Two large Idaho health systems spent weeks in court in late 2013 talking

about whether their doctors steer patients away from the competition.

The CEO of Saint Alphonsus Medical Center-Nampa testified that after a

group of primary care doctors joined St. Luke’s, they “virtually ceased ad-

mitting” patients to the St. Luke’s competitor’s nearby hospital. But the

buyouts breeded resentment and chilled relationships between former

colleagues, some doctors said. “I don’t get referrals from Saint Al’s any-

more,” a St. Luke’s respiratory specialist testified. Business reporter Au-

drey Dutton found these revelations in now-unsealed documents. Above,

Dr. Jeffrey Hessing, one of the physician owners of Treasure Valley Hospi-

tal, examines Marlon Pense, 52, of Kuna. Hessing specializes in shoulder injuries. DEPTH, D1

DEPTH: THE BUSINESS OF IDAHO HEALTH CARE

IN REFERRALS GAME, AREHOSPITALS PLAYING FAIR?Most patients don’t question the physician recommendation their doctor makes,

which is one reason a federal judge ordered St. Luke’s to undo its Saltzer deal

AUDREY DUTTON / adutton@idahostatesman.com

INSIDE OUR

HOSPITALS

What the St. Luke’s

antitrust trial

documents show

Idaho Statesman$2 AUGUST 9, 2015

SUNDAY EDITION

IDAHO STATESMAN: A McClatchy Newspaper, 1200 N. Curtis Road, Boise, ID • P.O. Box 40, Boise, ID 83707 • (208) 377-6200 • © 2015 Idaho Statesman, Vol. 151, No. 15, 4 sections, 46 pages

NOT TOTALLY SUNNY

91° / 65° SEE A15

INSIDE TODAYA NEWS Catching Up A2-3 | Local and Idaho news A4-6| Western news A7 | Nation/World A8-14 | Idaho History A5 | Weather A15

D DEPTH Robert Ehlert D1 |Opinions D4 | Letters to the Editor D5 | Guest opinion D8 | Editorial Cartoon D5 | Dana Milbank D8

E EXPLORE Michael Deeds E1 | TV E2 | Carolyn Hax E3 | Horoscopes E3 | Puzzles E3 | Books E4 | Religion E5 | Obituaries E8-9 | Sunday’s Child E7

S SPORTS Bam Jam S1 | The Bottom Line S2 | SportsTV/Radio S2 | Scoreboard S5 | College football S3 | Pro sports S4 | Motor sports S6

BOISE STATE FOOTBALL

Broncos look to develop next

wave of WRsSPORTS, S1

HEART OF THE TREASURE VALLEY

BOISE ATTORNEY DOES‘FRONTLINE PEACE WORK’Helping violence victims here, in Africa,

Kathy Railsback makes a differenceEXPLORE, E1

MICHAEL DEEDS

Next year, musicfestival plans to bust dust,

quench thirstsEXPLORE, E1

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Check out the best amateur pho-tography from the Idaho Out-doors/Idaho Camera contest atIdahoStatesman.com/outdoorsand send the title of your favoritephoto and the person who took itto outdoors@idahostatesman.com.

READERS’ CHOICE

Vote onlinefor your favoriteoutdoors photo

The town in St. Louis County, Mo.,saw a police shooting shatter thecommunity and set off riots, to thepoint that Ferguson became asymbol of how minorities arepoliced and treated. The tragedyrepeated itself in other cities, leav-ing America looking for change.Has any occurred? DEPTH, D1

DEPTH: RACE RELATIONS

ONE YEAR AFTERFERGUSON, U.S.STILL STRUGGLING

As mustard-colored, metal-ladencrud fouls the Animas River, EPAofficials race to find out just howtoxic and dangerous things are.The Animas flows into the SanJuan, which flows to Utah’s LakePowell. NEWS, A7

EPA ACCIDENT

MINE WASTE MAKESWAY TOWARD UTAH

Finding a career can be quite easyfor graduates of environmentaland agricultural programs at theUniversity of Idaho and otherschools, simply because there isdemand in the field. NEWS, A5

CAREERS

AG STUDIES HELPCOLLEGE STUDENTS

The bill for being transported to a

hospital not only can startle, it

also can cause bankruptcy. In the

Treasure Valley, St. Luke’s (right,

in 2011) and Life Flight fly patients.

Read about the costly venture

and what can be done to make it

affordable. NEWS, A4

HEALTH CARE

AIR AMBULANCES RESCUE, THEN RILE

IDAHO HISTORY

Controversial muralsin Ada courthouse arepart of heritage NEWS, A5

EDUCATION

Numbers show kids in preschool benefitfrom math NEWS, A12

D LETTERS TO THE EDITOR D5 • GUEST OPINION D8 SUNDAY, AUGUST 9, 2015

Depth

On most days one of my fa-vorite duties is to select aneditorial cartoon for publi-

cation in our print edition. Some make me laugh. Some

make me think. Some even makeme angry — at the subject, at thecartoonist or for some other rea-son.

An editorial cartoon’s edge is sosharp sometimes, or so repre-sentative of one end of that politi-cal spectrum on a given day, that—well, I hear about it.

We publish about 470 editorialcartoons per year. These days theMcClatchy Company also postssome online. These are the work ofcartoonists affiliated withMcClatchy-owned newspapers inplaces such as Charlotte, N.C.;Kansas City, Mo.; Miami; Sacra-mento; and Lexington, Ky.

