Part ONE

PROVIDENCE – Imagine the point where everything converges: gun violence, health care, hospital mergers, the opioid epidemic, racial justice, and a legislative call to arms.

In Rhode Island, that point of intersection and convergence resides today at the offices of R.I. Attorney General Peter Neronha.

In recent months, Neronha has found his voice as a legal “activist” – pursuing lawsuits against those “responsible” for the opioid epidemic, including drug manufacturers, distributors and consultants. [See link below to ConvergenceRI story, “The high cost of consulting firms making policy,” which detailed the $573 million settlement by McKinsey and Co, for “turbocharging” the opioid epidemic.]

Neronha has also taken on the  responsibility in serving as the state’s public health advocate, asking financial questions about the pending sale and purchase of the two-hospital system know as CharterCARE, Roger Williams Medical Center and Our Lady of Fatima Hospitals, demanding that there be escrow accounts set up to protect the hospitals from potential financial liabilities from the sale of the entity by a private equity firm. [See link below to the ConvergenceRI story, “ A wealth extraction system run amok?”]

Further, Neronha has emerged as a consistent voice in asking legal questions about the proposal by Sea 3 to expand the footprint of the fossil fuel industry in South Providence, as well as the proposed waste-to-energy facility in West Warwick that seeks to use an “unproven” technology to burn medical waste, according to opponents. Neronha has asked that efforts to fast track the state’s regulatory approval for both projects be halted until a fuller legal review can be undertaken. [See link below to ConvergenceRI story, “Giving consumers ownership of their energy choices.]

And, Neronha has been at the forefront in asking questions about the circumstances around the alleged efforts to “curtail” services at Eleanor Slater Hospital, operating under the auspices of the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals [RI BHDDH], linked to problems with Medicaid spending. [See link below to ConvergenceRI story, “What do the cost data on health care really tell us?”]

ConvergenceRI recently sat down with Neronha for an in-depth, one-on-one, in-person interview at the R.I. Attorney General’s office on South Main Street in Providence, a conversation that lasted nearly 90 minutes, the kind of detailed conversation that is so often lacking in coverage by our news world, captivated and consumed by breaking news and urgent tweets.

It represents the kind of long-form journalism that, frankly, is absent from the sound-bite driven world we live in. Because so much consequential content was covered, ConvergenceRI has decided to publish the interview as a three-part series.

Part ONE explores Neronha’s role as public health advocate, focused on access, accountability and quality when it comes to hospital mergers and regulation.

Part TWO delves into the Neronha’s role in ongoing lawsuits brought against the drug manufacturers, distributors and consultants most responsible for the opioid epidemic, with a further discussion of gun violence.

Part THREE tackles Neronha’s role as a legal “activist” in challenging the status quo when it comes to environmental issues facing Rhode Island.

It requires nothing more than readers being willing to become engaged with the content.

Here are some “teasers” to keep readers going:

• Neronha: “I think we need to be more robust as regulators in the health care space generally.”

• Neronha: “There are 27 lawyers in the civil division. Those 27 lawyers… are defending 573 state cases involving things like tort liability, with $67 million in exposure. That’s just defensive work alone That’s not environmental work, that’s not health care, that’s not consumer [protection], that’s not health care.”

• Neronha: “Something we don’t do in Rhode Island, or anywhere, is keep track of data very well. I asked my folks to go through their various cases, and let me know, in the past couple of years, how many times we have seized the high-capacity magazines.

We have seized at least 16 of them. What that tells me is that there are high capacity magazines – and they have been seized in the context of criminal activity, obviously – and there have been lots of other incidences where there have been lots of shell casings upon the ground.

We don’t have the firearms, so we don’t know if there are high-capacity magazines [in use], but you can draw a pretty sensible conclusion that when you have 20, 30 rounds of casings on the ground, that a high-capacity magazine may have been used.

We have recovered at least 16 of them in the last few years alone. So, banning those high-capacity magazines, with 20 rounds or 30 rounds in a magazine, will limit the number of bullets that are being discharged.”

