You could never say Providence lacks for hospitals. Within its 18.5 square miles, the city has Rhode Island Hospital and its Hasbro Children’s Hospital; Women & Infants Hospital; St. Joseph Hospital for Specialty Care; The Miriam Hospital and Butler Hospital on the East Side; and Roger Williams Medical Center and the Providence Department of Veterans Affairs Medical Center in Elmhurst.
In addition, there is Brown University’s Warren Alpert Medical School – a small program compared with those at Harvard or Yale universities, but a powerhouse within the state and an increasingly high-profile player in biomedical research. And of course, there are primary-care and specialty medical practices galore, many of them connected to Brown.
As of May, about 90,200 people in the Providence-Warwick-Fall River metropolitan area worked in health care, including 28,600 in hospitals, according to the R.I. Department of Labor & Training. It is one of the state’s, and the city’s, biggest economic sectors, bigger even than higher education.
Yet while the need for health care is only growing, many providers are struggling, their finances strained by low Medicare, Medicaid and insurer reimbursement rates, work force shortages and high overall costs. Even the strong, such as the Lifespan system, say they feel the economic pressure.
That is the context of the proposed merger between Lifespan and Care New England – already the state’s and the city’s top two private employers. As the companies’ CEOs have put it, no hospital in Rhode Island is immune to the common challenges, and even the strongest have to get stronger, leaner and more competitive in order to thrive.
The actual merger application, a roughly 50,000-page document submitted a few weeks ago to the R.I. Department of Health and the state attorney general – deemed incomplete, so it’s not yet being processed yet – will reveal crucial details that many say will determine whether the merger will be able to pass regulatory muster.
But the basic points, as outlined by the two companies and in public documents, are these:
• The two organizations would merge into a single health system named Lifespan, with more than $2 billion in patient revenue, more than 17,500 full- and part-time employees, and more than 3,000 affiliated physicians.
• The new system would control about 70 percent of hospital beds in the state, and an even larger share of the beds in Providence – more than 1,220 at Rhode Island, Hasbro, Women & Infants, Miriam and Butler hospitals combined, leaving just the 220-bed Roger Williams and St. Joseph Health Services of Rhode Island’s 70-bed Southern New England Rehabilitation Center, which is actually a joint venture with Rhode Island Hospital (St. Joseph’s 40-bed psychiatric unit is to be moved to Our Lady of Fatima Hospital in North Providence).
• Butler would be moved to a new facility close to Rhode Island Hospital, and a new Brain Science Institute would be created. That, combined with the planned relocation of the Brown medical school to a site on or near Rhode Island Hospital would create “a cohesive academic medical campus rivaling those in Boston and New Haven,” as an issue brief from Lifespan put it. Butler’s historic East Side campus would, in turn, be sold.
But how would all of this affect health care delivery in the city?
Lifespan and Care New England officials have said a merger would create “efficiencies” that would allow them to improve overall quality and provide more high-tech and specialized services, for which Rhode Islanders now travel to Boston. Yet several people and institutions, most notably the Rhode Island Medical Society, have expressed concern that the gains will come at the expense of primary care for the broader community.
For starters, the new system will have “a huge negotiating leverage,” said Dr. Al Puerini, president of Rhode Island Primary Care, a network of independent doctors’ practices. That will allow Lifespan to get higher reimbursement rates for its hospitals, and insurers will either pass the costs on to employers and consumers – making insurance less affordable for all – or try to offset the cost by paying other providers less.
To avoid negative consequences, the Medical Society has called for a moratorium on hospital mergers until the state develops a comprehensive, coordinated health care plan. In addition, doctors have asked Lifespan and Care New England leaders to commit themselves to strengthening primary care in conjunction with the merger.
But Dr. John B. Murphy, vice president and chief medical officer of Rhode Island Hospital, said that as much as he supports paying primary care doctors better, their prediction that the merger will suck resources out of the system “doesn’t make sense.” Lifespan and Care New England already have plenty of negotiating clout, he said, and if they can keep high-end services here, they’ll keep dollars in the state that now go to Boston.
Both systems also offer extensive primary care services themselves, Murphy noted – Rhode Island Hospital’s two outpatient clinics alone handle about 30,000 visits per year, and Hasbro is the single biggest pediatric primary care provider in the state – and they provide subspecialty care for many low-income people referred by community health centers who could not get care anywhere else.
“I wouldn’t argue that we’re the be-all and end-all in terms of primary care,” he said, “but I would argue we’re doing a lot, and we’re being a safety net for a lot of people.”
As he sees it, Murphy said, doctors are saying “there’s nobody looking out for us,” and because Lifespan “has some clout,” they want it to exercise that clout in their favor.
The other big worry expressed by many critics of the merger is that it will hurt the remaining community hospitals. Warde, in fact, said the planned St. Joseph-Roger Williams merger and talks between Landmark Medical Center and Memorial Hospital of Rhode Island are “in part, defensive reactions” to the larger merger plan.
Asked how St. Joseph leaders feel about the Lifespan-Care New England plan, President and CEO John M. Fogarty said they are waiting to see the details, but the timing of his own hospital’s merger plans does reflect a recognition that “it’s becoming a more consolidated market” and “a more difficult health care market,” and that larger systems “are at a competitive advantage to individual hospitals.”
It’s going to be important to ensure that Rhode Island maintains a strong primary care infrastructure, Fogarty said, because “there can’t be a good tertiary care system if there isn’t a good primary care base to refer to it.” And no matter how good Lifespan’s services are, he added, community hospitals are crucial as well, because “they play a very distinct role,” not only for local residents, but in support of the larger facilities. •
These "issues" can all be worked out. It would be a shame to impose regulatory paralysis, intended to keep predatory chains out of our state, against the earnest efforts of our own organizations to create a world class facility that would benefit our state so dramatically.