Delivery of Care

AG Neronha weighs in on future of health care

The state’s top public health advocate pushes forward with substantive solutions

Photo by Richard Asinof

R.I. Attorney General Peter Neronha talks at length in his office about the health care choices facing Rhode Island during a one-on-one interview with ConvergenceRI.

By Richard Asinof
Posted 1/29/24
Attorney General Peter Neronha sounds the alarm that Rhode Island is risking the prospects of a systems failure in health care delivery if it doesn’t increase state spending to pay Medicaid providers more money.
Why is it so difficult to get information about primary care practices in Rhode Island and the lack of coverage within health insurers’ networks? Will the leaders of the General Assembly step up to the plate and increase Medicaid provider rates by $45 million in this budget year, as proposed by OHIC? When will the practice of prior authorization deployed by health insurers be banned in Rhode Island? Are new regulations needed to restrict investments in health care and hospitals by private equity firms? What is the connection between access to public transportation, school attendance figures, and affordable housing?
The continual fallout from the apparent failures by St. Mary’s Home for Children to provide a safe environment for children in need of residential behavioral health care has its roots in the inability of the state to pay adequate reimbursement rates for Medicaid, as demonstrated in hearings two years ago before the Senate Committee on Health and Human Services. Unfortunately, too many reporters are driven by the news cycle and not by the ability to review reporting conducted earlier.
The same is true regarding the efforts by Steward Health Care to purchase hospitals in Rhode Island, including both Memorial Hospital in Pawtucket and Landmark Medical Center in Woonsocket, although both of these efforts failed. Without that context, the coverage of the current crisis in health care delivery in Rhode Island will have a distorted view of what really happened. Back in 2010, the health care reporters covering the story were Megan Hall, then at The Public’s Radio, Felice Freyer, then at the Providence Journal, and Richard Asinof at The Providence Business News. Which news outlet would be willing to convene an interview with those three reporters to talk about what really happened?

PROVIDENCE – In the latest of a series of in-depth interviews, ConvergenceRI spoke with R.I. Attorney General Peter Neronha for nearly an hour at his offices on Monday afternoon, Jan. 22, covering potential solutions for the growing crisis in health care delivery in Rhode Island.

The Attorney General voiced his concerns about warning signs of a broad systems failure in health care delivery, pointing to the troubled Steward Health Care system in Massachusetts. Proposed solutions, Attorney General Neronha cautioned, are going to take time. They are “not going to be easy; they are going to be hard,” he said. And, he continued, “Frankly, they are going to cost money.”

Neronha and his legal team now find themselves at the center of the growing conflict about the future of the health care delivery in Rhode Island – with skirmishes in the courtroom, in the corridors and hearing rooms at the State House, and in the headlines.

One of the latest such skirmishes occurred in the studios of WPRI-TV Channel 12, where Attorney General Neronha was the guest of Newsmakers’ hosts, Ted Nesi and Tim White. What emerged was a “knowledge” gap – not so much on Attorney General Neronha’s part, but from both Nesi and White, who displayed an apparent lack of curiosity about how to fix the mechanics of health care dysfunction in Rhode Island, in ConvergenceRI’s opinion.

During the Newsmakers session, Attorney General Neronha shared the latest dataset with reporters Nesi and White, detailing the facts that identified the lack of primary care providers in the state. Out of some 2,500 primary care practices in Rhode Island within 30 miles of Providence that were listed as being part of the providers’ network of Blue Cross and Blue Shield of Rhode Island, only half of those practices said that they were accepting new patients.

Many of the others did not have openings for a patient to be seen by a provider for six months, according to the telephone survey conducted by the Attorney General’s legal team during the last two months of 2023.

Like Gov. Dan McKee, who recently found himself in hot water last week when he attempted to minimize the “inconvenience” faced by commuters trying to navigate traffic jams caused by the highway bridges between Providence and East Providence, claiming that it added only a minor discomfort of 10-15 minutes of added travel time, Nesi and White appeared to discount the inordinate problems facing Rhode Islanders who could not gain access in a timely fashion to a primary care provider – for themselves, for their families, for their children, and for their parents – when they were sick.