ConvergenceRI: Thank you for making the time to talk with me. I see you as serving on the front lines of so much of what is happening in Rhode Island in your role as public health advocate, making important decisions, intervening on any number of fronts, from health equity to health care regulation to racial justice. How does the mantle of public health advocate fit? What are the types of things that have expanded in your thinking about what the R.I. Attorney General’s office should be working on?
NERONHA: I think, Richard, when I first got here, I had a very generalized notion of what we needed to be doing in health care. It was not overly well defined.

There are three words that I now hear all the time. Maybe people were saying them before, and I picked them up somewhere. But for me, it was always about “access, quality, and affordability [emphasis added].”

Those were the themes that were in my head when I arrived here. And, so everything that we try to do – and I think that we will continue to do – comes back to those three things. Now, those are really broad words.

So whether we are in the health care space functioning in our capacity as a regulator, which means we have to do an anti-trust review, say, of a proposed hospital merger, or whether we have to regulate a change in ownership, like in Prospect [Medical Holding], or whether we are an advocate where we don’t have necessarily, a regulatory role, [those concepts are key.]

Think about the vaccine rollout, particularly in the context of the board members of Lifespan and Care New England [which the R.I. Attorney General’s office reviewed]. It is not a regulatory function we serve there; [the review was conducted] in our capacity under Rhode Island law and statutory law as a health care advocate, where we advocate for good policy.

Another example would be in the insurance space, where we were advocating for little or no increases in health insurance [rates] in the individual market last summer, something that I felt very strongly about.

That was a matter before the R.I. Office of the Health Insurance Commissioner, OHIC. [It was] not a decision that we were making; but we intervened there, because we didn’t believe – and I still don’t believe – that any increases were warranted then, for lots of reasons we can go into.

We are operating in a lot of spaces, but it comes back to those things, and, as I try to link those areas [of access, quality, and affordability]. It’s what we are talking about in terms of [the pending sale of] Prospect [Medical Holdings].

There, really all of them [come into play]. If Prospect isn’t healthy enough to maintain our Rhode Island hospitals, then what suffers?

Certainly, quality suffers. Accessibility suffers. Now, affordability may not fit perfectly there, but accessibility and quality are real concerns there.

When you are talking about Lifespan and Care New England [and their proposed merger with Brown University], you know that costs are certainly a [potential] factor. If someone were to ask, speaking within a more general [framework], that when a big chunk of the market is consolidated in one entity’s hands, what does that mean in terms of cost? What does that mean in terms of accessibility? Is there no longer incentive to be in as many places to deliver health care, where it’s needed?

[When you talk about] quality, and again, in that context, you would like to think that an organization that is strong, because such an organization, I think, would be strong, the question is: Would it be too strong to properly deliver quality?

Perhaps not. Let me give you an example. Is it better for a patient, when they need to see their doctor on a weekend, to show up in the emergency room, or to show up at their doctor’s office, if their doctor’s office is having office hours on a Saturday or a Sunday?

I believe that you can get better health care seeing your own doctor or an associate of your own doctor with access to your records on a Saturday or a Sunday, rather than sitting in an ER for six or 10 or 12 hours, as my own mother has.

And so, when we are talking about consolidation, does consolidation drive certain incentives or lack of incentives that lead to a negative result? So, if you look at that issue, in that context…

Take the vaccine [being given to] board members. That’s really a matter, as I think about it, at the least, of accessibility. Some people are getting access to a vaccine before others. Is it being done in a way that makes rational sense?

Certainly, with the insurance rate increases, you are talking about, among other things, cost. But all of the things that we are doing in the health care space, I can link them back to those three themes [access, quality, and affordability], and they tend to drive our thinking about where we should intervene, what positions we should be taking, and how we should advocate or operate.

ConvergenceRI: In this week’s edition, I did a very deep dive about Medicaid, and in particular, Medicaid accountable entities, and the cost data analysis done for 2019. [See link below to ConvergenceRI story, “What do the cost data on health care really tell us?”]

And how the information that was presented to the public didn’t really fully account for what was doing on, in my opinion.

