Sentara Heart Hospital in Norfolk. (Ned Oliver/Virginia Mercury)

For nearly five months, an investigative watchdog blog called Checks & Balances Project has had Sentara Healthcare in its crosshairs.

Since mid-November, the outlet has posted more than 20 stories pegged to Sentara’s proposed merger with North Carolina-based Cone Health, another nonprofit health system.

“Our reporting shows that Sentara’s lobbying efforts, broadly defined, have extensive reach on the local and state level in Virginia,” said Scott Peterson, C&BP’s executive director. “So we’re probing how this Sentara lobby uses government to crush competitors, the lengths they’re going to do that and the impacts on average citizens.”

Begun about 11 years ago, Check & Balances has generated similar coverage across the country, mostly digging for news using old-school, shoe-leather tools but not shy of becoming part of the story by taking on the role of advocate, filing government complaints or, in at least one case, a lawsuit.

Its work occasionally has drawn the attention of national media, perhaps most recently last month, when Salon reported that C&BP had written to Senate Minority Leader Mitch McConnell, demanding that Sen. Lindsey Graham, R-SC, be removed from the Senate Judiciary Committee because of the pressure he put on a Georgia election official to reverse the results of the presidential election in the state.

In the fall, The New York Times, Washington Post and Politico reported on the blog’s filing of a complaint with a federal investigative office alleging that former Secretary of Education Betsy DeVos violated a federal ethics law.

Its masthead includes tabs linking to the project‘s coverage in recent years in Ohio, New York, North Carolina as well as Virginia. There are also links to stories related to work in Arizona, California, Nevada and Florida, among other states.

Another tab called “Tell Us Your Sentara Story” invites readers to send in stories about Sentara’s billing, collection practices or court action.

The backdrop to the blog’s reporting on Sentara is Virginia’s nearly 50-year-old statute typically requiring that health care providers in the commonwealth wishing to expand or develop a facility or service get a “certificate of public need,” or “COPN,” from the state’s health commissioner.

The story behind the certificate of need: What it is, why it exists, and why it has been a thorn in Virginia’s side for decades

The application process is no cakewalk and takes months of preparation, a “pile of paperwork,” often legal assistance and a fee of up to $20,000, according to a prize-winning paper by a former William & Mary law student who now works for Williams Mullen’s health-care section.

The COPN process can turn into a legal battlefield as other parties challenge facts in a competitor’s application or submit competing applications, according to the W&M study.

A theme running throughout C&BP’s coverage is that Sentara has become an 800-pound gorilla in Virginia’s health care landscape: “Sentara has sought to stifle competition through the COPN process, which has been criticized for years as rife with lobbying influence. The Bush, Obama, and Trump administrations all issued reports that criticized how health care companies use COPN as a cudgel to beat their competitors,” Peterson wrote in a post last month

Among other things, C&BP highlighted — as a kind of subplot to Sentara’s merger plans with Cone — what it called a push by Sentara “to offload the operational costs of Eastern Virginia Medical School onto Virginia taxpayers.”

On Oct. 31, The Virginian-Pilot reported that “private parties” began to study “potential integrations” of EVMS, Old Dominion University and Sentara about 10 months before informing top officials at the medical school.

C&BP posted its first story about the medical school machinations on Nov. 13 and never let go.

A Nov. 20 post included screenshots of emails between top EVMS leaders as they discovered the extent to which they had been left out of the loop. One of them cites alarm at having learned that the CEO of Sentara was a director at the local economic-development group driving a consultant’s study looking at the merger of EVMS with ODU, while letting Sentara hang on to the profitable EVMS Medical Group: “This was not disclosed to me or to others on the [Board of Visitors] at the time that we were asked to join in the consulting agreement,” the EVMS official wrote. “I believe that this raises the issue of a conflict of interest. I have substantial concerns.”

The same EVMS leader wrote in another email to the same colleague : “The only conclusion I can reach is that this has all been for the sake of a merger that will prove lucrative for Sentara.”

At the end of November, EVMS’ board cast a vote of no confidence in the consultant, citing a lack of transparency and freedom from conflicts of interest, among other things, The Virginian-Pilot reported.

In what were arguably its biggest scoops, C&BP posted back-to-back stories in February alleging ethical lapses on the part of a judge and an attorney in a case tied to a COPN application filed by Chesapeake Regional Medical Center.

The Chesapeake facility had won a COPN approval to start an open-heart-surgery unit in 2017, which Sentara then challenged successfully, C&BP reported.

