Delivery of Care

AG Neronha to offer bold prescription to solve RI health care crisis

Everything needs to be on the table, AG Neronha says. He and his legal team are busy constructing solutions to RI’s broken health care system. Are you willing to listen?

Photo by Richard Asinof/file photo

R.I. Attorney General Peter Neronha at a news conference talking about the rejection of the proposed merger of Care New England and Lifespan.

By Richard Asinof
Posted 7/24/23
Attorney General Peter Neronha is putting together a strategic plan to address the current health care crisis in RI with concrete solutions.
What resistance will be created from Gov. McKee to the Attorney General’s leadership in addressing the health care industry? What are the appropriate forums to talk about the Attorney General’s proposals – where patients and not just industry stakeholders have a seat at the table? Will other Attorneys General follow suit with Attorney General Neronha and challenge the private equity looting of hospitals and nursing homes? How many reporters in Rhode Island will be willing to share this groundbreaking story and credit ConvergenceRI?
The machinations involving Optum, the wholly owned for-profit subsidiary of UnitedHealth, continue to roil the waters around behavioral health care management in Rhode Island and Massachusetts. A planned merger between Harvard Pilgrim and Tufts was supposed to have occurred as of July 1, 2023. All mental health providers received a letter Optum would no longer be the behavioral health vendor for Harvard. But because there was an apparent data breach, the mental health aspect of the merger is said to be on hold.
In Rhode Island, OHIC has been alerted to the problem. It raises yet another question about the potential conflict of interest in having Optum manage behavioral health contracts for both Neighborhood Health Plan of Rhode Island and UniteHealthcare under the Medicaid MCO contracts.

PROVIDENCE – If R.I. Attorney General Peter Neronha had a career as a social influencer on Twitter, similar to that of writer Sophie Vershbow and her dog, Simon, as a person that news reporters, politicos and cultural mavens seek out for advice, the last week of headlines might make more sense.

Attorney General Neronha has found himself involved in any number of controversies where the practice of law, politics, health care, and community development seem to have collided. Many people want his legal advice, it seems.

Most recently, there was the decision on Friday, July 21, by the R.I. Board of Elections, on a 5-1 vote, to recommend that the Attorney General look into alleged problems of signatures submitted on behalf of Lt. Gov. Sabina Matos’s campaign for Congress. In response, as reported by The Boston Globe, Attorney General Neronha said: “This is not a lane that I should be in. I’m not really sure why they’re asking me to do this in the first place.”

Earlier in the week, on Monday, July 17, Gov. Dan McKee announced his decision to end the contract with Scout Ltd to develop the Cranston Street Armory. Gov. McKee’s decision following an ill-fated business trip in March by two former McKee administration officials, which led Scout to complain in an email about the alleged “racist and sexist” behavior displayed by then DCAMM Director David Patten and then DOA Director James Thorsen. [See link below to ConvergenceRI story, “Petty and petulant.”]

State Representative Enrique Sanchez criticized the move by the Governor to end the contract with Scout, in a joint statement put out with State Sen. Sam Bell.

Sanchez said that McKee’s move sent a message “that this is what happens if you speak out about extortion or sexual harassment in this administration,” according to a story in The Boston Globe. In turn, state officials said they were ‘not concerned” over legal ramifications of terminating the contract, according to The Globe.

The Governor, however, apparently was not interested in seeking out legal advice from Attorney General Neronha before making the decision to end the contract with Scout.

“Brian Hodge, a Neronha spokesman, told the Globe that the attorney general was not briefed ahead of the administration terminating its contract with Scout,” according to a news story.

Community activists involved in promoting the development plans for the Armory,, however, voiced their disappointment. They also expressed hope that the Attorney General would become involved.

Rebecca Atwood, president of the West Broadway Neighborhood Association, tweeted: “Again, it seems (and has seemed for a while) like McKee is executing a personal vendetta instead of working in the best interest of the people of Rhode Island. It’s not just about the Armory, it’s about the good faith we should expect from our government.” She added: “I really do hope @PeterNeronha looks into all this.”