“When you can’t get a provider, or you can’t get one for a long time, or you can’t get a test right away, or it takes six months to see a specialist, when you can’t get an operating room for three months if you need an operation, what that is telling me is that our system is weak,” Attorney General Neronha told ConvergenceRI in a recent interview.

“And, it is weak, I believe, because there isn’t enough revenue coming into the system to enable us to pay providers, to reimburse and pay hospital systems [so that] the hospital systems are healthy, providing great care, quick care, and where there are enough providers to provide care outside the hospital setting.”

The ConvergenceRI interview occurred as the crisis in health care delivery by the private equity-owned hospitals of Steward Health Care in Massachusetts captured the headlines in Massachusetts, what Attorney General Neronha worried was the potential future facing the Prospect Medical Holdings-owned hospitals in Rhode Island, Roger Williams Medical Center and our Lady of Fatima hospitals.

“It is the same exact scheme with the hospitals owned by Prospect Medical Holdings,” Attorney General Neronha said. “The private equity firm sold their hospitals and then leased them back to Medical Properties Trust. Prospect, with Roger Williams and Fatima, did the same thing as Steward did, for St. Anne’s in Fall River, Mass., and St. E’s [Saint Elizabeth’s] in my old neighborhood in Brighton, Mass., and the other hospitals they own. It is the same playbook,” Attorney General Neronha continued. “Private equity will always make money; hospitals and health care systems will always lose.”

Here is the in-depth interview conducted by ConvergenceRI with R.I. Attorney General Peter Neronha, in a defining conversation with the state’s top public health advocate during a time of a growing health care crisis.

ConvergenceRI: One way of knowing if you are doing a good job, it seems, is the way that people respond to you.  
NERONHA: Yes, indeed.

ConvergenceRI: Let me begin by saying what a strange world of health care we live in, at this point. The Governor seems to be taking his cue from you to all of a sudden be interested in addressing primary care. The idea that he proposed in his State of the State address, that he is going to pull together a team of stakeholders – when there already is an existing team of stakeholders that has been meeting and coming up with solutions. I find that bizarre.  
NERONHA: I think there are two ways of looking at health care. I think one is political; the other is substantive. I like to think – and I do believe – in fact, I know that our work is substantive.

This issue, for me, is not a political issue. It is one I feel deeply invested in, for a couple of reasons. One is the work that we have already done. So, I have seen through our regulation of Roger Williams and Fatima hospitals, the change in effective control process from two years ago, I’ve seen how fragile those systems are.

Now, they are fragile because Prospect [Medical Holdings, the California-based, for-profit private equity owner] has made them more fragile. But they are [not] fragile in a vacuum. They were fragile before Prospect bought them. And, they are fragile now.

And then, the merger that did not go through [between Care New England and Lifespan], through that process, we got a look into Rhode Island Hospital [Lifespan more broadly] and Care New England [Women & Infants, Butler, Kent – you know what they are] insight into those health care systems as well.

And then, I live with a primary care provider [Neronha’s wife]. And so, I understand some of the challenges that primary care [doctors] deal with. And, I am also aware, much more broadly, because I am around doctors a fair amount, of exactly the challenges they are facing.

For me, I don’t want to leave office in 2026, Richard, without having done everything I can to understand why health care is facing these challenges and coming up with some proposals to try and address them. And, those proposals are not going to be easy; they are going to be hard. Frankly, they are going to cost money, in some places.

But, if we want the kind of health care system we appear to want – what do I mean by that? It’s one where we can – all of us – get great care, and get it in a timely fashion, we are going to have to pay for that system.

It reminds me a little bit of infrastructure. The Washington Bridge is old. Someone asked me: Well, who are you going to prosecute over the Washington Bridge? The answer is nobody. It got old. You don’t prosecute people for having an old bridge.

You prosecute us all, I guess, the public, more broadly, for not caring enough about infrastructure, that we allowed a bridge to get old, without replacing it, and without having a plan to replace it, as apparently we don’t have.

