PART Two

PROVIDENCE – R.I. Attorney General Peter Neronha shared in great detail the worries that keep him up late at night, captured in a recent interview with ConvergenceRI. Those worries include: the lack of primary care physicians, the financial frailty of many of the state’s hospitals, and the apparent failure by the state to engage in strategic planning around looming crises in health care. [See link below to ConvergenceRI story, “AG Neronha sounds the alarm,” PART One.]

“I love being Attorney General,” Neronha said, in response to a question about whether he was considering running for higher office, apparently ruling out a run for Congress or for Governor.

“I think that perhaps what I do as Attorney General, differently from what Attorneys General have done in the past, [is to recognize] this office has a lot of latent ability and authority that we are now using. It’s not like it’s never been there; it’s just that we’re now using it.”

In PART Two, Attorney General Neronha described in detail his office’s plans to develop the necessary strategic tools to better protect the health of Rhode Islanders, moving forward.

ConvergenceRI: How is your office responding to the needs for more, better strategic planning around health care?
NERONHA: I think that the most important thing is that the team has endeavored to talk with people in the field. Julia Harvey is our Health Care Advocate. She has been talking to providers directly, the people who deliver medicine, not speaking to hospital administrators.

I think it is important to understand what is happening on the ground. For example, I know from my wife, who is a primary care doctor, that when ERs are overrun, and the Department of Health asks primary care physicians to handle as many patients in their office as they can, rather than sending them to the ER, it can create problems.

One of the problems is that a test ordered by the ER doesn’t need to be given prior authorization, if it is done in the ER. But, a primary care physician needs prior authorization from the insurer to order the test. And, that can take days.

So, when the primary care doctor [examines] the patient and [realizes], I need a test, and to get prior authorization is going to take time that the patient may not have, it’s off to the ER you go.

It may be a simple fix to correct this problem. But, where are we going to talk about finding a solution? Yes, getting patients to the ER costs more money; it puts more strain on the system, and health care becomes more expensive.

Those are the things you learn about only by talking to people who are delivering health care.

ConvergenceRI: Your team, under your auspices, can talk to people and get the information…
NERONHA: Yes.. There are things we can’t change, as the Office of the Attorney General. We’re not the Legislature; we’re not the Department of Health, we don’t issue regulations. But we can identify problems and propose solutions.

And, the reason we are doing some of that work, not withstanding the fact that we are not really built to do it, is because nobody else is doing it, and I believe we have to do it. Somebody in this state has to do it. And, I don’t believe that we are doing it right now. I could be wrong, Someone could read your story and call you up, or call me and say: “We’re doing exactly that; we’ve got it all in hand.” But, I’m not convinced that that is the case.

ConvergenceRI: Shifting gears a bit, your office has opened a docket for natural gas before the Public Utilities Commission [PIC]. Are there opportunities there to begin to ask questions about the health consequences of building out the gas infrastructure and, in particular, its role of the manufacturing in plastics?
NERONHA: Richard, that’s not an issue that I have given a lot of thought to, frankly. I will say we are certainly involved in the future of gas. There is a docket, as you point out.

But there is another issue before the PUC that we’ve weighed in on, and we are actually going to be putting out a news release on that within the next few days, where we are challenging Rhode Island Energy’s gas infrastructure proposals. Initially, they wanted to put in a plan over 21 months, which meant that they wouldn’t be complying with the law, which said that they had to do so in 12 months, not 21 months.

We are questioning whether we should be making these investments in the gas infrastructure, when we have a mandate to transition away from fossil fuels under the Act On Climate law.

If we were to make unnecessary investments, who is going to pay for them? Rhode Island Energy will profit from these investments, for sure. Who is going to pay for these investments that, ultimately, we may not need?

We have already submitted a fairly lengthy, 15-page position a few weeks ago. We will be making that more publicly known in a release in the next couple of days.

But we are actively involved in that docket, because we want to make sure that any investments in gas infrastructure that we are making make sense in the context of moving away form gas as a principal source of energy.

There is a sweet spot there. We want to ensure that the system delivers energy in a way that keeps homes heated in winter We saw what happened, when I first got here [as Attorney General] four, five years ago, when Newport went dark for a number of days in January. But, we also don’t want to make unnecessary investments, so finding that sweet spot is really important.

But that broader question of the gas industry and plastics, I haven’t given a lot of thought to that; it’s an interesting one, and I will bring that back to the team.

ConvergenceRI: It’s a broader conversation, one that might be worth pursuing in the broader context of climate change.
NERONHA: Richard, for me, there is a broader question here: To what extent are state agencies really being aggressive in protecting the interests of Rhode Islanders? How much health care strategic thinking has been going on in state government?

My view is, it needs to happen. In terms of energy, we were the ones who were challenging some of the terms of the sale of Narragansett Electric last May, and we delivered a lot of value back to Rhode Islanders, particularly in the context of heightened gas prices, when nobody else was in that fight.

In fact, the Department of Public Utilities and Carriers filed a brief in court opposing our position. Think about that for a minute: The Department of Public Utilities and Carriers before the Superior Court, challenged the Attorney General’s right to advocate for Rhode Islanders.