Iget to choose from McClatchycartoonists and some others wepurchase from The WashingtonPost, Politico and independentsources. The cartoons — like all ofthe other features we publish onthe Opinions page (with the ex-ception of Statesman Editorials)—are not necessarily our views,but those of the author or creatorof the feature. We serve up a varie-ty in an attempt to present thatspectrum.

I’ll be the first to admit thatchoosing cartoons, Letters to theEditor, Guest Opinions and syn-dicated commentary is an inexactscience. During the same weekpeople have contacted me or oth-ers at the Statesman to say we areleaning too far left and too far right.When that happens, I figure we’reabout where we are supposed to be.

Recently we published a car-toon that was on the topic of theMinnesota dentist/trophy hunterwho killed Cecil the lion. It is notuncommon for our stable of avail-able cartoonists to seize on thesame “topic of the day.” Almostevery one of them that week endedup depicting some version of amounted head of a trophy hunter.

About a half-dozen peoplecontacted us offended by one weused that was drawn by the Lex-ington Herald-Leader’s PulitzerPrize-winning cartoonist, JoelPett. His offering suggested aterrorist had done in the trophyhunter, and the caption read, “In aslightly more perfect world ... ”

We were accused of supportingterrorists and terrorism, which,obviously, we don’t and neverhave. But the lessons here arethese: I wouldn’t run that oneagain because the mixed meta-phors went out of bounds, andthere is such a thing as too edgy topublish. For the record, I rejectcartoons every day for a variety ofreasons (see “inexact science,”

See EHLERT, D3

Help uschoose

a ‘TuesdayToon’

Eyes on Idaho

ROBERT EHLERT

FERGUSON, Mo. — Before lastsummer, Ferguson was just onemore patch in the crowded quilt oftowns that make up St. Louis Coun-ty — a mixed-race, working-classcommunity of about 21,000 peopleon six square miles of unremarka-ble urban landscape northwest of

St. Louis.Today, to America and to the

world, the word “Ferguson” meansfar more than that. The fury thatripped through the small city in thesummer and fall of 2014 inaugu-rated a national debate about po-lice tactics against African-Ameri-cans that continues a year later. Fer-guson now dwells on an exclusivelist of locales — Little Rock, Selma,Watts — that have lent their namesto key chapters in the sprawlingtale of race in America.

The story of how Ferguson went

from a city to a symbol began with amidday confrontation betweentwo people. Exactly what hap-pened between Michael Brown Jr.and Darren Wilson one year agoAug. 9 may be forever controver-sial. What resulted — an unarmedblack man dead at the feet of a whitepolice officer — provided a blue-print for outrage in other police-re-lated deaths of unarmed blackmales in New York, Cleveland, Bal-timore and South Carolina.

RACE IN AMERICA

JEFF ROBERSON / The Associated Press

Lesley McSpadden, the mother of Michael Brown, wears a sweatshirtremembering her son during a news conference in Clayton, Mo. Brown’sparents filed a wrongful-death lawsuit against the city of Ferguson.

Ferguson, one year later: From a city to a symbol

A police shooting shed abright light on dealings withminorities across the U.S.

BY KEVIN MCDERMOTT

ST. LOUIS POST-DISPATCH

See FERGUSON, D3

Do you have a favorite editorial cartoonist? If so, who and why?

JOIN THE CONVERSATION AT FACEBOOK.COM/IDAHOSTATESMAN

Patients who walked into a St. Luke’s Internal Med-

icine clinic a few years ago may have seen something

that later became evidence in a federal lawsuit against

Idaho’s largest health system: a notice to patients

about exclusivity.

“If you need emergency

care ... Please use the Emer-

gency Department at St.

Luke’s in Boise or Meridian.

St. Luke’s Internal Medicine

doctors admit patients only

[bold italics in original] to St.

Luke’s facilities. Therefore, if

your treatment requires hos-

pitalization, we can manage

your care more efficiently

and effectively if you have

received your emergency

care at St. Luke’s.”

The notice was stamped

with the trademarked St.

Luke’s logo. Then it left pa-

tients with a second thought

that, for a large segment of

Southwest Idaho’s popula-

tion, contradicted the first:

“If your situation is life threatening, call 911 or go to

the nearest [italics in original] hospital emergency

room.”

The notice was meant to keeppatients from being unpleasantlysurprised when learning in an ERvisit that their primary doctorcouldn’t see them there. It wasamong thousands of pages of re-cords filed in a lawsuit. They illu-minate the extent to which St.Luke’s and Saint Alphonsushealth systems care about wherepatients go, and why, and howthose decisions affect their bot-tom lines.

In some cases, the health sys-tems sought to keep patients tothemselves unless there was acompelling reason not to. Theymade it harder for doctors to send

patients elsewhere.The documents, which were

part of the antitrust lawsuit thatSt. Luke’s lost last year, show thatSt. Luke’s tracks its doctors’ refer-rals and has used technology tomake it more of a hassle for doc-tors to refer outside of St. Luke’s.They also show that Saint Al-phonsus tracks its doctors’ refer-rals and in 2010 began requiring

HEALTH CARE

Money motivates hospitals’quest for referrals

This notice to patients of St. Luke’s Internal Medicine was used asevidence of referral steering in the case against the health system.

INSIDE OUR

HOSPITALS

What the St. Luke’s

antitrust trial

documents show

Once-secret documents shed light on the strategies local hospitals

have used to influence where doctorssend patients for care.

