What’s Up, Doc?

At the height of flu season, a daily surge of patients from Pawtucket and Central Falls descends on the Miriam Hospital. But this year the surge has been bigger tham usual: after months of painstaking negotiations, the Rhode Island Department of Health approved the closure of Memorial Hospital, the cash-strapped Pawtucket facility that contributed heavily to the financial troubles of its parent company, Care New England (CNE). The healthcare giant has been working to ease the burden on Blackstone Valley in the absence of Memorial and its 300 beds, but the Miriam Hospital, a Lifespan facility on the East Side of Providence, is bearing the brunt of the closure.

While Memorial’s closing is having immediate effects on Miriam, the recent surge is part of a larger trend at Lifespan facilities. According to Lifespan data, over the last five years, emergency room volume at Miriam has increased by 13 percent, more than double the increase across the entire system. Lifespan officials are noting that in the absence of Memorial, scores of patients from Pawtucket and Central Falls are now turning to Miriam, which is only three miles away.

Memorial Hospital was a bulwark in Blackstone Valley for more than a century. Funded by Saylesville Finishing Plant founder William F. Sales after his death in 1894, the hospital was chartered to provide healthcare to Blackstone Valley residents regardless of their ability to pay, long before most hospitals were legally mandated to do so. Over the next century, Memorial expanded from 30 beds to 294 over 13 acres in Pawtucket. The hospital operated a nursing school for 70 years and enjoyed an early affiliation with the Warren Alpert Medical School at Brown, housing its Family and Internal Medicine residency programs.

Still, Memorial barely stayed afloat. In 2013, CNE acquired the struggling hospital but was unable to alleviate the financial woes; in the last fiscal year alone, the hospital recorded a $23 million loss. Its parent company therefore began searching for parties interested in acquiring Memorial, ultimately entering into negotiations with Partners Healthcare. The largest hospital group in Massachusetts, Partners includes Brigham and Women’s Hospital and Mass General.

But the fate of Memorial quickly became a controversial issue in the talks. The Pawtucket hospital gradually began winding down services until the board finally voted to allow CNE to close the Emergency Department and shut down

At the end of last year, the Department of Health permitted Memorial to cease all operations, provided CNE met a few stipulations. The healthcare giant, second in scale to Lifespan, is required to pay $300,000 to the city of Pawtucket and $200,000 to Central Falls in order to offset the costs of diverting patients to other hospitals. Additionally, CNE established a walk-in clinic in Pawtucket open seven days a week.

All of these efforts notwithstanding, the staff of Miriam toil daily to meet massive new demands. Miriam has been a mainstay in Providence healthcare and has deep roots in the Jewish community of the East Side. Founded in 1907, the Miriam Hospital Association sought to create a hospital for Jewish immigrants to receive quality and culturally responsive healthcare. As the hospital grew into a pillar institution serving all Rhode Islanders, it was chartered by the state legislature in 1926.

From there, the hospital expanded from a 63-bed building on Parade Street to its present facility, a bustling complex on Summit Avenue boasting 247 beds. With a staff of 2,800, Miriam offers a wide range of primary, secondary, and tertiary treatment in 34 specialties. The hospital has been recognized nationally for its research on HIV/AIDS, behavioral health, and preventative medicine.

The breadth of services and expertise offered at Miriam also figure into the surge of patients from Pawtucket and Central Falls, says Richard Salit, Senior Media Relations Officer at Lifespan.

“Clearly, we’ve seen a shift in Pawtucket and Central Falls patients going to The Miriam Hospital from Memorial Hospital,” Salit says. “But this has occurred over many months as Memorial’s services declined and, ultimately, its emergency department closed.”

Dr. Paul Larrat, dean of the College of Pharmacy at URI, also underscored that the gradual decrease in operations at Memorial has prompted more and more patients to turn to Miriam. “They were down to providing very little inpatient care,” he says.

Perhaps the largest factor, though, is the flu. The closure of Memorial’s emergency room “is also hitting at the time of the biggest flu epidemic in a bunch of years,” says Larrat. “Nationally, emergency rooms have been flooded because of the flu epidemic. A true test of all of this, after flu season is over, is seeing what utilization of the Miriam Hospital Emergency Room in particular looks like.”