Chesapeake later sued in circuit court, where Judge Mary Jane Hall eventually ruled in favor of Sentara in 2019.

C&BP’s two-part series reported that Hall and Jamie Martin, an attorney representing Sentara in the recent court case, had worked together for four years in the late 1990s as attorneys on behalf of an unsuccessful Sentara COPN application.

There are no records showing that Hall offered to recuse herself or mentioned her previous relationship with Martin or Sentara; similarly, Martin did not disclose that she and Hall previously had worked together on behalf of Sentara, C&BP reported.

In early March, the blog reported that it had filed ethics complaints with the state against Hall and Martin. A couple of days later, C&BP received a letter from the Virginia State Bar stating that it was conducting a preliminary investigation of the complaint filed against Martin, the blog reported.

The court case that Hall oversaw has since been appealed to the Virginia Supreme Court, according to C&BP. A court manager said in an email that “the canons of judicial ethics forbid Judge Hall from making any public comment on a pending case.”

Asked to comment on C&BP’s coverage, Sentara said in an email: “Sentara Healthcare is focused on our patients and not-for-profit mission to improve health every day by providing safe and quality care to the communities we serve. We appreciate media partners who work with us to ensure our communities get factual and relevant information.”

In an email, an EVMS spokesman responded: “We responded to FOIA requests and media inquiries from the Checks & Balances Project blog. It would not be appropriate to comment on its coverage as we are still actively in discussions with Sentara, Old Dominion University and Norfolk State University about possible collaborations.”

Much of C&BP’s coverage to date, nationally, has veered toward the intersection of government, energy and the environment. While it has done at least a handful of other health-care-related stories, its body of work on Sentara stands apart.

“I live in Virginia; I don’t live in Oklahoma,” Peterson said. “This appears to be an area of interest that no one else is really looking into.”

Checks and Balances, according to its website, began at a climate-change conference in Copenhagen in late 2009 when its founder, Andrew Schenkel, a former TV journalist turned climate-communications consultant, met up with Mike Casey, president of Vienna, Va.-based Tigercomm LLC, a clean-energy communications firm that provides strategic support to Checks & Balances and shares offices with it.

A chance conversation between them led to the group’s mission: “Address the decline of the media’s investigative reporting capacity and the growth of the influence-peddling industry through an online watchdog effort. Hold government officials and lobbyists accountable on energy, good government and public policy.”

As the idea took shape, a 501(c)4 nonprofit group called Renew American Prosperity Inc. was formed to support C&BP and efforts like it, its webpage states.

In 2014, Peterson, a former spokesman for the New York Stock Exchange and NASDAQ, took over as Checks & Balances’ executive director.

Peterson’s name and a boilerplate description of C&BP appear at the bottom of the majority of the posts about Sentara to date, with the notable exceptions being several stories by Ray Locker, since mid-February the blog’s enterprise and investigative editor, who previously worked as national security editor of USA Today.

Peterson said the work involves an array of associates: “We also call upon a team of attorneys and researchers and writers and graphic artists and web experts,” adding that everything the blog does is “looked at by an attorney, first of all.”

He declined to say how big his staff actually is.

“We basically pick what we report on through a combination of leads from readers and — we get a lot of tips, it always surprises me — and what we see in the news,” he noted.

Renew American Prosperity’s tax return for 2018 — the most recent available — reported total revenues of $620,224 and paid Tigercomm LLC $426,886 for management services. It also reported paying subcontractors $327,218.

Tigercomm pays the invoices submitted by Checks & Balances, Peterson said.

Renew American Prosperity’s 990 form states that it was founded “to support organizations, individuals and campaigns that gather and publicize information about the real costs of fossil fuel, extractive and polluting industries, as well as their various spokespeople, allies, activities and policy impacts on Americans.”

Tigercomm, which began in 2006, was built “to provide an intensive level of service designed for companies, organizations and leaders working in clean energy and sustainability,” according to its website. “Their success is our mission.”

Checks & Balances’ focus, according to Renew American Prosperity’s website, is “on holding government officials, lobbyists, and corporate management accountable for their actions related to energy, government spending, public health, and the environment.”

Peterson says the Sentara coverage is in line with its goal of reporting on good government issues and the influence of lobbyists.

“We’re really still pursuing the questions that we started out with in November,” he said. “Will Sentara’s expansion plans hurt EVMS’ ability to serve southeast Virginia? And will Sentara’s march to become a regional power crush EVMS and everything in its path?”

Records the blog has received from EVMS, he added, “told us that there is some there, there.”