BY AUDREY DUTTON adutton@idahostatesman.com© 2015 Idaho Statesman

DARIN OSWALD / doswald@idahostatesman.com

Intermountain Medical Imaging, a business on the corner of 9th and Myrtle streets in Downtown Boise, is partly owned by Saint AlphonsusHealth System. When St. Luke’s leaders noticed their doctors were sending patients there, they made it a priority to find out why.

SEE CHARTS ON REFERRALS

AND HOW THEY CHANGED

AFTER PURCHASES

D2

8READ PASTSTORIES

IdahoStatesman.com

See HOSPITALS, D2

D2 l SUNDAY, AUGUST 9, 2015 IDAHO STATESMAN l IDAHOSTATESMAN.COM

They didn’t care where St. Luke’sdoctors sent their patients, as longas the patients were getting qualityhealth care. If it just so happenedthat doctors employed by St. Luke’sended up referring to colleagues, itwas a preference issue. Not, as itsopponents in the case argued, be-cause of things like in-house refer-rals being the default in St. Luke’ssoftware.

Roth said St. Luke’s electronichealth records system now allowsphysicians to search for, and referto, anyone in the area, includingcompetitors.

Besides, the lawyers for St.Luke’s told the judge, Saint Alphon-sus wasn’t sending all its patients tothe cross-town competition. WhenSt. Luke’s hired a group of Boise sur-geons in January 2012, those sur-geons had been performing half oftheir procedures at Saint Alphon-sus, with two surgeons practicingexclusively at Saint Alphonsus. Af-ter the deal was announced, a docu-ment from the trial says, the sur-geons felt a “caustic environment”swirling around them at Saint Al-phonsus. They moved their surger-ies to St. Luke’s hospital in Merid-ian.

Lawyers for St. Luke’s offeredthe freezing-out of doctors as oneexplanation for the sudden drop inreferrals after St. Luke’s buys apractice.

An expert witness for St. Luke’sshowed data that he said was evi-dence that Saint Alphonsus doc-tors steered patients away.

its employed doctors to refer pa-tients to other Saint Alphonsusproviders, with exceptions for in-surance coverage, patient prefer-ence or quality concerns.

The federal and state govern-ments, Saint Alphonsus and Trea-sure Valley Hospital sued St. Luke’sfor buying Nampa’s Saltzer Medi-cal Group — then Idaho’s largestphysicians group. St. Luke’s pur-chased the group in 2012 despitebeing warned not to by the IdahoAttorney General’s Office. U.S.District Judge B. Lynn Winmillagreed with the plaintiffs that theacquisition gave St. Luke’s near-monopoly power over the Nampaprimary care market.

Winmill commented on the re-ferrals at length in his January 2014ruling.

“There is nothing in the [con-tract to buy Saltzer and employ itsdoctors] that expressly ties com-pensation for the Saltzer physi-cians to where they make referralsor to the volume or revenue gener-ated by Saltzer physicians for ancil-lary services, such as laboratory orimaging services,” he wrote. Hequoted David Pate, CEO of St.Luke’s, as saying: “[As] a physician,I would find it completely objec-tionable for us to direct where ourphysicians are supposed to referbusiness.”

Nonetheless, patients trust theopinions of their primary doctorson where to go for a CT scan or aknee surgery, Winmill said. Anddoctors who work for hospitals canbe influenced to increase their re-ferrals and hospital admissions,thus raising costs, he said.

“It is true that Saltzer physicianshave complete discretion underthe terms of the [contract] in refer-ring patients,” he said. “While thiscomplete discretion has been therule for years, in practice that dis-cretion has been exercised to favorthe hospital where the physicianwas employed.

“After St. Luke’s purchased fivespecialty practices, ‘their businessat Saint Alphonsus Boise droppeddramatically [and] the amount ofbusiness that they did at St. Luke’sfacilities increased dramatically,’”Winmill wrote, quoting an expertwitness for Saint Alphonsus.

Winmill cited examples laid outby St. Luke’s opponents:

ä Idaho Cardiothoracic andVascular Associates was pur-chased by St. Luke’s, and their 34percent of inpatient referrals toSaint Alphonsus in Boise fell to ze-ro. All their referrals were to St.Luke’s.

ä Boise Orthopedic Clinic in-patient admissions to Saint Al-phonsus dropped from 57 percentto 6 percent after St. Luke’s boughtthat clinic.

ä After a group of seven pri-mary-care doctors previously withthe Mercy Medical Group went towork for St. Luke’s, the share ofimaging services they did at SaintAlphonsus fell from 81 percent to 19percent.

Lawyers for St. Luke’s had ar-gued to Winmill that the numberswere skewed by soured relation-ships between doctors after abuyout, and by technical record-keeping issues. St. Luke’s really wassending patients to Saint Alphon-sus and wanted to continue doingso, they said.

Winmill wasn’t swayed.“After the acquisition, it is vir-

tually certain that this trend willcontinue and Saltzer referrals to St.Luke’s will increase,” the Boisejudge concluded. “Services thatused to be performed outside thehospital setting will increasingly bereferred to St Luke’s and billed outwith the higher hospital-based bill-ing rates, increasing the cost to thepatient.”

‘PREVENT LEAKAGE’That notice to St. Luke’s Internal

Medicine patients about where togo in a medical emergency was re-leased to the public late last year, af-ter the Idaho Statesman and othermedia groups sued for access to therecords. The documents show thatboth health-care organizations

have tried for years to find ways tokeep patients in their own camps.

