PROVIDENCE – With the Rhode Island health care sector cast of characters constantly shifting, MergerWatch’s recent report, “When Hospitals Merge: Updating State Oversight to Protect Access to Care,” is particularly timely. As hospital mergers become more common – both to shore up struggling hospitals and enable other hospital networks to expand their footprint – issues of oversight and accountability arise: Who’s minding the proverbial store? Will patients have more – or less – access to essential medical services? Who’s making the decisions to approve or deny those mergers?
The merger of Care New England and Southcoast Health is anticipated, as is the merger of Westerly Hospital’s parent entity, Lawrence + Memorial Corp., with the Yale-New Haven Health Services. And, on a smaller, yet still significant scale, there are several certificates of need pending before the Rhode Island Department of Health – including Rhode Island Hospital’s request to establish an obstetrics unit and Lifespan’s request to establish two pediatric beds at Hasbro Children’s Hospital and two adult beds at Rhode Island Hospital for bone marrow transplant patients, with support from the Dana Farber Cancer Institute.
Those requests, if granted, would enable Lifespan to compete with Care New England’s Women & Infants and Kent hospitals’ obstetrics practices and the adult bone marrow transplant unit at CharterCARE Health Partners’ Roger Williams Hospital.
The hospital industry remains tight-lipped; a Hospital Association of Rhode Island spokesperson stated that the organization’s policy is not to comment on issues related to CONs. Representatives from Lifespan and CharterCARE Health Partners had no comment, and Care New England did not respond to a request for comment.
MergerWatch, a New York City-based nonprofit entity that analyzes the hospital industry, reviewed health care laws and regulations in all 50 states and the District of Columbia, and assigned a grade to each state based on how useful the state’s CON laws and regulations are in protecting community access to needed health care. The report noted, “A robust CON law ensures that the affected community is notified about a proposed hospital merger and has an opportunity to comment, and requires state regulators to consider those comments and the potential impact on patients’ access to care if the merger were approved.”
The MergerWatch Project’s report awarded Rhode Island an “A-,” as it did California and Tennessee. Only three states earned an “A” ranking – Connecticut, Illinois and New Jersey; Massachusetts earned a “B-.” A vast number of states across the country earned failing grades.
Here’s why Rhode Island earned its high ranking, according to the report:
Criteria for triggering a CON review
Rhode Island earned an “A.” In Rhode Island, criteria that trigger the review are: new hospital construction, capital expenditure development or adding beds to an existing hospital; a sale, purchase or lease of a hospital; transfer of control of a hospital, a hospital closure and loss or relocation of health care service(s).
Organizational structure of review board and transparency
The state earned a “B”: The certificate of review is conducted by a joint administrative team and appointed board.
Communications with the public
Rhode Island earned a “B.” The report noted that a website contains details about the CON process, including summaries of regulations, laws and other relevant information; it is easy for consumers to find information about the CON process on that website. While the public is notified about the CON applications through newspapers or other widely circulated platforms, the website does not contain information about each CON application, including dates of public hearings and information about submitting comments. (Visit http://health.ri.gov/systems/about/requests/ for more information.)
Accountability and public engagement
Rhode Island earned a “B.” When requested, a public hearing is held, where members of the public can participate in the review process by testifying and in the review process by submitting written comments; however, there is neither a mandatory public hearing nor a regularly scheduled review board where the public can testify.
Post-approval review and enforcement
The state’s “A” ranking is due to these factors: After a CON is denied, there is a post-approval challenge process and a mechanism exists to enforce compliance with certificate of need requirements and restrictions.
Review standards
The Ocean State earned its lowest ranking here, a “C.” Why? While review standards evaluate whether the project will impact underserved populations, the CON review does not look at whether the project is financially feasible, will impact health care access within a geographic region and is compatible with state health planning goals. Moreover, there is no requirement for consumer representation on the review board.
The Rhode Island Department of Health expressed satisfaction with the overall grade of “A-,” with a caveat or two regarding the low grade on the review standards. “That “A-” is reflective of the comprehensive approach we take in this area,” said DOH Public Information Officer Joseph Wendelken.
Asked about the “C” grade for Rhode Island’s CON review standards, Wendelken said the state’s Hospital Conversions Act and the “change in effective control” provisions within the Licensing of Health Care Facilities Act, rather than the CON review standards, mandate the procedures by which DOH examines proposed hospital affiliations or mergers. Those laws, either individually or collectively require that Rhode Island assess a proposed project’s financial feasibility, impact on health care access within a geographic region and compatibility with state health planning goals. With different states’ diverse laws and regulations, it can be difficult to compare one state with another, Wendelken said. Moreover, Wendelken said, the state’s Health Services Council, which makes recommendations to the DOH director on CONs, initial licensures and change in effective control, etc., includes a community representative, contrary to MergerWatch’s assertion.
Massachusetts received grades of “C” for criteria or triggering review, “A” for structure of review board, “Bs” for communications with the public, accountability and public engagement and post-approval review and an “F” for review standards.
For a copy of the full report, visit mergerwatch.org.
