U.S. healthcare spending climbed past $4 trillion in 2021. That’s about $13,000 for every household in the country. But what do healthcare consumers get for all this spending? Rhode Island and Massachusetts face a shortage of primary care doctors and many non-emergency patients complain about waiting weeks or months to get in to see a doctor. Rhode Island’s largest hospital chains face a challenge, too, since they get a high degree of reimbursement from Medicare and Medicaid, which pay less than private insurance. Is there any reason to think that things will get better? Or is Rhode Island bound to see more consolidation in its healthcare marketplace? I’m Ian Donnis. This week I’m going in-depth with two healthcare experts: Dr. Michael Fine served as head of the state Department of Public Health from 2011 to 2015. He is now a writer, community activist and chief health strategist for the city of Central Falls. Christopher Koller served as the nation’s first health insurance commissioner. He is now president of the Millbank Memorial Fund, a public health foundation.
TRANSCRIPT:
Michael Fine: We don’t have a right-sized healthcare delivery system. We’ve invested in technology and in hospitals as specialists, and but we haven’t invested in a coherent primary care delivery system. And we don’t have anywhere near enough primary care doctor so that every single American, every single Rhode Islander has a primary care doctor.
Ian Donnis: Chris Koller you were formerly Rhode Island Health Insurance Commissioner, what responsibility do vested interests like the insurance industry bear for the situation?
Christopher Koller: Well, I think when you look at our health care system in the US compared to other countries, the big difference is not the number of providers that we have, but how much they get paid. So we spend a lot more money on health care in the United States compared to other places, because we pay a lot more for our health care, not because we use more, but because we pay more. And that means everybody involved in it, providers, hospitals, insurance companies are getting paid more than they get other places.
Ian Donnis: Speaking of paying more, we see how big pharma recently sued the Biden administration to try and stop Medicare from charging lower prices for drugs and medication that seem pretty bald faced on the face of it. What does that tell us about the situation?
Christopher Koller: It says there are a lot of people who are making a lot of money in health care, and they want to keep making a lot of money. And that includes the pharmaceutical industry.
Ian Donnis: Well, let’s bring things back to the local level where Rhode Island’s two largest hospital groups Lifespan and Care New England face financial challenges, in part because they get a lot of their reimbursement from Medicare and Medicaid, which pay a lot less than private insurance. Michael Fine. What can be done about that?
Michael Fine: Well, we’ve got a bunch of challenges around hospitals and and hospital reimbursement. One of the things to point out is that a significant percent of hospital income is public money. 60 to 70%, at least, is public money from Medicare and Medicaid. And what’s really interesting is we have not taken advantage of that opportunity to create meaningful regulation about what hospitals do, how often they duplicate services, and how they run the meter by over utilization.
Ian Donnis: Is there a mismatch in Rhode Island, Chris Koller, between the number of hospital beds and what the state can properly afford?
Christopher Koller: No, actually, I think my office when I was Health Insurance Commissioner conducted a study and we found that in terms of inpatient beds, we were relatively appropriately staffed. I think, a couple of things, your average hospital gets their money, mostly from outpatient services, we think of hospitals as inpatient bricks and mortar, but the bulk of the revenue comes from the outpatient side. So we think they’re really more health systems. And the second thing I would say is, Ian, back to the question that you asked, we actually don’t have a good line of sight into the finances of our health systems, we can tell you to almost to the penny, how our insurers are doing, but we do not know the financial state of our health system. So when they come to the state, and they talk about their financial condition, we have to take their word for it. There should be an there actually is on statute, but it’s not enforced, much greater authority to understand the finances of health systems, particularly if they’re relying on public money. As Michael noted.,
Ian Donnis: Let’s switch gears and talk about COVID The threat of the virus has abated, the impact has greatly been reduced. We hear that most of the vast majority of people can protect themselves through vaccination. But at the same time there is a lot of people there are a lot of people in America who see vaccinations as kind of a signal of what they consider to be heavy handed government and even other people who might not have that view, but just who didn’t choose to avail themselves of booster shots or follow up vaccinations. Michael Fine. What are your thoughts on the takeaways from COVID?
Michael Fine: Well, I think we lost or have lost progressively public confidence in the primary care process. I’m sorry, public confidence in the public health process. And I think some of that happened when we have — when we turned over much of what we do to the for profit world. So people don’t know who to trust, they are, are convinced that somebody’s trying to make a profit on their back. And that’s often because somebody’s trying to make a profit on their back. That means that their confidence is diminished. They don’t have routine access to primary care most of the time, or much of the time. So they don’t have a primary care doctor saying, gee whiz, let’s talk about whether you need a shot or not. Instead, they’re getting their information from the internet and from social media. And that’s undermined our ability to do this well. And Ian it has cost lives like you can’t believe. I just actually compared what Rhode Island did, and how Rhode Island did to how Australia did. Australia is a country that in many ways is like the United States. Australia’s case fatality rate was a fraction of ours. If we had Australia’s case fatality rate, we would have lost five to 600 people, instead of over 4000.
Ian Donnis: Given how we are very politically divided as a nation, Chris Koller, how can the US do better in promoting public health? If and when there’s another pandemic?
Christopher Koller: I think Michael put his finger right on, it has to do with the extent to which we trust public institutions. You cannot have effective functioning public health if you don’t have a reasonable amount of public trust in institutions in general. And so I think it gets directly to things that have nothing to do with healthcare, it has to do with our trust in government, our trust in our public servants. And how do we rebuild that, so that when a pandemic comes our public health officials can be trusted?