A St. Luke’s executive told theIdaho Statesman that efficiency,not just patient retention, is St.Luke’s goal.

“It’s not our intent that our pa-tients get all of their care within oursystem,” said Chris Roth, chief op-erating officer of St. Luke’s HealthSystem. “Our intent is that patientsreceive care in the most seamlessand efficient way possible. A sys-tem implies there is some level ofcoordination and communica-tion.”

He said keeping a patient withinasingle record-keeping system cancut down on duplication of expen-sive tests. One example: “Knowingsomeone has already had an MRIand doesn’t need another one.”

Saint Alphonsus executiveshave said they, like St. Luke’s, do notpressure doctors to refer withintheir system.

Three and a half years ago, aSaint Alphonsus team — which in-cluded Rodney Reider, now CEOof the system, and Karl Keeler, CEOof the system’s Nampa hospital —was working on ways to bring morepatients into the system and keepthem coming back. Among theteam’s ideas:

ä Give Saint Alphonsus Re-gional Medical Center oncologistsalist of primary-care providers andspecialists in the area, highlightingthe ones who have referred in thepast year. “Target those physicianswho we would expect to be refer-ring to us and are not for meet andgreets.”

ä When it came to independentdoctors — those not employed bySaint Alphonsus — the groupwanted to work “to improve quan-tification of information showingwhere our referrals come from anddo not come from (using newtracking system called PROS –Physician Referral Outreach Sys-tem).”

ä When it came to doctors whoworked directly for Saint Alphon-sus, the group said its “goal is tomaximize alignment (preventleakage) with employed physi-cians.”

And the system was makingheadway on that goal, increasingthe number of referrals within thesystem to 2,862 in a single month —an 83 percent increase since twoyears earlier, Saint Alphonsus doc-uments said.

But it could do better when itcame to services for women andchildren, the group said, putting onits to-do list to pinpoint “leakage”and review “spreadsheets to iden-tify and action plan around specificproviders.”

David Ettinger, lead attorney forSaint Alphonsus in the trial, told theStatesman that his client, “like oth-er hospitals, tries to attract physi-cians who, of course, have a say inwhere patients go. ... You focus onthose doctors and try to make yourcase to them.”

BEING EXCLUSIVESt. Luke’s Health System almost

three years ago employed or hadexclusive contracts with 630 doc-tors across Idaho, mostly in theTreasure Valley.

Its main competitor, Saint Al-phonsus Health System, lookedwith dread at a buyout it knew St.Luke’s was contemplating.

Even though it also employed orhad exclusive deals with doctors,too, Saint Alphonsus said it wouldsuffer economic harm if St. Luke’swas allowed to buy Saltzer MedicalGroup, a practice made up of doz-ens of physicians.

That’s how Idaho’s two largesthealth systems ended up in court in2013, fighting for weeks over refer-rals worth millions of dollars.

The fear, Saint Alphonsus said,was that St. Luke’s would steer pa-tients away from other hospitalsand specialists. It would keep alarge share of the medical market-place to itself. And, Saint Alphon-sus said, there was historic prece-dent: after doctors joined St. Luke’smassive network, their referrals toSaint Alphonsus and smaller Trea-sure Valley Hospital would drop offacliff.

In court, St. Luke’s officials toldthe judge that wasn’t really true.

“It shows that prior to the acqui-sition we’re tracking2,300-and-something referrals,and afterwards it falls to 1,700,”economist David Argue testified.“That’s an overall decline of 27 per-cent. That’s a very — in my view, avery substantial shift in the SaintAl’s [primary care providers’] re-ferral practices or patterns.”

Ettinger, the Saint Alphonsus at-torney, told the Statesman thoseclaims were false. “There was zeroevidence,” he said.

Ettinger said he confirmed lastweek that Saint Alphonsus doctorsin Caldwell admit their patients toWest Valley Medical Center, a for-profit competitor in Caldwell, in-stead of sending patients to theSaint Alphonsus hospital in Nam-pa.

“There are no incentives or dis-incentives applied with regard toreferrals,” Saint Alphonsus spokes-man Joshua Schlaich said in anemail to the Statesman. “Saint Al-phonsus does utilize a form that in-cludes information on referrals,though the information has neverbeen used to generate any reports,to track referrals, or to providefeedback or other reactions to phy-sicians. Nor has it been used to eval-uate physicians.”

He said the hospital uses theforms to find areas where it fallsshort or leaves gaps in the health-care services it offers.

Their intents weren’t solely fi-nancial: If you’re a health-care sys-tem, it is hard to take the blame for apatient’s staph infection or takecredit for his under-control dia-betes if that patient is getting onlyone-third of his care within yourwalls.

But it was partly financial. Anemail from 2011, written by Tho-mas Reinhardt, a Saint AlphonsusHealth System cardiology vicepresident, explains why:

“Their job is to educate [SaintAlphonsus Medical Group] pro-viders and nurses about who is inour referral network and to trou-bleshoot problems with keepingpatients in the system. The mes-

sage is that every referral matters.It may seem harmless to give a pa-tient the choice of St. Luke’s for amammogram. But if you follow themoney, mammograms generate in-come. If there is a tumor, the biopsy,surgery, chemo, radiation, and allfollow-up care that results will alsogo to St. Luke’s. When that happens,it cannot support our mission toprovide care, cannot support ourstaffing and equipment needs, etc.We take great care of patients in allour clinics and in the hospital, sowe’d like to see our patients direct-ed our way.”

Documents from the trial sug-gest similar efforts within Saltzer tokeep referrals inside the group.