To come back to your question, I view health care as something that I, and more broadly, this administration, this office while I am Attorney General, need to address, because we have played a role here already. I think we understand it, and we understand these issues as well as anybody. I don’t believe that elsewhere in state government there is the coordinated strategic thinking that we need to move the ball forward. We are filling the vacuum.

ConvergenceRI: You released some statistics when you talked with Tim White and Ted Nesi about your survey of primary care providers – and the fact that many Rhode Islanders could not get an appointment. Could you repeat those statistics for me?  
NERONHA: Sure. Let me give you the background of why we are interested – and why we did the project, and what it showed.

Part of the problem is that we don’t have enough primary care providers in this state. What are the reasons why we don’t have them? Well, reimbursements are lower [in Rhode Island], compared to Massachusetts and Connecticut, for Medicaid, Medicare, and commercial insurance. All three components of our health insurance world, and that’s the pie – commercial private insurance, Medicare, which is, as you know, care for older Americans, and Medicaid, which is for the more economically challenged Rhode Islanders. Those are our three components.

We know that those reimbursements, or we strongly suspect in the context of commercial [health insurance] are lower in Rhode Island than elsewhere. We believe that that rate difference is driving physicians across the board, but particularly in primary care, out of state, into retirement, or they are not coming here [to practice] in the first instance.

The project that we did: Why did we  do it? The commercial insurers have a duty to provide what is called an adequate health care network – “network adequacy.” What that means is, when you sign up for insurance, they have to have doctors that will take care of you.

That makes sense, right? When you buy a car, the car has to have wheels. If you buy a car with no wheels, the car can’t take you where you need to go. When you buy a car, that car has got to have wheels.

It’s the same thing with buying health insurance. If you buy health insurance, the law requires the health insurer – Blue Cross, for example – to have doctors that can give you the medical care that you need, and for which you are buying insurance.

That data is available to the R.I. Office of the Health Insurance Commissioner, OHIC. We asked them for that data, and they would not share it with us.  Their reasons for that are unknown to me.

I don’t think there is a good reason for them not sharing it with us. But they didn’t. And, we may try to get a legal fix to that, where they are compelled to give it to us.

In any event, what we realized is that we can get the same information by doing the project. And that project was: Let’s go online, and identify on the Blue Cross website, how you would find a doctor if you needed one.

So, we clicked “accepting patients” and we clicked “providers within 30 miles of Providence,” and we got the list, and we called them all.

And, when we called them, what we found was that roughly 50 percent of primary care providers that, according to Blue Cross’s network, when you clicked on the button that said they were taking patients, in fact, were not taking patients. So, half of the providers were not taking patients at all….

ConvergenceRI: What was the total number of providers your office called?  
NERONHA: I believe it was around 2,500.

ConvergenceRI: Out of 2,500, the fact that some 1,250 primary care providers were not taking any new patients….  
NERONHA: It might have been a little under 50 percent, but it is in that ballpark. When we talk about providers, those are practices. Right? So, it could be a solo practitioner. Or, it could be a group of four doctors in that particular office.

Take, for example, my wife’s office in Wakefield. There are four doctors there. I know that my wife is not taking [on new] patients. I don’t know if any of the others are taking on new patients. But let’s say you called that practice. That would be “one” practice.

The bottom line is this: half the time, when you are calling [to find a doctor], you are not getting a provider that will take you. And, the ones that would take you would take you six months out. What that shows us is that our system is failing. I think that the early warning that a system is failing is the inability to access the services that the system provides.

Let me give you an example. I think we would be worried about an oil and gas industry if every third gas station didn’t have gas. If you went out to put gas in you car, and every third, or every other gas station you passed had a sign that said, “No gas today,” you would think that there was something wrong with the system that needs fixing.

The same is true here [with health care delivery]. When you can’t get a provider, or you can’t get one for a long time, or you can’t get a test right away, or it takes six months to see a specialist, what’s that is telling us, telling me, when you can’t get in the operating room if you need an operation for three months, what that is telling me is that our system is weak.