On the hot seat
When it comes to prosecuting gun violence, promoting consumer protection and advocating for public access to the Rhode Island coast, the Attorney General’s office maintains a high profile on Twitter.

Indeed, this week Attorney General Neronha will host the 25th Annual Open Government Summit on Friday, July 28, to talk about policies that guide access to public records and open meetings. Some 750 people have registered for the event.

ConvergenceRI conducted a wide-ranging interview with R.I. Attorney General Peter Neronha, on Thursday, June 29, for more than an hour at his office. What to do strategically about the state’s looming health care crisis was the major focus of conversation – a topic that the Attorney General has put front-and-center on his agenda.

“To me, to solve all this, we have to put everything on the table,” Attorney General Neronha began. “Everything’s on the table. Commercial insurance is on the table. Are they doing things the right way? Can we get more out of Medicaid? Can we get more out of Medicare? Are the hospitals running as efficiently as they can be?”

Attorney General Neronha continued: “Over here, to the right or the left, you’ve got this primary care problem. What is important to remember is: It’s not just that you can’t get an appointment. It’s that you can’t see a specialist. Because, if you can’t get the referral, then, the insurance company won’t cover it.”

The health care system is in real jeopardy, Attorney General Neronha warned. “What is happening now is that there are lots of people who can’t meet a specialist – your neurologist, your cardiologist, whatever. They can’t get a referral to those specialists because their primary care doctors don’t exist.”

His message: “The entire foundation of a health care system is in real jeopardy, because primary care is the foundation in terms of delivering care, and then, for acute care, that’s the hospital systems, and they are in danger as well.”

Rhode Island is in a really difficult place, Attorney General Neronha believes. “In part, it’s a function, I think, that we are simply too small. We are simply too small to have competing systems, that, at the same time, you need competition in the marketplace, to keep, among other things, prices down and quality up. And so, we are in a sort of a conundrum here. What I am suggesting by that is, in the long-term, it may mean that we need out-of-state investment to keep our systems where they need to be in terms of their health. And I don’t think that the fear that I’ve always heard, consistently, is that we’ll lose control. And, I think you can solve for control. “

The first challenge is to identify the problem; the second challenge is to develop a series of comprehensive solutions.

Such a proposal is now in the works, being developed by the Attorney General’s legal health team, led by Julia Harvey, Special Assistant Attorney General and Health Care Advocate.  Its public release is expected shortly.

“We know that we have got to move quickly,” Attorney General Neronha told ConvergenceRI, saying he expected to use his bully pulpit to promote the plan. The question is: Will the public – and government – be willing to listen?

Here is the ConvergenceRI interview with R.I. Attorney General Peter Neronha, a conversation focused on health care problems and solutions – and the political will needed to avert the breakdown of health care delivery in Rhode Island.

ConvergenceRI: Congratulations on your willingness to step in with the new task force looking at primary care. You are now in a position where you can actually play a pivotal role. [See link below to ConvergenceRI story, “When a strategy of convergence works.”]
NERONHA: I identified the challenge in health care, which is getting people to pay attention, before it heads down the road to destruction. That is why I talk about it so much.

I was on “10 News Conference” with Gene Valicenti [this past] weekend. Gene is a reporter who pays attention to the news.

I don’t want to say he is uninformed, but the structural problems underlying health care were plainly news to him. And, I think, people don’t realize how vulnerable our health care system is, in many respects.

So, the hospitals are vulnerable – and we’ve talked about this, Richard. We’ll get to the primary care story in a minute. But the hospitals are vulnerable because their payer mix is too weighted toward public payer.

It’s about 70-30 percent. Some are little above; some are little below. But they are all within striking distance of 70-30 percent. That is not a pie chart that will support our health care institutions, our hospitals, long-term or even short-term.

It’s a problem that [we are going to face] with Fatima or Roger Williams in just a matter of years, before I leave office, because the $80 million that we worked hard to get into escrow will be gone in 2026 or early 2027.