“I really appreciate your statingthe importance of keeping referralsin-house in your financial reportslately,” said one 2009 email from aSaltzer doctor to its then-chief fi-nancial officer. “I have seen a defi-nite increase in referrals from mostof the primary care physicians atSaltzer over the past severalmonths, and I believe it’s one of theprimary reasons my numbers areup from last year. There are still acouple of primary care docs whoneed to do a better job of keepingreferrals in house but most seem tobe getting it.

“I think it's important to tell allthe physicians in one of your up-coming financial reports that theirefforts are really appreciated by thesurgeons and specialists,” he con-tinued. “I’ve talked with physiciansat both St. Al’s and St. Luke’s whostate their patient numbers aredown from last year; I’m fairly cer-tain that Saltzer is doing well be-cause of the effort by primary carephysicians to keep referrals withinSaltzer; please let them know thatwhat they’re doing is helping ourgroup not only survive, but evenflourish, in this economy and toplease keep it up.”

And a St. Luke’s internal reportcreated sometime after March 2011explained the “situation” in Nampaas including “active diversion ofpatients from St. Al’s facilities inNampa and Ontario through ED/referral protocols.”

LOYALTY = HIGHER SALARIESIn the run-up to the multimil-

lion-dollar buyout deal, St. Luke’slaid out its compensation offer toSaltzer Medical Group’s physi-cians: a total $4.1 million increase.That was tantamount to a 30 per-cent raise. St. Luke’s planned to payfor that by making more moneythan Saltzer did on the same servic-es.

“Funding for [the] compensa-tion increase is provided throughhigher hospital-based reimburse-ment (approximately $4,500,000+)and other downstream revenuesources,” said a 2011 progress re-port on the Saltzer buyout negotia-tions.

0%

0%

2%

4%

6%

8%

10%

60%

40%

20%

80%

B efore acquisition

After acquisition

SA

INT

AL

'S B

OIS

E S

HA

RE

ST

. L

UK

E'S

SH

AR

E

Percentage of admissions from the practices to each hospital, before and after St. Luke's bought them. St. Luke's acquired these practices between 2008 and 2011.

Data are not comprehensive and excludes some

patient cases and acquired practices.

SAINT AL’S: DOCTORS WHO JOIN ST. LUKE’S STOP SENDING PATIENTS TO US

100%

0%

60%

40%

20%

80%

100%

ST. LUKE'S: OUR DOCTORS DON'T CUT OFF REFERRALS TO SAINT AL'S

Percentage of referrals the practices sent to Saint Al's specialists, before and after St. Luke's bought them.

Source: St. Luke's expert witness testimony and exhibits in the St. Luke's antitrust case.

Reporting by Audrey Dutton. Graphic by Audrey Dutton and Lindsie Bergevin

Boise Orthopedic

Clinic

Idaho Cardiology

Associates

Idaho

Cardiothoracic &

Vascular Assoc.

Idaho Pulmonary

Associates

Intermountain

Orthopaedics

Capital City Family

Medicine

Idaho Family

Physicians

Mercy Physician

Group

Mountain View

Medical Center

St. Luke's

Family Health

Before acquisition

After acquisition

HOSPITALSCONTINUED FROM D1

This chart from a 2009 report showed the amount of money that doc-tors employed by Saint Alphonsus Medical Group brought into thehospital system. It didn’t include the revenues that Saint Alphonsusmakes from joint ventures it co-owns, such as Intermountain MedicalImaging in Downtown Boise.

See HOSPITALS, D3

“I think this has to do with St.Luke’s historical willingness topreferentially direct patients toSt. Luke’s affiliated practices ...

We have also discussed hisrequest that as the [St. Luke’s

electronic health records] systemis developed that it is designed

to promote use of St. Luke’sspecialists over non-St. Luke’s

specialists, etc. I have discussedthat we are moving in that

direction ...”December 2011 email from a then-St. Luke’s Health System

physician services director to several top executives

“[The committee] also approvedchanges to their imaging order

screens that eliminates theability to easily choose from

several Imaging centers. The onlyoptions will be ‘St. Luke’s’ and‘Other.’ The ‘other’ categoryrequires manual entry and astated reason for the outsidereferral. This will also help us

identify opportunities forimprovement to the service andquality of our imaging centers.”January and February 2012 meeting

minutes for a St. Luke’s HealthSystem joint operating committee

“If a referral has to leave Canyon County, make sure it

goes to Saint Al’s.”

June 2009 report, Saint AlphonsusRegional Medical Center

planning and finance committee

“...steering a patient out of [SaintAlphonsus Medical Group] is notwhat I’d like to see when we have

so many physicians that couldsee the patient, like Drs.

Kaczmarek, Lamm or even Reddwho are all new in Nampa,

can we fix that?”

August 2012 email from a SaintAlphonsus executive to a clinic

administrative employee

IDAHO STATESMAN l IDAHOSTATESMAN.COM SUNDAY, AUGUST 9, 2015 l D3

The Ferguson riots camein two waves: in August 2014,immediately after the fatalshooting of Brown, an18-year-old resident of Fer-guson, by Wilson, a28-year-old Ferguson policeofficer; and again in late No-vember, after a grand jury de-clined to criminally chargeWilson in Brown’s death.

All told, it resulted in adozen nights of violence,dozens of injuries, hundredsof arrests and millions of dol-lars in property damage. Per-haps miraculously, therewere no additional deaths.

