A Fine Plan for Accessible Health Care

R.I. director of health has a vision for a sustainable health-care system

Editor’s note: Second in a seven-part series about creating a sustainable health-care system for Rhode Island.

By KARINA LUTZ/ecoRI News contributor

Since long before the Affordable Care Act became such a highly debated law, Rhode Island director of health Dr. Michael Fine has been mulling, testing and establishing ways to make health care more affordable and sustainable. Fine wants to make basic health care easily accessible to all Rhode Islanders — to provide for the needs of Rhode Islanders in the present — and also cares deeply about environmental health.

He helped launch Health Access RI, the nation’s first statewide organization providing affordable primary care to those without health insurance. In 2000, he and a town committee created a process to provide primary health and dental care for the town of Scituate; the program is now run by the nonprofit Scituate Health Alliance.

Fine is passionate about behavioral health — healthy lifestyle choices and the community structures that support them, or constrain them. He's experienced and interested in integrating medical care with holistic-health modalities, which are inherently greener as they rely on hands and plants. He even promotes fasting. In short, Fine is not your average Western medical practitioner.

Fine brought his vision of sustainable health care to state government when he became head of the Rhode Island Department of Health in July 2011. His background as a family doctor, or primary-care physician, has informed his latest efforts to develop sustainable health-care models centered on primary care, but integrated with all basic services.

As director of health, he's proposing a statewide system of neighborhood-based, community-scale, primary-care centers. Each center would provide primary care to 10,000 people — making primary care as accessible as your neighborhood library. Each of these “neighborhood health stations” would house doctors, nurses, physical therapists, mental-health professionals and supporting services, working as a team.

“Health means the ability to function in communities,” according to Fine’s definition.

“Primary care is not expensive,” he said. Fine estimates that 90 percent of the health needs of each community are for primary care, yet it now represents only 5 percent of health-care costs. “Beyond primary care, most of the dollars are being sucked away from the community by multinational corporations.” Poorer neighborhoods’ wealth ends up in Barrington and East Greenwich. But “patient-centered” health centers in each neighborhood would upend that.

The patient-centered model is something Fine applied at his own family practice at Hillside Avenue Family & Community Medicine, at Scituate Health Alliance and at Health Access RI. Health Access RI continues to provide primary care to qualifying low-income Rhode Islanders for a flat, prepaid fee of $35 a month. The new system would be for everyone, regardless of income.

Fine envisions the new neighborhood health stations, once established, could provide mental-health and behavioral-health services as well as exercise opportunities. The centers could also advocate for healthy lifestyles to be built in, literally, to the built environment, such as smoke-free housing, bike paths, local food, and other environmentally and community-friendly things people want but for which currently “there's no natural institutional advocate.”

Fine oversees the state health department’s broad public health programs that save money and protect the environment by reducing the need for more expensive and polluting interventions. These include behavioral-health efforts, such as promotion of healthy eating, reduction of binge drinking and prescription drug abuse, tick-borne disease education and lead-poisoning programs. He noted that the state's breast-feeding and child-birth education programs also help move us toward sustainability.

Fine would like to increase people’s access to healthy, local food. One of the barriers is affordability — or perception of affordability. He cited a rarely promoted way to save money on food: “We can shrink calories by about one-third for most people.”

The savings come from buying less food and avoiding health-care costs associated with obesity. He also has people on the health department staff, Eliza Lawson and Chris Ausura, thinking about the “food desert”  issue — places where people, particularly in poor neighborhoods, don’t have supermarkets at all, never mind healthier food choices.

Integrating low-tech, low-cost interventions such as bodywork, herbs and acupuncture isn't easy at this point, mainly because of payment system barriers. It’s something “we’ll sort out over time, allowing individual flexibility at the front end, being sensitive to ethnic and cultural differences,” Fine said. If located “next door,” alternative-health practitioners could be “natural partners” to neighborhood health centers, he said.

Fine believes a strong primary-care system could also address American culture’s fear of death — and its heroic efforts to extend life for those who are dying. Patients and their families “need a relationship with someone you can trust, to let you know if the patient is dying, when that starts to happen,” he said.

Experienced doctors aren’t afraid of death, he said. “I noticed after years of practice that no one lives forever,” Fine said. But doctors need to learn “how to know when to fight, and when to just listen.”