And, it is weak, I believe, because there isn’t enough revenue coming into the system, to enable us to pay providers, to reimburse and pay hospital systems, to where the hospital systems are healthy, providing great care, quick care, and where there are enough providers to provide care outside the hospital setting.

ConvergenceRI: How do we move forward? You’ve created the “evidence” that appears irrefutable. Based on the hard work of your team, how do we then go about correcting that? There seems to be an issue of what I would call the  “prosperity gap.” There is somehow the idea that there is not enough money to go around to pay for this.  

ConvergenceRI: I was somewhat chagrined because neither Tim White nor Ted Nesi seemed to understand the economics of this, when you brought it up during the Newsmakers interview.  

ConvergenceRI: It was astonishing to me that they didn’t seem to get the fact that until you increase the rates that providers are paid, that is the linchpin that allows things to move back toward better health care delivery.  
NERONHA: Yes. There are two ways to correct this. They don’t have to be exclusive of one another.

One is to change our mix, change our mix from 70-30 percent, public payer to private payer, across the board. Maybe a little better in some places; maybe a little worse in others.

What that means is this: 70 percent of our population is on Medicaid or Medicare; 30 percent is on commercial insurance. And Medicaid is reimbursed at 37 percent of Medicare. And, Medicare is reimbursed much lower than commercial [health] insurance.

What that means is that commercial health insurance is really the engine pulling most of our health care revenue train. When you combine that with the fact that rates across the board are lower in Rhode Island than our neighboring states, it is sort of a double whammy.

You can address this in a couple of ways. One is to grow our economy. Why is that important? It changes that 70-30 mix. What that means is you get more people onto commercial insurance, and your commercial insurance is going to have a bigger piece of the reimbursement pie, and your revenue is going to go up.

So, in that interview – and I have a lot of respect for Ted Nesi and Tim White, and I like them both – but I think to dismiss growing the economy, as frankly they did so quickly, ignores the strong component of how Rhode Island gets to a better place in health care. We should always be looking to do that [to grow the economy]. And, our leadership should always have a plan to do that.

And, if they are not delivering that, we should them accountable for that. You can’t ignore that piece of it – that we’ve got a lot of our population on Medicaid. Medicare is what it is – those are older Rhode Islanders. I’m not suggesting that they should keep working at 75 or 85 and stay in the workforce and have commercial insurance.

What I am saying is that we can move some of those Medicaid patients into commercial insurance to grow our economy.

Some of it also is increasing our Medicaid reimbursements. That’s the part that is state money, in part. That is what we can control. But the advantage of raising those rates is this: not only do we begin to fix this problem of “provider flight,” or not coming here in the first place, or getting out of the workforce, but we can leverage that into [more] federal dollars.

Because for every $1 that we spend, we get $1.29 back from the federal government. What looks like a big number is not as big a number because the feds are paying at least half, more than half of that number.

And so, I believe what is in the governor’s proposed budget are Medicaid rate increases across a few areas. But the truth is we have to examine raising Medicaid rates across a broader line of areas of service. Because if we do not [raise Medicaid rates], we are not going to [be able to] solve this critical problem.

If we want to have providers in this state, and we want to be able to see a doctor, and we want to be able to see a specialist, and we want to be able to get an MRI done, so that we can rule out a tumor, for example, within 48 hours, as opposed to within four weeks, we’re going to have to pay for it. And we are going to have to make those choices.

And, I think health care is the most critical problem that we face, but it is also the most critical problem that we can solve if we decide to solve it by frankly paying for it.

And, we have to put health care at the top of our priorities, rather than something that is somewhere in the middle, simply because it is too hard for us to focus on. We need to raise our Medicaid rates more broadly – and get the federal match. And then, I think there are opportunities as well with Medicare. Right now the team is looking carefully at ways that we can change our Medicare reimbursements so that those are higher as well. And then, take a look at commercial rates as well, to see if their reimbursement rates are where they should be.

But, when you put all that together, Richard, it is going to take a little bit of time. But, when you pout all of those components together, then you begin to raise the revenue that our hospital systems and our providers need to keep them in the game.