By the time it was over, ithad added a twist to Ameri-ca’s intractable discussionabout race, with a new focuson police militarization. It re-vealed how cities use trafficfines and court policies asmallets against their mostvulnerable citizens. It under-lined the idea that a policeforce should reflect the cul-tural makeup of its commu-nity, and drove home thereality of how often itdoesn’t.

It validated the principlethat, as syndicated columnistEugene Robinson put it,“policing is something thatshould be done with a com-munity, not to it.”

Politically, it was a mine-field. It drew America’s firstblack president into what hasso often proven a risky topicfor him and figured promi-nently in his 2014 State of theUnion address. It probablyended whatever national po-litical ambitions Missouri’scurrent governor might oncehave had. It has already madean appearance in the 2016presidential campaign, andalmost certainly will again.

“This is not going away” asa political issue, says KenWarren, a political scientistat St. Louis University who isconducting a study of mun-icipal court issues raised byevents in Ferguson. “The gutreaction of politicians has al-ways been to defend the po-lice … but now people are tak-ing pictures of white copsroughing up blacks. It’s goingto continue to be in candi-dates’ faces, and they willhave to address it.”

As with most epic con-flicts, Ferguson engenderedsome myth-making. Mostnotably, it fostered a devas-tating new civil rights slogan— “Hands up, don’t shoot!”— that a U.S. Department ofJustice report would later de-termine was based on a fic-tion. But the shooting alerteda sobered nation to somebroader truths about police-minority relations in an erathat not so long ago was be-ing smugly declared “post-racial.”

“It really pulled the coversback on how people of colorhave been treated for years”

by police, says MirandaJones, vice president of theBetter Family Life Neighbor-hood Resource Center, anonprofit community ser-vice organization based inFerguson. “It was a nationalwake-up call.”

THE SHOOTING

Aug. 9, 2014, a Saturday,was overcast and mild in Fer-guson, with temperatureshovering in the mid-70s asnoon approached. Brownand Dorian Johnson, 22,were walking down the mid-dle of the 2900 block of Can-field Drive, a curving resi-dential street that snakesthrough the Canfield Greenapartment complex.

Wilson, who had been onthe Ferguson police force forfive years, pulled up in hisSUV squad car and told thepair to move off the street.They ignored the order. Itwas then, Wilson would latersay, that he realized theymight be suspects in the theftof a package of cigars.

At 12:02 p.m., Wilson ra-dioed in: “Put me on Canfieldwith two,” meaning two sus-pects. “And send me anothercar.”

By the time the backup ar-rived, less than two minuteslater, Brown lay dead in the

middle of Canfield, with sixbullets in his body.

There was dispute fromthe beginning about whathappened. Some witnessesclaimed Wilson killedBrown as he was attemptingto surrender, literally withhis hands up. But the Depart-ment of Justice report wouldultimately conclude thatBrown attacked the officer,tried to take his weapon andwas charging at him whenWilson shot him.

“While credible witnessesgave varying accounts of ex-actly what Brown was doingwith his hands as he movedtoward Wilson … they all es-tablish that Brown was mov-ing toward Wilson whenWilson shot him,” the reportsaid.

Within hours of the shoot-ing, residents had set up amakeshift memorial andlaunched protests at the site.The protests continuedpeacefully through the daySunday.

Then, with nightfall, theymorphed into full-fledgedrioting — the first of 10 con-secutive nights of unrest —with two police injuries, 32arrested, several businesseslooted and one gutted by fire.

President Barack Obamastepped into the smoldering

issue in those first days, re-leasing a statement callingthe shooting “heartbreak-ing” and urging peace: “Weshould comfort each otherand talk with one another in away that heals, not in a waythat wounds.” But in fact, thewounds were just beginning.

RISING TENSION

The fuse had been set longbefore Brown’s death lit it.

For years, Ferguson, likemany other African-Ameri-can or mixed-race commu-nities around Missouri andthe nation, had quietly sim-mered in tension betweenthe black population and apolice force that was mostlywhite — a little-noticed rem-nant of the urban “whiteflight” trends of the late 20thcentury.

In 1980, Ferguson’s racialmakeup was 85 percentwhite and 14 percent black;by 2014, it stood at 29 percentwhite and 69 percent black.But the town’s power basedidn’t change with thechanging racial makeup. Atthe start of the Fergusonriots, the mayor, police chief,five of six city council mem-bers, and six of seven schoolboard members were white.Of 53 sworn officers on theFerguson police force, justthree were black.

Police contact with thecommunity had long beensimilarly out of whack withits demographics. Blackdrivers in Ferguson weretwice as likely to be stoppedas white drivers, accordingto an annual report by theMissouri Attorney General’soffice in 2014.

“It is not difficult to ima-gine how a single tragic inci-dent set off the city of Fergu-son like a powder keg,” then-U.S. Attorney General EricHolder said in releasing theDOJ report.

The second powder keg,in November, was differentfrom the first in that officialsknew it was coming and hadmonths to prepare for it, as aSt. Louis County grand juryconsidered whether to levelcriminal charges againstWilson in Brown’s death.

With August’s destruction

still a fresh memory, Missou-ri Gov. Jay Nixon declared astate of emergency in ad-vance of the announcementand readied hundreds of Na-tional Guard troops.

Still, when St. Louis Coun-ty Prosecuting AttorneyRobert McCulloch an-nounced the no-indictmentdecision Nov. 24 — in a con-tentious news conference atwhich he blamed socialmedia and “the 24-hournews cycle” for the unrest —the speed and ferocity withwhich the violence reignitedappeared to surprise people.