We know those hospitals can’t meet their bottom line; they never have been able to meet the bottom line. They can’t pay their ongoing expenses. And they are not unique.

And so, if we don’t somehow restructure how we pay for health care, those hospitals only really have two choices: the current owner is closing hospitals around the country. You know that, there has been a lot of coverage of that.

There is no reason for them not to close these hospitals. That is what they are doing to all the others. The only reason why they can’t close these hospitals is because we are preventing it, by having the $80 million in escrow. I firmly believe that.

What happens when the five years is up, and the $80 million has either been invested in or given back to them, because they have done what we have forced them to do?

The hospitals are without an endowment. There is no pot of money to rely on. They can’t meet their own ongoing expenses, let alone invest in their infrastructure. What do they do?

They only have two choices: they either close, or they go to the General Assembly [to ask] for money. And, there is no appetite for that. We know that.

There is a real prospect that those two hospitals won’t be with us in 2026 or 2027. That is an immediate issue that is not getting the news coverage that it deserves. That is a problem.

More broadly, it’s not like the other larger health care systems [in Rhode Island] are doing much better. It is striking to me. I sat with both Dr. Wagner and President Fernandez from Lifespan. Dr. Wagner is president of Care New England.

I think it was President Fernandez who told me that he had been, at one point in his career, at City Hospital in Boston. And Boston City Hospital was running at the same 70-30 percent mix. And, ultimately, it had to go to the City of Boston for financial support, either the city, or the state, or both. And so, they are now a publicly subsidized hospital.

If you think about it, that means that all of our hospitals, if we don’t change the way we do health care, are potentially headed toward being publicly subsidized hospitals.
We can’t afford that. So, we have to fix it. How do we fix it?

• Part of it is economic: if we can get more people onto private insurance, that’s great. That means we have to grow our economy. In Rhode Island, that has been a consistent struggle.

• Medicaid reimbursement rates need to come up.

• We can get more federal money, if we re-imagine how we do Medicaid and Medicare.

ConvergenceRI: How do we get to that point of re-imagining Medicaid and getting to higher rates? There seems as if there is one opportunity coming up in how to do that, which is the renewal or the re-procurement for the Medicaid Managed Care Organization contracts that are pending. There may be an opportunity to audit the finances of the current MCOs.

One of the things you were able to do with the proposed mergers and also with Roger Williams and Fatima was that you were able to get the numbers.
NERONHA: Sure. That’s how I know how big the problem is [in health care].

ConvergenceRI: Can we get the numbers on what the MCO spending on Medicaid is?
NERONHA: It is difficult for this office to get them, because we don’t regulate them. You are asking: what is it that we’re doing in health care? Our health care team is far too small but growing, because we have managed to get the resources I asked for [but the Governor denied me] from the General Assembly, for which I am incredibly grateful to them.

My challenge to them is: Let’s come up with a plan by which we lay out how we do this, and how it is done in other states, and we can replicate what’s done there. And bring that to someone who can effect change. Whether that is the Governor, because he holds the levers of power, I understand that that may be a bit of a challenge. Or, the General Assembly. Or, by use of the bully pulpit, we simply make it happen, because it has to happen; it has to happen.

And, that’s why I keep talking about it; it has to happen. But, I don’t control the levers of government. And, my regulatory authority is very narrow. It gives me insight. But that doesn’t give me the ability to effectuate change.

ConvergenceRI: I believe that the bully pulpit is there, if we can actually get the numbers in public view. Until those become publicly known, you can’t move forward, because you don’t know where the money is being spent. How do we know how the money is being spent?
NERONHA: It’s a great question. I think one of the challenges that we have is we don’t see the finances of any organization. So, for example, I have no insight into South County Hospital, or Westerly Hospital, or Landmark. I have no ability to get inside their finances.

Same thing with insurance companies. We’re not inside their finances, either. The rates come up, we object. But, the reality is, we don’t know where they are spending their money. And, that’s why, to me, to solve all this, we have to put everything on the table.