I will say it again. Think about that for a minute. The Department of Public Utilities and Carriers filed a brief in Superior Court opposing the Attorney General’s right to advocate for Rhode Islanders when it comes to energy rates and the Act On Climate. That is something, in my view, that should concern Rhode Islanders.

I am heartened, though, by other things. The DEM, I think, really needed us to be a partner to take on some interests that are not in the best interests of Rhode Islanders.

And, take the Coastal Resources Management Council [CRMC]. Over the past four or five years, has the agency really protected the interests of Rhode Islanders? Why are we the ones in the fight out on Block Island to prevent the expansion of that marina?

Why aren’t our state agencies allies in protecting the interests of Rhode Islanders, when the law is clear as to what the results should be?

I think you really need to think about where is leadership at these agencies, and whether they are really working to protects the interests of Rhode Islanders.

Some of them are doing a really good job. We’ve had a good relationship with the Department of Business Regulation [DBR], for example, and, as I said, DEM just needed a wing person to help them fight for Rhode Islanders.

And, I think that with the Department of Health, we’ve had good partnerships there on lead, for example. But I do think that strategic thinking needs to happen, and I’m just concerned that it’s not. These are things that we will continue to advocate for here.

ConvergenceRI: What form will that advocacy take?
NERONHA: My voice, I think, is one that when I speak, it has some impact. I am going to continue to [speak out]. It’s why, during my inauguration speech [in January], I talked about two things: environmental protection and energy, and health care.

We have to think about them in three, four, five years out. Not 15 years out. These problems are going to present themselves in the context of Roger Williams and Fatima [hospitals] in just a few years. And, I’m concerned that we are not doing enough.

I think that people tend to look at us as an office of prosecutors. And, we are. And, that’s a really critical part of what we do. But our civil division can really act on behalf of Rhode Islanders. And, in places where we don’t have authority, we can really advocate for change and for strategic thinking that needs to happen.

In health care, we have regulatory authority. And that is all well and good, on a transaction-by-transaction basis. But, if you go up to 50,000 feet, you realize that what you are seeing, in the context of these regulatory decisions, are time bombs that are going to go off.

The only difference between Roger Williams and Fatima [hospitals], and that hospital headquartered in [Delaware County in] Pennsylvania, is that here, the Attorney General was able to prevent [the hospital closings] from happening, by having $80 million in escrow that forced [the private equity owners] to do the right thing.

What is particularly concerning about that, as I look back, is that the Department of Health wasn’t there with us, they weren’t there with us on the merger, either.

The Department of Health never issued a decision on the merger [between Lifespan and Care New England]. Think about that for a minute. The Department of Health, in what would have been the largest health care transaction in the state’s history, putting 80 percent of health care in one place, never issued a decision as to what [its position was], and never made public what its position was, whether they believed it should happen, or not.

That is symptomatic of a more serious problem, which is: that kind of capacity probably does not exist there – and it needs to exist there. And so, we are trying to fill the vacuum, Richard. But this office is not built to fill it.

We will do what we can, but we are not built to fill it. I have one health care advocate. But we are not the Department of Health. They should really be leading us here. I do not mean by that to be criticizing them. They do a lot of really important work.

My understanding is that they are much smaller than they were a decade ago, and so, is that an agency that we should be investing in, because we see this problem coming? If it doesn’t exist, then build it. Recruit it, and build it.

ConvergenceRI: There has not been the leadership, on top, in my opinion.
NERONHA: Correct. Think about that for a minute. When that merger [between Lifespan and Care New England] was coming to a head, Dr. Alexander-Scott stepped away. She wasn’t involved with that merger going forward. I know that she was kept on as a consultant, but she didn’t consult on the merger. We didn’t have any conversations with her about that merger.

I remember hearing, frankly, [from critics] during the campaign, that the Attorney General should defer to the Department of Health. If we had deferred to the Department of Health, we wouldn’t have issued a decision.

To me, it’s like: if you’re driving in a car, and Boston is your destination, we were going by the gas tanks on the Southeast Expressway, and the Department of Health was somewhere near the Rhode Island-Connecticut border.

They just weren’t there. Going forward, they need to be there. They weren’t there on Prospect, either. The Health Advisory Council actually approved that change of ownership, which remains a mystery to me. The Department of Health wasn’t there, either, on that one.

My only point is this: is if that capacity doesn’t exist, because that agency has not been invested in, it needs to be invested in, because these issue are only going to become worse, and those time bombs are going to go off.

ConvergenceRI: One of the areas where I think you have been successful has been working to prevent gun violence, seeing that as a real public health opportunity, and being able to push the envelope, working with a task force. Is that the type of cooperation and collaboration that needs to be done in the health care setting?
NERONHA: I think it does. We have the Office of the Health Insurance Commissioner. We don’t really have the Department of Health; you have this office.

Nobody has the authority to really look into hospitals and see what they are doing. Again, we are siloed, and we are looking too much at the near term, and there is too much turnover.

I think bringing in academic partners to think about health care, where they don’t come from a position of vested interest, would be really helpful for [looking strategically] at the future of health care.

But, finding that capacity in those other agencies or the willingness in those other agencies, when there is no leadership there, that’s a challenge. We will have to see whether we can build this kind of colalboration moving forward.