In a news conference at1:30 a.m. Nov. 25, St. LouisCounty Police Chief Jon Bel-mar reported that there wasbasically “nothing left” alongWest Florissant Avenue be-tween Solway Avenue andChambers Road. “What I’veseen tonight is probablymuch worse than the worstnight we ever had in August,”Belmar said. “Frankly, I’mheartbroken.”

POLICE TACTICS

Just as news footage ofSouthern civil rights abusesin the 1950s and Vietnam Warscenes in the 1960s helpedmobilize public opinion onthose topics, so the imagescoming out of Ferguson in2014 molded the debate overpolice tactics in black com-munities: police in riot gearleveling military-gradeweapons at civilians; cloudsof teargas wafting throughcrowds of protesters; ar-mored assault vehicles roll-ing down the streets of asmall American city.

The scenes would promptCongressional review of thepractice of supplying U.S.military equipment to localpolice forces. “(M)ilitarizingpolice tactics are not consis-tent with the peaceful exer-cise of First Amendmentrights,” U.S. Sen. ClaireMcCaskill, D-Mo., said inone Senate hearing. Sen.Rand Paul, R-Ky., called thesituation “crazy out-of-con-trol.”

Police tactics, too, werecriticized as out of control.Police initially enforced a“keep moving” policyagainst protesters to preventthem from standing in oneplace, ultimately promptingan injunction from a federaljudge prohibiting the tacticon First Amendmentgrounds. Police snipers“lowered their rifle sights tomonitor the crowd,” accord-ing to a draft Department ofJustice report that called thetactic “inappropriate as acrowd control measure.”

Underlying the newishdebate over police militari-zation was the age-old oneover race.

The Rev. Al Sharptonspoke at Brown’s funeralAug. 25, telling mourners,“All of us are required to re-spond to this.” In a late No-vember NFLgame, five black

Rams players gave a “Handsup, don’t shoot!” pose as theycame onto the field. The St.Louis Police Officers Associ-ation responded with a state-ment slamming players forignoring “mountains of evi-dence released from the St.Louis County Grand Jury”and engaging in “a displaythat police officers aroundthe nation found tasteless,offensive and inflammato-ry.”

WHAT’S CHANGED?

Looking around Fergusontoday, you wouldn’t know ithad been the violent epicen-ter of a national movement.

There are still someboarded-up windows alongWest Florissant Avenue andelsewhere, and some vacantlots where buildings stoodbefore August 2014. But forthe most part, the only visibleremnants of what happenedhere are the occasional yardsigns — “We Must Stop Kill-ing Each Other,” and “OurCity Matters” — and placessuch as the “I (heart) Fergu-son” storefront on South Flo-rissant Road, where volun-teers sell T-shirts and coffeemugs to help area businessesdamaged by the conflicts.

But across town, on Can-field Drive, within sight ofwhere Brown died a yearago, racial tension, particu-larly involving the police, isstill a reality. Lewis Washing-ton stood outside his Can-field Green apartment andshook his head when askedwhether things had changed.

“No, sir,” said Washing-ton, who is 27 and black.

Still, some things clearlyhave changed, in Fergusonand around America.

Ferguson officials now re-quire officers to wear bodycameras, an idea that iscatching on around thecountry. In July, the city hiredits first black police chief, onan interim basis. Anew Mis-souri law limits local courtrevenue, the result of a DOJreport that slammed Fergu-son’s court fee collectionpractices as essentially ashakedown of Ferguson’spoorest citizens. Obamabanned in May the federalgovernment’s transfer of cer-tain military equipment tolocal police departments.

But even as those and oth-er changes inspired by Fer-guson have unfolded, police-related deaths of black malesaround the country contin-ued — and, to many, nowlooked like part of a theme.

“Michael Brown … maynot have been without blamein the altercation with awhite police officer that ledto his death,” wrote politicalcommentator David Horseyin The Los Angeles Times inApril. “Brown, though, nolonger needs to be the primeexample of an innocent vic-tim killed by a cop. Morecompelling and appalling ex-amples keep showing up.”

FERGUSON

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NICK SCHNELLE / The Columbia Daily Tribune

NAACP President Cornell William Brooks, right, said that measures passed by states inresponse to the events in Ferguson are just the beginning of what need to be done.

JEFF ROBERSON / The Associated Press

Legislators in almost every state have proposed changes tothe way police interact with the public, including measuresaddressing limits on the flow of surplus military equipment.

When a hospital operates an out-patient clinic, under current Medi-care rules it can bill patient servicesat a higher “hospital-based” rateand make money off the “down-stream” services like lab tests andX-rays that accompany that clinic.

Blue Cross of Idaho ran somenumbers and found that, based onwhat usually happened after St.Luke’s bought a practice, the sameservices would cost 43 percentmore after the buyout for MedicareAdvantage policyholders and 34percent more for other policyhol-ders.

At the same time, St. Luke’s andSaltzer leaders both said in internaldocuments that they expectedSaltzer doctors to send more pa-tients to St. Luke’s — to the extentthat one St. Luke’s executivewarned it would “place more stresson the schedule” for surgeries at St.Luke’s Meridian hospital.

The health system decided tobuild a new surgical center in Me-

ridian to help ease that stress. Itcost about $8 million to build, ac-cording to witness testimony in thetrial.