Ian Donnis: Michael Fine. You mentioned earlier how there’s a shortage of primary care physicians in Rhode Island. We hear that’s true even in Massachusetts. My wife is a nurse who works for Lifespan, she tells me there’s a crisis in nursing. And we hear people complain that it takes what seems like an overly long time to get an appointment with a doctor, if they have something that is less than an emergency. What would it take to fix that?
Michael Fine: I think what it would take is building a public primary care medical school that obligates people who go to medical school to practice primary care in Rhode Island, but lets them go for free. That’s the opportunity —
Ian Donnis: Sounds like a good idea. But what is the realistic outlook for whether that can be can happen in Rhode Island?
Michael Fine: Well that’s where the politics and the leadership comes in. If we had that kind of focused leadership in state government, anything is possible. You know, a medical school like that might cost us $100 million to build, which sounds like an awful lot of money. But we spend $8 billion on health care in Rhode Island in a year. It’s a tiny fraction of what we spend. And there are reasons for thinking that if we actually had enough primary care clinicians overall, we would significantly decrease the cost of health care, it would essentially pay for itself.
Ian Donnis: Chris Koller?
Christopher Koller: Yeah, I think as we have this discussion in Rhode Island, it’s really important for us to note that we begin this discussion on primary care from a position of strength, we actually have one of the highest amounts of primary care clinicians per capita in the country, we have more people declaring and having a usual source of care than any other place in the country. So in some ways, if it’s tough here, imagine what it’s like everyplace else. The way that I would say it is we begin from a position of strength, whether you’re talking about Michael’s discussions around public medical education, or if you think about reimbursement and our ability to work with commercial insurers to increase the amount of money that’s going to primary care and to pay them in different ways.
Michael Fine: We start from a position of strength relative to other states, but not relative to other countries. Relatively we do quite poorly. Remember, our health care costs twice as much on average, as the other industrialized countries, but our public health outcomes, infant mortality and life expectancy, rank us 50th in the world, despite the fact that we’re spending twice as much as anybody else. So our position of strength is like we have the best lounge chair on the Titanic.
Ian Donnis: I recall reading in the New Yorker some time ago that Costa Rica has longer life expectancy for its people because it’s emphasized a public health approach that emphasizes health rather than treating disease. But let’s switch gears. Rhode Island has been without a permanent state health director for some time. Governor McKee tells me that as long as the acting director is qualified, that’s a non issue. Michael Fine, as a former State Health Director, do you agree? Or is there a downside to not having a not having a permanent health director?
Michael Fine: First of all, the acting director is a wonderful, wonderful physician with many years of experience, who does a fantastic job. That said, the difference between interim and permanent is huge. I was in the interim position for six months. And my ability to do what I needed to do was much compromised. The moment that I became, you know, the director for real. That’s when I was able to pick up the gauntlet of health policy, and really begin to work on making the changes we need to make, making the improvements we need to make and making sure that our healthcare institutions and professionals did what they were supposed to do.
Ian Donnis: One final question about 30 seconds each. A recent story in The New York Times said we might be entering a new golden era of medicine, thanks to innovation and technology, Chris Koller, do you agree? And if so, will those benefits be equally shared across different economic classes?
Christopher Koller: My measure of progress is life expectancy and degree of disparities. I don’t think that our golden era of medicine, if we’re entering that in terms of technology will help either of those, as you may know, our life expectancy is lower than other countries that are much poorer than us. That’s not going to be changed with more medical technology. It’s going to be changed with a focus on prevention, a focus on the social determinants of health, like getting our kids into school, ready to learn, healthy, and then having good education.
Ian Donnis: Michael Fine?
Michael Fine: I totally agree: getting safe and healthy housing for everyone. Critically important. We have the technology we need to massively improve the public’s health. We have the technology we need and we have it now to expand life expectancy, reduce infant mortality. Our problem is that we’re only getting it to 43% of the population. 57% don’t have the access they need to robust primary care, which is how you make prevention work.
Ian Donnis: We’ve got to leave it there. Thank you so much for joining us. Dr. Michael Fine, a former state health director, now a writer, activist and Chief Health strategist for Central Falls. And Christopher Koller, the nation’s first health insurance commissioner, now president of the Milbank Foundation.
Christopher Koller: Thank you very much, Ian.
Michael Fine: Thanks for having us.
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Donald Trump was riding high when he made a campaign appearance in Warwick back in 2016. Although Rhode Island has a strong Democratic lean, hundreds of Trump supporters turned out to cheer on the man who would go on to win the presidential race later that year. Seven years later, Trump faces mounting legal problems, as evidenced by a third indictment this week. But he remains the frontrunner on the GOP side of the presidential race. And the Republican base continues to support Trump. About the only GOP member with Rhode Island ties who criticized the ex-president this week is former Cranston Mayor Steve Laffey, who is himself running for president. In a statement, Laffey says he’s at a loss to understand why Republicans still support Trump. You can read more about that in my Friday TGIF column posting around 4 this afternoon on what used to be known as Twitter @IanDon and the publics radio dot org.
That’s our show for this week. Our producer is James Baumgartner.
I’m Ian Donnis and I’ll see you on the radio.
