restrain costs.

South County Health, as befits a, well, beloved local institution is big on promoting community-wide collaboration of institutions that can help improve not just healthcare in a clinical sense, but population health.

Toward that end, it has brought together such diverse agencies as the YMCA, the five Federally Qualified Health Centers in its area, school systems, the local Community Action Program and community members to harness the resources of the community. Whatever happens to the ACA, the move toward community and population health will continue, and South County Health will help lead it in southern Rhode Island.

Mr. Giancola has written: “Our long-term goal is to inspire the broader community to see health as a community issue and to mobilize government, schools, businesses and citizens at large to rally around efforts to ensure a healthy community.’’

What hospital consolidation means in a tiny state


Downtown Providence, Rhode Island.

Here’s a look at what hospital and other healthcare consolidation means in one state — tiny Rhode Island. Kristin Gourlay of Rhode Island Public Radio concludes:

So there’s all this consolidation. What about the proliferation of {Rhode Island-based CVS} MinuteClinics and freestanding ERs? I think it’s a side effect of consolidation, a response to long waits, overburdened primary care doctors and emergency departments. And I think it’s a recognition that hospitals are changing. Not everything has to be done in hospitals – witness the growth of outpatient surgery, imaging centers, and more. And as community hospitals struggle and shut down, we’ll see more of these freestanding clinics or chains popping up to fill in the gaps. Of course, I don’t believe big trauma center/teaching hospitals are going anywhere any time soon. You still need catheterization labs and surgery suites and specialties. But maybe you don’t need as many of them within a small radius. Or at least, it’s turning out to be too expensive to maintain some of the same specialties at so many different sites.

Then again, it could be that consolidating so many services or hospitals under one roof leads to higher prices – we have yet to see what happens in the next couple of years in Rhode Island. With the consolidation that’s already taken place, spending has not risen as fast here as everyone thought it had.

Consolidation clearly has its up and down sides. Upsides include perhaps an easier-to-navigate system, maybe lower costs. The downsides include less patient choice, and, most importantly, the loss of jobs. But in a state that’s getting older and sicker, let’s hope there’s room for growth in healthcare jobs to take care of us.

Westerly Hospital owner seeks to affiliate with Yale New Haven


Watch Hill Harbor. Watch Hill is a particularly rich part of Westerly.

Westerly (R.I.) Hospital’s parent company, Lawrence and Memorial Hospital,  seeks to affiliate  with much larger  and famous Yale New Haven Health System. This would leave Rhode Island’s two dominant hospital systems, Lifespan and Care New England, out  in the cold in an area of southwestern  coastal Rhode Island and southeastern Connecticut with many affluent patients with good private insurance. Lifespan and Care New England themselves have resumed merger talks.

L&M spokesman Michael O’Farrell  told Rhode Island Public Radio that if regulators approve the affiliation,“Yale New Haven Health System will invest $300 million  in eastern Connecticut and western Rhode Island.”

Lifespan, Care New England revive merger talks


Care New England’s Women & Infants Hospital in Providence, right next to Rhode Island Hospital, owned by rival chain Lifespan. Some observers think that this proximity is financially and clinically bizarre.

Lifespan and Care New England, Rhode Island’s two largest hospital systems, have quietly revived merger talks, Rhode Island Public Radio reports.

Timothy Babineau, M.D., Lifespan chief executive, told Rhode Island Public Radio that the  talks “are in very early stages’’ and are in response to Care New England’s recent request for partnership proposals.

As Scott Mackay of RIPR noted: “The two large hospital chains, which control roughly 70 percent of the state’s healthcare market, have been down this read twice before, only to see the efforts crash amid a series of state regulatory and financial challenges.”

“The recent evolution of medical care in southern New England may augur in favor of such a combination now. Obamacare and the expansion of the federal Medicaid program have given hospitals more revenue. Yet, the competition from Massachusetts is, if anything, stronger than ever, with Bay State health providers moving relentlessly to poach patients, particularly those with private health insurance, from Rhode Island.”

“A merger would make sense on many levels, especially in building a stronger Rhode Island-based medical provider network. Many medical observers have long wondered why Women & Infants Hospital, which shares a campus with Rhode Island Hospital, is in Care New England, while Rhode is part of Lifespan.”




Will retail clinics transform primary care?



A story in the Providence Business News investigates whether retail clinics  set up in drugstores by CVS and other pharmacy chains will transform primary care. That Rhode Island is also the headquarters of CVS adds a certain piquancy to the issue in the tiny state.

“It’s the latest iteration of easy-access care that’s forcing doctors, hospitals and insurers in Rhode Island and across the country to take notice, as they brace for federally mandated changes designed to stem the ever-rising costs of health care delivery,” noted the newspaper.

“The retail clinics are filling a market void, and they will continue to be relatively successful until the primary care physicians are able to fill that void,”  Augustine Manocchia,  M.D., chief medical officer of Blue Cross & Blue Shield of Rhode Island, told the paper.

Michael Fine, M.D., a former Rhode Island state health director, said  easy-access care  offered by CVS MinuteClinics and similar outlets, is cutting into primary-care physicians’ “bread and butter.”

“[Physicians’] economic survival depends on their ability to treat the sore throats and rashes. The more complicated conditions – they’re not well-paid for,” Dr. Fine told the publication. “The danger is that from a business-model perspective, we’re peeling away their margins.”

But Steven R. DeToy, director of government and public affairs at the Rhode Island Medical Society, says retail clinics could be a “great help” to providers if they stick with basic services .  But he’s wary that clinics might try to become something more. The paper said that “He says that could further fragment an already disjointed system of care.”

“I think hospitals are going to be the most challenged health care organization of the next 20 years,” Dr. Fine predicted to the paper. “If the rest of us are good at what we’re doing, hospital [visits] should drop by 40-50 percent and their volume will diminish. If it doesn’t diminish then we’re going to be a collaborative failure.” •

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