ConvergenceRI: Much of the health care reporting in Rhode Island is not very good, in my opinion. It lacks the kind of in-depth reporting that is essential if you want to create a bully pulpit for major changes in health care.
NERONHA: Richard, let me give you an example. It sort of ties in to what you are saying – not about reporting, but about the inability of people who have issues to get them addressed.

There is an eye surgeon whom I know personally. I’m not a patient of hers, but I know her; our kids grew up together. She texted me within the last week, and she wanted to know where her patients, who could not find a doctor, could go to inform government that they couldn’t, to complain about it, and to seek solutions.

I’m reading that text, and I’m thinking: where do they go? Where do they go to say, “I can’t find a primary care physician.” Where do they go to let people know that finding a primary care physician is hard? Who is studying whether it is hard to find a primary care physician?

Who’s tracking how many primary care physicians we have? Who’s studied how many we need? Who’s studied how many we are losing to other states? Right? Who’s doing that kind of analysis? I don’t think anybody is. And so, what I asked her to do was to refer her patients to our team, so at least we could get a sense of what their experience was.

I would love to build in this office a health care strategic team. It requires more resources than I have. I am asking them to do it anyway. To me, that’s what me need. What I just suggested is the beginnings of the solution. If you don’t understand a problem, you can’t craft a solution.

And, that, to me, is the biggest challenge. And, what else we need to do, in my judgment, is invest in health – and that part of EOHHS, the Medicaid office, which is in my judgment, far too small to do what it should be doing: Which is to think beyond what’s right in front of them. They need to be doing more strategic thinking as well.

I don’t have the answer to how we leverage our Medicaid investments to get more federal money. But I know it can happen, because other states have done it. But somebody has to study it. That’s not something lawyers can do. But there are people who can do it, and we need to get them into state service – or hire them, so we can take advantage of that as well. We need to leverage Medicare.

We can do Medicare differently. I have had conversations with Sen. Jack Reed about it. He is very interested in coming up with ways to deliver more Medicare money. And, there are ways to do that now, and he is looking at that – and our staff is looking at that.

But, what frustrates me is that, if this kind of thinking is going on anywhere else in government. I’m not aware of it. And, it is telling to me that based upon my public statements and some of your reporting, that people who do health care are constantly reaching out to us.

They want to come in and talk to us, about what their problems are. I don’t know that they are going to others. Because I think we are the ones who are doing the strategic thinking.

I have tremendous respect for the Department of Health. And so, I don’t want my comments to be misinterpreted. They are a fine group of people that have managed the pandemic brilliantly, but they are understaffed – probably everywhere, but certainly on the regulatory side.

We saw this in the merger, where they simply were not in a position to even decide what should happen. To say it plainly, they couldn’t tell Rhode Islanders whether the proposed merger was a good thing, or a bad thing. And they never did.

Think about that for a minute. The Department of Health in this administration couldn’t tell the people of the state of Rhode Island whether the merger [of Care New England and Lifespan] was a good thing for them, or a bad thing for them.

What should that tell leaders in government? That if my people can’t get to that place, I need to understand why and make sure that they can. Because it’s not going to be the last time that the health care decisions are going to have to be made. And, the Department of Health, in my view, ought to be at least as capable as we are in doing the [review], and they are not. We have to get there as government.

ConvergenceRI: So, what can I do? I have done everything that I can think of to beat the drum, to call people out, to call reporters out for their bad reporting, to continually push the envelope of saying: We need to talk about this. It’s like I want to lead a school of mischief, I don’t know what to call it, for reporters, to teach them how to cover what questions they should be asking about health care.
NERONHA: Richard, I think, here’s the problem. For one thing, they don’t do a lot of long-form reporting. You do long-form. But, most of the time, people don’t do it.

I have tremendous respect for Tim White [at WPRI] and Ted [Nesi} and also Gene [Valicenti]. Those shows are 23 minutes and they want to cover 10 topics. In fact,  I just did a Newsmakers, right before I went out for surgery. And, I think Tim actually said, “We can do a whole portion on health care.” We could. We could do an hour show on health care, and talk about it.

