PROVIDENCE – Sen. Sheldon Whitehouse, D-R.I., sees two opportunities for improving Rhode Island’s health care environment, but they won’t last long.
The first is to create a consensus health regulation that would allow for greater collaboration among hospitals and protect them from out-of-state “predation." The regulation could set terms for out-of-state hospital transactions and collaboration among in-state hospitals.
“Many of us can remember when our health care organizations weren’t getting along well with each other and many of us can remember when they were not getting along financially,” Whitehouse said during a health care summit held at the R.I. Statehouse Tuesday morning that he hosted with House Speaker K. Joseph Shekarchi and Senate President Dominick J. Ruggerio. “Now we have a window of sunshine.”
The other opportunity is to improve the state’s reimbursement model through the U.S. Centers for Medicare and Medicaid System’s General All-payer Health Equity Approaches and Development, or AHEAD model.
According to the CMS website, states that are interested in participating in the AHEAD model must apply during a Notice of Funding Opportunity, or NOFO, period. The next NOFO application period opens June 12 and states will have 60 days to submit their applications.
States that are chosen to participate will receive up to $12 million in what’s called “Cooperative Agreement” funding, which is meant to pay for planning and implementing activities that could include: investing in new technology, hiring new staff to support the model, recruiting primary care providers and hospitals to participate in the model, and supporting a Medicaid and commercial payer alignment.
Whitehouse said the program is particularly helpful for Rhode Island because it could help pull the state away from fee-for-service and into a value-based care model that would bring Rhode Island out of its “regional funding hole.” Additionally, it would create a secure environment for hospitals to help lower costs with better care.
“This opportunity may not last, so let’s at least try,” Whitehouse said.
But Attorney General Peter F. Neronha disagreed.
“Let's put the AHEAD program over there until we can get our act together here,” Neronha said, noting that the application is due in August, adding that some aren’t clear on who in the state would be in charge of applying. “The AHEAD program may well be a means to increase our Medicare rates, but if you can't get our application in [in] time, then the ship sailed.”
He also pointed out the “definition of a crisis” is occurring, as the fates of Roger Williams Medical Center and Our Lady of Fatima Hospital are still uncertain. Currently, Neronha’s office and the R.I. Department of Health are assessing an application from The Centurion Foundation to purchase the hospitals from CharterCARE.
“We know we can’t close those hospitals,” Neronha said, adding that representatives from Lifespan Corp. and Care New England Health System have told him they cannot handle the overflow of patients if the hospitals shut their doors.
But the crisis the hospitals are facing doesn’t just fall on their owner, Neronha continued. It’s also because Rhode Island doesn’t bring in enough revenue to allow hospitals to function, much less to invest back into the health care system, he said.
Neronha and Whitehouse were among several lawmakers and industry leaders who discussed the most pressing issues facing the state’s health care system.
Lifespan CEO and President John Fernandez had a simple message that captured the thoughts of fellow speakers.
“We need more money for Medicaid funding – period – and we need to create jobs in the state,” he said.
Fernandez said Lifespan is operating public hospitals without public funds.
“[That] may be the most important point you hear today,” Neronha said, interrupting Fernandez’s speech to highlight what Fernandez said.
Boosting the economy so people can get off of Medicaid and onto commercial insurance plans is one way to begin solving the issues created by Rhode Island’s low Medicaid reimbursement rates, Neronha said.
The portion of Rhode Islanders on Medicaid or self-pay is at least 5% higher than Massachusetts and Connecticut, said Dr. Michael Wagner, CEO and president of Care New England. Though this does not sound like much, Wagner says, getting that 5% of Rhode Islanders on commercial insurance would bring dramatic improvements to reimbursements for hospitals and physicians.
While raising state Medicaid puts pressure on the budget, Martha L. Wofford, CEO and president of Blue Cross & Blue Shield of Rhode Island, said that for every dollar provider rates are raised, the state contributes 35 cents compared with the 65 cents the federal government contributes.
“It is just smart to maximize the federal dollars and bring home more dollars to Rhode Island,” Wofford said.
Indeed, many of the issues primary care providers face will not improve until reimbursement rates are raised, said internal medicine physician Dr. Howard Schulman.
But also the value-based care model right now is “terrible,” Schulman said. It has required doctors to spend too much time away from their patients to document and navigate technology systems, leaving little time to communicate with patients.
Schulman says he spends too much time each day logging into electronic medical record systems and once he’s in, it’s difficult to transfer necessary patient information between health systems.
Dentists also face many of the same issues as primary care providers.
Dr. Frank Paletta noted that when he first came to Rhode Island about 25 years ago, there were approximately 40 oral surgeons in Rhode Island. Now there are less than 30, and three oral surgeons have retired in the last year alone. On top of that, he said 10 practices have closed. But very few of those dentists, if any, participate in Medicaid, he said.
As a state without a dental school and with lower reimbursement rates than neighboring states, it’s difficult to recruit and retain dentists.
“We’re in a crisis and we need to fix it,” said Paletta, who is president of the Rhode Island Association of Oral and Maxillofacial Surgeons.
Many patients rely on emergency rooms as their primary source for dental care, further straining an already overburdened system.
The problem is particularly pressing for children, as dental complications represent the most common infectious disease in kids, said Dr. John Kiang with Rhode Island Children’s Dentistry and Orthodontics. Dental complications also directly relate to a child’s overall health, as many who come in with severe tooth decay are underweight, he said.
Kiang projected a series of photos showing children with dozens of teeth in severe decay and some of whom had facial swelling. These are cases he sees every day and the number of children with severe dental decay is rising at an alarming rate, as there are 500 kids in Providence alone who need urgent dental care, he said.
“We are failing these children,” Kiang said.
Neronha agreed that improving the state’s health care system will require collaboration from all corners of the industry.
“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,” Neronha said. “There are moments in history that require urgency and direct speaking and not being afraid to rock the boat.”
(UPDATE adds paragraphs 13, 15-23, 32 and 33 with additional comments from Attorney General Peter F. Neronha, Lifespan CEO and President John Fernandez, Care New England CEO and President Dr. Michael Wagner and Blue Cross CEO and President Martha L. Wofford, plus other minor changes throughout.)
Katie Castellani is a PBN staff writer. You may contact her at Castellani@PBN.com.