I sat recently with a plastic surgeon a thoracic surgeon, a surgeon who works on thyroids, an adult primary care doctor, an internist, a pediatrician, and a dermatologist. And, they all told me the same thing. It’s very difficult to attract people to take over their practices or to join their practices. The primary care doctor had gotten out of primary care and is now in concierge medicine. The pediatrician who was practicing with one partner, has been waiting a year to get paid by Medicaid.

The takeaway from that conversation and others that I have had, both with hospital system leaders and with the people providing health care, is that if we don’t change our rates, we will not have the hospitals we want to take care of Rhode Islanders, we won’t have enough of them, and they won’t be able to provide the kind of services we want. And we won’t have people working in them to deliver that care. That storm is coming, and it’s not far off.

What’s fascinating to me is, if you think that anything I am saying isn’t accurate, or is not as dire as I am painting it out to be, pick up The Boston Globe from the last week, and read the articles about Steward Health Care.

ConvergenceRI: That leads to my next question. Steward is a great example of what has gone wrong with private equity in health care.  
NERONHA: Just like Prospect; it’s the same story, Richard.

ConvergenceRI: And what’s interesting is that the people who want to buy Prospect now, the Centurion Foundation, who is their major business partner? Medical Properties Trust.  

Editor’s Note: On Monday, Jan. 29, 2024, the R.I. Attorney General’s office and the R.I. Department of Health released the final application from the Centurion Foundation under the Hospital Conversions Act to purchase Roger Williams Medical Center and Our Lady of Fatimia hospitals, both currently owned by Prospect Medical Holdings, a for-profit private equity firm headquartered in California. See link to application below.

Regulators from the Department of Health and from the Attorney General’s office will now review the Centurion Foundation application, which must be completed by June 11, 2024. Two public hearings will be held in the near future on the proposed transaction.

Ben Mingle of the Centurion Foundation responded to the story, saying that “The Centurion Foundation has never had any kind of business relationship with Mdical Properties Trust.” Further, Mingle said that the Centurion Foundation, which is a not-for profit based in Atlanta, Georgia, said that its mission “is to advance the mission of other non-profit hospitals and the communities they serve, versus the business model of MPT which is to generate profit for shareholders.”

The projects that the Centurion Foundation is involved with, according to Mingle, have, “over the last five years, …completed more than $1 billion in transactions. Over he life of these transactions  Centurion is lowering the cost that the hospitals would otherwise have to pay in excess of $1 billion,” Mingle claimed.

ConvergenceRI: Medical Properties Trust are the owners of Steward Health Care and other hospitals.  
NERONHA: And the Prospect hospitals. It is the same exact scheme. Private equity firms sold their hospitals and then leased them back to Medical Properties Trust. Prospect, with Roger Williams and Fatima, the same thing as Steward and St. Anne’s in Fall River, and St. E’s [Elizabeth’s] in my old neighborhood in Brighton, and the other hospitals they own.

It is the same playbook. Private equity will always make money; hospitals and health care systems will always lose. We look at Massachusetts and say: “Oh, if we could only do health care that way.” And there are many elements of that that are true.

They leverage their Medicaid dollars much better than we do. They have health policy thinking that can get to some of these answers, so that your AG doesn’t have to do it. And, frankly, the AG shouldn’t be doing it.

That’s not where this expertise should be. But those Steward articles paint the same picture that I have been talking about now for 18 months. The phrase that Tim White used when we started the interview was: “You fret [emphasis added] about health care.”

And that suggests to me that I am worrying about it needlessly. And, that’s probably not how he meant it. But that is what that word connotes to me. And, that’s just wrong. I worry about it, for sure. But, I worry about it because it is serious. And it’s real, and it’s being ignored, and it’s being ignored in too many places in government.

ConvegenceRI: I agree with you. As someone who has covered this extensively, it is dismaying to me to see how much of the reporting gets it wrong. I am only one person, and I do my best to shed a light on what is happening, and to seek out the stories to tell what is going on.