But, what worries me is: what’s going to cause people to start to think about change, at a time when it may be too late? Is it when, “Hey, what happened at a suburban Philadelphia hospital, when a mother with a breast infection went to the emergency room, and just learned that they were closed.” And, was told by the person at the door, Google another hospital, and find your way there. That is when people will start to cover health care.

I mean, they are shocked. We have a problem. Oh, yeah. Of course, we have a problem. We’ve been talking about it for some time. I am amazed, frankly, by the short memory of some reporters as to what even happened at Prospect [regarding Roger Williams and Fatima hospitals]. They don’t even remember the $80 million in escrow, and who obtained it, and why.

Oh, there was a fight with state elected officials. There wasn’t a fight with state elected officials. There was a fight with me. The [reporters] were here, and they don’t even remember what happened two years later.

That’s the problem. We are too focused on what is in front of our face. And, that is important for some issues. You have to plow the streets today. Right? But other issues require more long-term thinking, and we don’t think long-term enough.

We are two years into this. We are two years past [enacting] the Act On Climate. And we’re just now funding the experts that can help the agency that is supposed to get us into compliance with money. So, for two years, we wasted two years, because we didn’t fund the experts to come up with a plan. That’s our problem. It’s short-sighted.

We can’t be short-sighted on the most important things that are facing us. And, in my view, climate and health and then education of our children are all right there. On education, I’m not an expert. It seems to me we just churn. We churn leaders; we churn ideas, and nothing ever changes. But that’s not my area of expertise.

ConvergenceRI: Where do we go from here?
NERONHA: I watched an interview on one of the local stations. People who couldn’t find a primary care doctor. It was a collection of outrage. And, I understand that completely, for a lot of reasons. They are really outraged that they couldn’t find a doctor. Whose fault is that?

It’s not the doctor’s fault. The doctors would happily take more patients, if they could take more patients. But their panels are already full for primary care. It’s not the doctor’s fault. It’s the fact that we have done nothing to attract primary care doctors to the state, because doctors can go over the border and make significantly more money to do the same work.

We like to think about doctors just being about health care and not being about economics. They are as much about economics as anyone else. Because med school is incredibly expensive,  many of these young doctors come out of med school with financial obligations that they need to meet. While at the same time, they are at the age getting married and having families.

If Rhode Island wants to compete with Massachusetts and Connecticut, we have to figure out a way to make sure that they are reimbursed the right way, because they are paid by reimbursements. We have never elevated primary care to the place where it needs to be.

We don’t even know how many primary care doctors we need for our population. We are not tracking the need.

ConvergenceRI: Will the new task force help to determine those numbers?
NERONHA: I don’t know. It ought to. If you want to solve the problem, you first have to understand it.

How many do we need? How short are we? How do we get to the place where we need to go? It’s pretty simple. The answers aren’t as simple. Those are the questions. The first step in solving a problem is identifying what the problem is. [pause]

You want to know what we are doing here, in health care?

ConvergenceRI: Yes.
NERONHA: I have asked Julia Harvey [and her team] to really think through why our health system is failing here, and to come up with solutions that we can propose. So what I’ve charged them with is: understanding the problem.

We’ve had Christopher Koller in here; we’ve had the head of the hospital group; we’ve had primary care physicians in here to get their perspective.

ConvergenceRI: Consider this an open invitation. When you are ready, I will be happy to publish your report.
NERONHA: When it is ready, I will do that. We met with Sen. Jack Reed and made a presentation to him. It’s not quite where I would like it to be yet. I anticipate doing a similar presentation with the Speaker in the near term. The Speaker is interested because he knows, and the Senator President knows, that the bill is going to come due for Roger Williams and for Fatima, on their watch, potentially, in 2026. We are working toward a deliverable ‘

I think we have done a pretty good job of identifying the problem. Now we have to get to a place where we propose solutions, recognizing that some of the people that we need to talk to have a stake in the game. We are trying to do this on anobjective basis.

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