St. Luke’s closed on its acquisi-tion of Saltzer in December 2012. Itis still in court, as Winmill enforceshis 2014 order for St. Luke’s to un-wind the deal and release Saltzerinto a competitive marketplace.

DOCTOR: ‘IT GOES

BOTH WAYS’

Things have changed for doc-tors involved in the trial. Referralsare different in their post-lawsuitworld.

Treasure Valley Hospital wasone of the four entities that sued ov-er the Saltzer deal. Jeffrey Hessing,a shoulder-specialist orthopedicsurgeon in Boise and one of the hos-pital’s shareholders, said his refer-rals from Nampa fell after the trial— but not for the reasons he ex-pected.

A rift emerged at Saltzer in therun-up to the buyout between doc-tors who wanted to remain inde-pendent — including those who,like Hessing, owned part of a surgi-cal center that competed with St.Luke’s — and those who wanted tosell the practice. Several surgeonsand other doctors severed ties withSaltzer during the negotiations.They went to Saint Alphonsus in-stead. Their former colleaguesjoined St. Luke’s.

When that happened, referralsthat Hessing says he used to getfrom Nampa doctors dried up,even from his hospital’s coplaintiffin the case.

“I used to get many referrals ...two or three a week from the work-ers’ comp out of Saint Al’s in Nam-pa,” Hessing said.

After the Saltzer surgeons joinedSaint Alphonsus, Hessing said

“most of my referrals” that used tocome from Saint Alphonsus inNampa went to those former Saltz-er doctors, to make up for the loss ofreferrals from their former col-leagues.

“Those of us who were truly stillindependent, we suffered,” he said.“Our group probably dropped 30percent of our volume. ... We stillhaven’t recovered from that.”

There’s also a logistical reasonfor lost referrals whenever a doctorjoins a system, he said. When doc-tors join a big system like St. Luke’sor Saint Alphonsus, they start usingelectronic medical records tech-nologies that make intrasystem re-ferrals “very streamlined for thephysicians. It’s easy. It’s quick.”

Those technologies don’t al-ways interact well with others, sodoctors prefer the ease of referringwithin their own systems, Hessingsaid.

His own doctor joined St. Luke’s.Since then, his doctor’s office hasreferred him for tests to St. Luke’sfacilities, Hessing said.

“I said, ‘Well, I’d prefer to go tomy own place,’” he said.

The office worker replied,“‘Well, no, we can’t do that. It’s gotto go through the [St. Luke’s] elec-tronic medical records,’” he said.

Hessing and other independentphysicians are now looking forways to make it easier to refer toeach other. The Independent Doc-tors of Idaho group, whose 225members include Hessing, is put-ting together an association thatwould make it possible for insur-ance companies to offer plans de-signed just for people who want tosee independent doctors, he said.

He is also looking to a statewidehealth-data and health-recordssystem to make referrals easier.The Idaho Health Data Exchange is

about to launch a new portal thatwill make it easier for doctors tocommunicate with each otherabout patients.

THE ROLE OF THE REFERRAL

Schlaich, the Saint Alphonsusspokesman, echoed St. Luke’sChris Roth in noting that there is apractical advantage to doctorskeeping business within the wallsof their employer.

“I think it’s important to recog-nize that there are benefits to mak-ing sure that there’s a medical home— that things are seamless for thepatient, and that we are providing aseamless experience for the pa-tient,” Schlaich said. “But, again, wenever contended in the lawsuit thatreferring patients within a hospitalsystem is bad. [We contended that]control of too many referrals byone system does harm competi-tion.”

Roth said every hospital andclinic — and hospices, pharmaciesand others, nationwide — keepstrack of where its doctors are send-ing patients or admitting them forhospital care.

“The referral is really the life-blood of how care is provided with-in the health care system,” he said.“It’s a determination of how webest serve people.”

Audrey Dutton: 377-6448;

Twitter: @IDS_Audrey

HOSPITALS

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“Significant number of referrals ...are being sent to IntermountainImaging that could be sent to St.

Luke’s. There are significantimplications to revenue.

[A St. Luke’s joint operationscommittee] was supportive of

ensuring MR referrals be directedto SL’s (unless there’s a

patient-centered reason such asinsurance coverage, patient

expresses a preference, etc.)”

January and February 2012 meetingminutes for a St. Luke’s Health

System joint operating committee

AUDREY DUTTON

Audrey covers health care forthe Idaho Statesman. She hasseen doctors fromSaint Al’s and St.Luke’s health sys-tems in Boise, aswell as independ-ent providers.

above). I appreciate thefeedback we got from ouraudience on this one. Itmade me think and gave mean idea.

Iwould like some morefeedback. Today on theStatesman’s Facebook page Ihave posted three cartoonsthat are candidates for ourTuesday Opinions page. I’velabeled them topically:Voting, Coal and Subway/Jared.

I’m asking those of youwho are willing to chooseone to do so in a comment onour Facebook page. The onewith the most votes betweennow and Monday morningwhen I come in will be theone I will publish Tuesday.

I’m going to try this inter-active opportunity for thenext couple of weeks — loadthree cartoons on our Face-book page on Sundays —and see what kind of partici-pation there is. I hope youplay along and include thereasons you picked onecartoon over the others.

The Today’s Questionfeature we implementedearlier this summer and nowthis “Tuesday Toon” initia-tive are just two ways wehope you’ll become moreinvolved with your IdahoStatesman.

Robert Ehlert is the Statesman’s

editorial page editor. Reach him

at 377-6437 or follow

@IDS_HelloIdaho.

EHLERT

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