PROVIDENCE – As the health care crisis deepens in Rhode Island, the debate over what to do has also sharpened. On one side of the policy equation is Gov. Dan McKee, who on Tuesday, April 29, surrounded by his impromptu health care cabinet at a State House news conference, announced long-term plans on how to right the financially swamped ship that is health care delivery in Rhode Island.

On the other side is R.I. Attorney General Peter Neronha, the state’s public health advocate by statute, who wasted little time in voicing out loud his dismay with the Governor’s plans.

The mainstream news media, for the most part, has been stuck in its narrative mode of “he says this, she says that” style of reporting, leaving much of its audience to puzzle out on their own what strategy will work best.

From both the patients’ viewpoint and the caregiver’s standpoint, the health care delivery system in Rhode Island is both broke and broken. The question is: How do you fix it? And, Will the General Assembly have the political will to raise reimbursement rates for primary care providers now?

What follows is an in-depth, candid interview by ConvergenceRI with Attorney General Peter Neronha. For those who may not have been paying attention, Attorney General Neronha has put together a team of lawyers to manage the health care legal challenges occurring during the last few years. The AG’s legal team:

•    Prevented the private equity owners of Roger Williams Medical Center and Our Lady of Fatima hospitals from looting their properties and kept the hospitals operating.
•    Halted an ill-advised merger between the state’s two largest health care delivery systems, Lifespan and Care New England, joining in a successful lawsuit with the Federal Trade Commission.
•    Held drug companies, such as Purdue Pharma, and their consultants, such as McKinsey and Company, accountable for corrupt business practices, wining more than $300 million in awards from lawsuits, then channeled that money into prevention efforts.

Most recently, Attorney General Neronha, in collaboration with some 23 other state attorneys general, has won a series of victories in federal District Court to prevent the current administration from making illegal cuts in federal funding.

At his State House news conference held on April 29, Gov. McKee aggressively sought to control both the stage and the microphone to promote his rescue plan for the state’s disrupted health care delivery system.

In turn, Attorney General Neronha has been outspoken in attempting to explain what is wrong with the Governor’s plans.

Here is an in-depth interview by ConvergenceRI with Attorney General Neronha, providing the context and the nuance to what is happening in health care in Rhode Island – and identifying the responsibilities now facing the General Assembly to take action.

ConvergenceRI: Thank you for taking the time to talk with me. Yours is a trusted voice, I believe, detailing what we need to learn about what is happening in health care in Rhode Island.    
NERONHA: You wouldn’t know that by listening to [many of the news stories]. You would think that by criticizing the Governor’s plans that somehow I am doing something that reflects poorly on Rhode Island – that we can’t have a debate about health care.

ConvergenceRI: What is the most important messaging that people need to hear – and understand – about health care and how to fix it?    
NERONHA: I don’t think we get anywhere by gas lighting the public. That doesn’t help.

ConvergenceRI: What do you think should happen?    
NERONHA: You and I have talked about this before. There is no real mystery to it. We have to increase revenue. Let’s start with primary care.

There are a lot of [health care] crises out there now. But that is the one that has been coming. It is a subset of the overall problem. It’s the most acute; it has been for sometime. It’s not all that surprising, because it is the part of the health care delivery system with the least [profit] margin.

Doctors are voting with their feet, as they did with Anchor [which is shutting down]. They all could have all had jobs at Brown [Health], but decided not to take them, because nobody wants to work as a Brown Health primary care physician. By the way, that’s no reflection on Brown; that’s just what it is like to be a primary care doctor today.

They are not having any better experience at Care New England these days. It’s just a bad environment; [the pay] is lower than it should be, and there are too many patients and too many prior authorizations, and all that.

How do we address that in the near term? Well, there are a couple of ways to do it.

One is to raise rates, both for commercial and for Medicaid reimbursements for primary care providers, doctors included. But, more generally, we need to [raise the rates for] the advanced practitioners as well and the practices that employ them.

[The raised rates] should be for Medicaid, first and foremost. And commercial.

Medicaid is an investment. For every dollar that you invest, you get two dollars back, since if the state simply raised Medicaid rates for primary care, they would get two dollars back from the federal government.

To hear the Governor talk about the uncertainty in Washington. Well, the uncertainty that is down there is more about transportation than it is about Medicaid, because the need for Medicaid reimbursements crosses red as well as blue states.

There may be saber-rattling about that. But, at least right now, it would be prudent to make the investment rather than to do nothing at all.

We also need to hold commercial insurers’ feet to the fire. Every August, as you have followed, they come in and want to be able to charge higher premiums. We always object; my office always objects. OHIC always gives them half of what they want, generally speaking, so they win. But, do we know where that extra money goes that they are charging people for health care? We don’t know if it goes to primary care. We can’t track that.

We have to pressure the [commercial insurers], and we are working on ways to do that in my office. I think if [the commercial insurers] could be pressured elsewhere in government, [such as] by the Governor and his team that he had with him earlier this week.

We are trying to use some of our leverage, too. We are going to do what we can, mostly, around network adequacy. I’m happy to talk about what I mean by that.

ConvergenceRI: Yes, please. What do you mean by network adequacy?    
NERONHA: Blue Cross and other commercial insurers tell you, that as policy, they are committed to giving you a network of doctors, including primary care doctors. But that network never seems to be adequate.

You should be able to call a doctor in that network when Blue Cross tells you they are accepting patients, and be able to find a doctor in that network. And look, there are going to be some doctors [for which] that “network” will be somewhat fluid – but not to the tune of 51 percent not taking new patients at all, as we found when we [tested] Blue Cross’s network 18 months ago.