 I don’t understand why there is such aversion – from the Governor’s office, from the hospitals themselves, in many cases, to being truthful about what is going on. And, from the insurance companies. Why are they afraid to tell the truth about what is actually going on?  
NERONHA: Richard, I know that people in health care who actually deliver are paying attention. I know that nurses are paying attention. I know that doctors are paying attention. Why do I know what? How do I put this?

Newsmakers is on at like, the interview we are talking about is on at like 5:30 in the morning. Unless you are my mother, you are not waiting up or getting up to see Newsmakers. I view that, I don’t know what their demographics are, but I don’t view that as being something that many Rhode Islanders will see.

People inside the political game watch it, because we are inside the game. I don’t think regular Rhode Islanders watch that. I will tell you that I have run into two doctors that you would think that the last thing they would be watching was Newsmakers, but told me that that interview was circulating within health care circles, because people are talking about it.

Because, to them, it is incredibly important. And, it is incredibly real. And, I think the reason that it doesn’t get the attention yet that it should is because it is hard, and it is hard to understand. And, it has taken me a long time to get to the place where I feel like… I am not where my staff is, they are way ahead of me, but I can talk about it intelligently. And, I feel like I understand it at a decently high level.

It is something like math. How do I put this? When I knew I wanted to be a lawyer, I did everything I could to avoid math. But this is math, and it cannot be avoided. And, it is only going to be given the attention it needs when something fails spectacularly. What leads the news on most weekend nights? The car crashes and the fires.

ConvergenceRI: Murder, mayhem, anxiety-provoking stories.  
NERONHA: Right. It’s not going to be until something crashes spectacularly that we’re going to be paying attention to it.

If you were learn today that Roger Williams’ ER just closed, that would lead the nightly news, the news cycle here, for three or four days. But what is happening at Prospect-owned hospitals around the country? And so, part of me believes that – and I hope we never get to that point. We’re going to work really hard here to make sure that doesn’t happen. But were it to happen, that’s the moment at which the light would dawn on some that this is a serious problem.

ConvergenceRI: As a reporter, I know that I have asked you this before. What can I do differently?  
NERONHA: Replicate yourself a few times [laughing].

ConvergenceRI: Clone myself? I did a long interview with Maureen ‘Moe’ Tkacik, who is a reporter for American Prospect. [See link below to ConvergenceRI story, “Has health care fallen under the sway of organized crime syndicates?”] When Medical Properties Trust’s stock value plummeted the first week in January….  
NERONHA: By 40 percent…

ConvergenceRI: ....she republished my interview with her. Which got a lot of attention on X [formerly known as Twitter]. I have an interview coming up with David Cicilline, the president and CEO of the Rhode Island Foundation. It was supposed to be last Friday, but it has been postponed for a month. I want to talk with him about what his position is moving forward in terms of health care. Because the Rhode Island Foundation, for better or for worse, that is where the money is.  
NERONHA: My understanding is, and you may know this, that they are doing a study of commercial rates, Rhode Island versus Massachusetts, and perhaps Connecticut. So, we may have some insight into how those rates stack up.

ConvergenceRI: The Rhode Island Foundation is doing that?  
NERONHA: Yes. And they hope to have that dataset, I think, relatively soon, which will be very helpful.

One of the frustrating things here, and we’ve already talked about the difficulty of getting the small component of information out of OHIC, it what I have asked out team is: What is the difference? Can someone quantify the difference? The dermatologist whom we met with, who has practices in Seekonk, Mass., and in Rhode Island as well, can tell you that he is making 20-30 percent more over in Massachusetts.

But we have been unable to quantify that in a way, in a dataset, that we could actually draw conclusions from. We hope to get that from the Rhode Island Foundation relatively soon.

What sometimes is forgotten is that by law, by statute, we are the health care advocate. We view that position as giving us broad authority and a broad mandate to advocate for a better health system in Rhode Island.

We obviously can’t do that if we don’t have the information we need to take a position in advocacy. That’s a small component of what we are trying to do here. I worry that we are just not thinking about health care from a fully strategic point of view.

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