Memorial’s closing and the accompanying increase in patient volume at Miriam will invariably have implications for how Rhode Islanders access healthcare, but also for the economy, as healthcare is one the central industries in Rhode Island. According to a Department of Labor and Training study, healthcare was the fastest growing industry between 2000 and 2007. In that same period, more than 18 percent of jobs in the state were healthcare-related. The state’s higher education institutions contribute to the workforce, from the highly ranked nursing schools at Rhode Island College and URI, the College of Pharmacy at URI, and Brown’s Alpert Medical School. Healthcare is, in short, critically important to Rhode Island.

Between Lifespan and Care New England, this industry employs more than 22,000 Rhode Islanders. Lifespan is the largest private employer in the state with over 14,000 employees. Miriam is one of Lifespan’s partners, along with Gateway Healthcare and Rhode Island Hospital – the state’s only trauma center – as well as Newport and Bradley Hospitals.

CNE, Rhode Island’s second largest hospital group, employs more than 7,500 people. Its principal facilities are Women & Infants, Kent and Butler Hospitals, the Providence Center, and Care New England Wellness Center in Warwick. Nonetheless, the healthcare giant has struggled financially, which many ascribe to Memorial, whose inpatient volume decreased sharply in the last ten years.

But Larrat says this is not unusual.

“There’s been a drop nationally – and state by state, for that matter – in utilization of hospital beds,” he says. “People are getting better and more effective homecare. The VNAs [Visiting Nurse Associations] of the world are taking care of people in their homes, so that’s part of the reason for the decline.” Rhode Island, he says, “is just mirroring that.”

Larrat points out, too, that this is not the first time a hospital has closed in the state, referencing Notre Dame in Central Falls and Cranston General. “Utilization of the facilities [at Memorial] was dropping,” he says. “I don’t think that’s a unique problem.”

What is unique is the interplay in Rhode Island between healthcare companies and institutions. CNE’s financial woes have prompted unwelcome merger proposals from Lifespan, which the former declined. As negotiations with Partners Healthcare of Massachusetts progressed, another major player in Rhode Island entered the picture: Brown University. Brown President Christina Paxson proposed in January that the university acquire CNE with Prospect Medical Holdings, a for-profit, California-based healthcare company with a checkered history of patient care, according to the United Nurses and Allied Professionals union. Brown’s Alpert Medical School, the only medical school in the state, has affiliations with both CNE and Lifespan but does not operate its own hospital. This is unusual for a high-ranked medical school, and particularly an Ivy.

A factor in Paxson’s proposal, undoubtedly, was Partners Healthcare’s affiliations with Harvard Medical School. Paxson cautioned that the merger would shift the center of Rhode Island healthcare to Boston. As a result, she reasoned, it would also encourage healthcare professionals to relocate, raising costs for Rhode Islanders and contributing to the “brain drain.”

Though state lawmakers, including Governor Raimondo, have welcomed CNE’s merger with Partners, Paxson raises an important point: CNE’s position, as evident in Memorial Hospital’s floundering and subsequent closure, created a vacuum, and in one of the most significant areas of the Rhode Island economy. A large, out-of-state entity becoming a powerhouse in Rhode Island healthcare will surely have ramifications for CNE and the shifting healthcare landscape.

While the future of Care New England remains unclear, Lifespan appears poised to not only maintain its dominance, but to continue expanding as well. Miriam is currently building a 10-bed Clinical Decision Unit in the Emergency Department, projected to open in March.

“It’s intended to relieve pressure on the demand for inpatient beds,” says Richard Salit. “That, in turn, can help improve emergency department patient flow.”

And, Salit clarifies, “Patients who arrive at The Miriam Hospital Emergency Department will never be turned away. On rare occasions, hospitals throughout the state – when severely taxed by high patient volume in their ED – will go on ‘diversion.’ This means that ambulance providers are directed to take patients to other nearby hospitals.”

Despite the many uncertainties raised by Memorial’s closing and Care New England’s merger, Miriam, for its part, appears not to be shaken. And though the hospital is adjusting to the surge of new patients on the East Side, the full impact of Memorial’s closure remains to be seen.