And, we are going to repeat that study. We did that internally in my office. We called every primary care practice that Blue Cross represented as taking patients within 30 miles of Providence, and over 51 percent were not taking new patients at all. Many of the remaining practices were not taking on any new patients for six, 12, 18, or 24 months. So, that is not an adequate network, in my mind.

And, one reason that is not an adequate network is because we don’t have enough doctors. Blue Cross, to me, is contributing to the problem by not paying primary care doctors enough. So, we cannot keep them, and we cannot attract them.

Commercial insurers are part of the problem, too. They have to raise their reimbursement rates. Medicare [rates] have to go up, too. But there is not much that I, or we, on the state’s side, can do about that.

That’s something that the Congressional delegation has to keep working on, and hopefully, have a little more success than they have had in the past. Frankly, [they need to have] much more success than they had in the past. No doubt, they are trying.

That is, in broad strokes, what we need to do right now. We have some other things on the table. We are targeting some work on PBMs [pharmacy benefit managers]; there are a few other things in the mix that we are going to be announcing in the next couple of weeks.

Both things that we have already found, things that we are planning on doing, things that we are recommending, in the near and long term, some things that will mean a whole lot more than what the governor proposed. Because what the governor proposed will not put a dent in this at all.

And that’s why I was so quick and it was so easy to so quickly criticize and respond to his proposals., because on their face, they are laughable.

For instance, $400,000 worth of loan forgiveness won’t forgive the loans of two doctors.

The average loans, which can be easily found by researching it on the Internet, the average person graduating from medical school has $250,000 in loans. So, $400,000 won’t fix the problem.

And $75,000 in grants to practices that agree to take on more patients – well, practices are not taking on new patients, they can’t take on new patients for any amount of money. My wife [is a primary care doctor], and she can’t work any more hours in the week than she is already working.

So, I asked her the other day whether she and her three colleagues would take on more patients, and her answer was no; it was not humanly possible, so [$75,000] is not going to solve the problem, either.

Reducing [the amount of] prior authorization is not reducing burden and overhead, if you reduce [prior authorizations] by 20 percent, as OHIC has recommended. You would have to reduce them by as much as 80 percent or more, as we have recommended.

And, you can’t wait two or three years to determine that we need to raise rates. Well, I loved the Governor’s comment: “If you’re the doctor, then show it to us.” Well, are you not familiar with the Rhode Island Foundation report?

ConvergenceRI: Can the General Assembly step up?    
NERONHA: They could. They could. Yes, they could.

ConvergenceRI: Are they lacking the political will to do it?    
NERONHA: I don’t know. I don’t know. I think there is a misconception in this state, everywhere in leadership, that fixing health care is optional. And, as we continue this death spiral, it will become increasingly clear, even to the most uninformed, that this is not optional. How long that will take, Richard, I don’t know.

I’ve talked about it for a long time; I haven’t seemed to be able to make any headway. I find state government to be enormously frustrating.

ConvergenceRI: How do we change the narrative? I am asking that because I write about it. And I feel like what I write has traction. But it is as if people don’t want to listen, to take in what the facts are.    
NERONHA: Listen. I agree. I just watched the interview with the Governor by Dan Jaehnig. Jaehnig said:  “Well, there’s a need. You addressed it.”

No Dan. There’s a need, but [the Governor] didn’t address it. That’s the point. This is the problem This is where some Rhode Islanders get their news. We can’t fix it unless the public puts pressure on the political leaders to fix it. And, when we go out there and gas the public, and the mainstream media like Jaehnig don’t ask the hard questions, then how are we ever going to get better. That was a direct quote from him: “Well Governor, there was a need, and you addressed it.”

There was a need, and the Governor didn’t address it. That’s the point. That is what is so frustrating, Richard, really.

ConvergenceRI: How do we make it more attractive to practice medicine in Rhode Island?    
NERONHA: I spoke to the Rotary Club about this the other day. If you are a doctor getting out of internal medicine residency somewhere, and you want to come back east, where you grew up, and you have an opportunity to go to Westport, Conn., or go to Newport, R.I., and in Westport, you are going to make 30 percent more money, why wouldn’t you go to Westport?

ConvergenceRI: That is a hard thing to argue against.    
NERONHA: Especially when you have $250,000 in med school loans coming out. You are 30 years old or older, you’ve lost your twenties as a decade to make any money or put any aside, you want to have a family, or raise children. And you’ve got the equivalent of a pretty good mortgage,

So, you want to make it back as quickly as possible, I think it is a real stretch to try to attract doctors here. Look, primary care is kind of the tip of the iceberg. Some other sub-specialties and specialties are facing similar challenges,

ConvergenceRI: Let me switch gears here. You have joined with a number of courageous attorneys general who are challenging the Trump administration and you continue to win in court.    
NERONHA: We’ve done well.

ConvergenceRI: How important do you see your work in challenging the lawlessness of the Trump administration?    
NERONHA: It’s critical. I think the judges have shown some real spirit and backbone. But we have to put these cases in front of them. And I am glad we’re doing it. I’m glad we are not shying away from the fight, the way some law firms are and the way some colleges are.

We’re engaged. We're ready to go. And our legal teams are terrific; they are integrated. We speak, the attorneys general, with one another, all the time, three days a week, for a half-hour to an hour. Our staff talks every day.

There’s more to come. I expect to file another case in Rhode Island as early as next week. It’s an important case. That will be number four. I am really proud of the work we are doing there. I think Rhode Islanders can take some hope in it.  People are really inspired by the work that we are doing.