Peter Freeman, MPH
Public Health Strategist & Senior Advisor
In mid-2019, the New Hanover Board of Commissioners announced its intent to explore opportunities for new ownership of the New Hanover Regional Medical Center (NHRMC). The NHRMC is looking for its potential new owners to help the health system, as NHRMC CEO and Present John Gizdic put it, “prepare for an uncertain future.” On March 16, 2020, six health systems submitted proposals outlining their vision for a path forward for the NHRMC: Atrium Health, Bon Secours Mercy Health (Healthspan), Duke Health, HCA Healthcare, Novant Health, and UNC Health. This week, the Partnership Advisory Group (PAG) will meet (virtually) to discuss the proposals and begin formulating recommendations.
While the ultimate fate of the NHRMC rests in the hands of a select few stakeholders, the public has been encouraged to review the proposals. So Atrómitos did. And we have some feedback.
Did the community get everything the RFP said it wanted to know?
The answer depends on your point of view. The Request for Proposals (RFP) asked respondents for responses to twelve sections, each consisting of parent questions and a litany of related questions. From a volume perspective, a lot of information was shared. But there are areas where more directive in the RFP could have gleaned more detailed responses:
LET’S TALK ABOUT CLINICAL QUALITY
The sixth section of the RFP, Driving Quality of Care and Patient Safety, provided respondents the opportunity to show off their clinical prowess. The questions, however, largely focused on policies and processes related to quality, asking how the strategic partnership can be integrated into the NHRMC’s infrastructure or how it can help NHRMC improve and measure its own quality of care. As any quality person will tell you, developing, implementing, and improving outcomes based on intervention are all separate activities, and success in one does not automatically equate to success in the other two.
It is vital that the NHRMC bring in a partner that can bolster and strengthen its quality infrastructure; there is no challenging that reality. However, the community deserves to know, within the body of these responses, how the respondent does with its own clinical quality. Dashboards and outcomes are shared intermittently from all six respondents, but not always for measures that are meaningful to the community. The RFP should have clearly specified a requirement for inclusion of clinical quality measures most relevant to the NHRMC communities. And taking it one step further, providing a uniform format for presenting the data would have enabled the community to make side-by-side comparisons of the metrics to see how the respondents measured up against one another.
LET’S TALK ABOUT CLINICAL QUALITY AND VALUE
Clinical quality data is also relevant to answer another question that the NHRMC is looking for a line of sight on: how to successfully transition into a value-based world. Here, again, a direct ask for tangible outcomes would have been ideal. The RFP asks respondents to describe philosophies, their impact on, or strategies they may have related to value-based care. In all fairness, all philosophies, potential impacts, and strategies can look good on paper if they do not need to be substantiated with data.
PROVIDE A COMPLETE EXECUTIVE SUMMARY
That the public is given access to the full and executive summary versions of each response is laudable. The Executive Summary includes snapshots from ten RFP sections. If the RFP only had ten sections, this would have been sufficient. However, Sections 11 and 12 are absent from all of the executive summaries. It could be argued that Section 11, Proposed Strategic Partnership Structure(s), is possibly of the highest level of interest to the community. As such, it’s noteworthy that when asking the public to review responses for community feedback, comprehensive executive summary versions are not provided.
What the RFP didn’t ask about
Regardless of how well the RFP may or may not have done in asking respondent’s to address the NHRMC’s “uncertain future,” there were also important topics not covered that we feel are relevant to the community this Strategic Partnership is going to impact:
LESSONS LEARNED FROM PREVIOUS STRATEGIC PARTNERSHIPS
All of the six respondent entities have experience merging, acquiring, and/or otherwise partnering with providers that were not originally part of their system. As such, we would expect that all six respondents have a breadth of experience in challenges and roadblocks when a health system comes under new management. It could be argued that these lessons come out in the respondent’s responses to the questions posed, but the RFP is written in such a way that the only information captured is the respondent’s point of view and experiences. We think there is merit in asking respondents to identify a pain point: what hasn’t gone well? What didn’t their new community react well to and how was it addressed? What obstacle are they still facing? When interviewing for a job, we are all asked to identify an experience in which we did not shine. Though no one enjoys talking about failures, the question is asked for a reason: it illustrates the ability to identify obstacles and problem-solving skills.
REDUCING THE NEED FOR CHARITY CARE AND FINANCIAL ASSISTANCE
The RFP asks multiple questions about the respondent’s impact on the financials of the NHRMC’s patients. These questions range from controlling out-of-pocket costs to their approach to charity care and financial assistance. It is important for health systems to have an answer to financial assistance (including charity care) for their patients. But what about overall reducing the likelihood that its patients need financial assistance? Health systems are powerful entities in price negotiations with payers, be that payer commercial or public. Why not ask respondents to describe how this power could be leveraged to begin negotiating down patient-facing costs from payers? If that feels too unreasonable, then consider another option: what is the strategic partnership’s plan for expanding the number of NHRMC’s patients who have health coverage?[1] Be it a Medicaid reimbursement or charity care, these dollars will ultimately come from the state of North Carolina; perhaps this could have been an opportunity to creatively find ways to shift those dollars into a preventative line item and off of a debt record.
HOW WILL THE STRATEGIC PARTNERSHIP NOT INTERRUPT THE SAFETY NET?
One of the major impacts the 2019-2020 COVID-19 pandemic has illustrated in the United States is the inequity in the country’s healthcare system and the dire need to support those whose access to services rests on the politics of others. The providers who care for these patients (the Safety Net providers) operate under immense strain and are challenged to remain solvent when health systems move in and open new access points that pull patients away from the Safety Net. The front end of the RFP asks respondents how they will increase the NHRMC’s access points. Rather, the question posed should have been in the spirit of asking how the strategic partnership will leverage the current healthcare infrastructure to optimize patient utilization of preexisting providers (e.g., the Safety Net) and minimize the development of unnecessary points of care.
And now the PAG works towards a decision
Regardless of this feedback, the responses are in and the PAG is moving forward with virtual meetings to decide the fate of the NHRMC. New Hanover County deserves a transparent and thorough process that allows for the community to thrive. The PAG has done well in providing access to all responses, and by encouraging the community to review and provide feedback. However, some of the shortcomings will require the PAG to read between the lines of these responses to fill in the blanks of what wasn’t asked.
[1] It needs to be noted that Question 3.1 asks respondents to describe how their proposal will, “expand coverage for uninsured and underinsured individuals.”