You have an accountable entity, when you are looking at cost trends over time, with a 14 percent increase from 2018 to 2019, versus a 0.2 percent increase or a 0.3 percent increase, by some of the apparently better-managed providers.

My question is: Who is holding the accountable entities “accountable?” And, when you look at everything that is happening with Eleanor Slater Hospital, it all seems to be related to Medicaid spending. If you haven’t read it, I suggest reading the story.
NERONHA: I will. I do read your posts. I do. Sometimes I am a little behind, by a week or two. But I do read them.

You are raising a point, which the takeaway is, for me: I have said this more than once. This office is doing far more health care than we’ve ever done [before].

No question about that. Our resources haven’t kept up with that. The reality is that I think we’ve added one lawyer since I’ve been here – one lawyer FTE. The reality is, I have four people, in addition to Miriam [Weizenbaum, the new Chief of the Civil Division at the R.I. Attorney General's Office], in addition to the Deputy Attorney General, in addition to me, doing health care now.

Keeping up with all of the health care needs, realistically, I probably need a full-time, five-six person health care unit. I effectively have a one, one-and-a-half full-time health care unit.

So, for me, certainly, there is a lot of health care to do. And, I need more resources to do it the way that I’d like.

But it’s not just limited to [my office]. I think we need to be more robust as regulators in the health care space generally. I think the R.I. Department of Health needs to be a more robust regulator. I am not criticizing them. I think they have done a particularly fabulous job during the pandemic that we’ve just gone through.

But they need to have the kinds of resources to enable them to really get inside health care and regulate it. The R.I. Health Insurance Commissioner. Same thing. I don’t have a lot of insight into how that office functions.

I think if you are a regulator, and if you are not bringing a healthy skepticism to everything that is in front of you, if you are not challenging everything that is in front of you, if you don’t dive deep into the facts underlying what you’ve been asked to believe, then you are not doing your job as a regulator. One thing that I worry about is [the fact that], for lack of resources, we are not doing enough regulating.

By regulating, I don’t mean holding things up with red tape. I mean understanding what is being proposed. And being able to decide whether or not what is being proposed should be approved, or not, or approved with conditions, and what those conditions ought to be.

ConvergenceRI: I agree with you. And Miriam, from my interview, and from I know about her work, seems to be doing an excellent job. [See link below to ConvergenceRI story, “You cannot be risk averse.”]

I thought that your response to what happened with Prospect Medical Holdings sale – and the public relations campaign apparently conducted against your office, falsely claiming that your conditions would cause two hospitals to close, was spot on. In my view, they tried to bully you; I don’t think you are a person who can be bullied easily.
NERONHA: That’s right. I’ll say again what I said the next day [after the [CharterCARE] news release was sent out]. I think it was really important for me to come back the next day, and say what I needed say. And, I appreciate you printing a lot of that.

What I said, needed to be said, which is this: My goal, and I think this is important for all regulators, is not to take at face value the promises of people who want to do something in this state, particularly when you do a dive into those folks, and you realize there are reasons not to take their promises at face value.

I’m not suggesting necessarily bad faith. What I am saying is, if you are going to promise to do something, you need to have the wherewithal to be able to deliver it. And, if we are not certain that you can, we need to take steps to make sure that you can.

Look, the reality is, we can’t solve, I can’t solve, all the problems. I can’t take health care in this state and make it function in a way that delivers all the things we talked about at the top – accessible, affordable, quality health care – because health care is too complicated for me to fix all of it.

So, what I’m trying to do, whether it be in that context, or others, when we’re regulating, is to make sure that I can solve, for the most basic problems, which is, when it comes to Prospect, is that I want those hospitals to be able to function, for at least the term of the Hospital Conversion Act, which is five years.

I want to make sure that every Rhode Islander can wake up and know that those hospitals are going to be there – and that [the hospitals] are going to keep functioning.

And, if I can’t assure the people of Rhode Island of that, then I need to take steps to ensure that it does happen. Or, at least, to be honest with them as to the state of affairs.