Here is a link to an interview with Dr. Eric Reinhart, a physician and medical anthrop "Amanopour and Company" TV show on February 21, about the major flaws in the American health care system, that is leading to a record high rate of physician burnout. It is about 30 minutes into the show. It's about 20 minutes into the show, and is well worth watching.
Here is a link to it:
https://www.youtube.com/watch?app=desktop&feature=youtu.be&utm_source=pocket_saves&v=_CxGhEuXcG8
It’s time to say goodbye to our imaginary friends
By Jill - Ellsworth American - January 9, 2023
Remember when you were a kid and you had an imaginary friend? Like Bonnie, or Dave. Our parents twigged to it quickly and played along, offering Bonnie a snack or reminding Dave to buckle his seat belt. The trouble is when the chips were down there was a reckoning. Our imaginary friends hung us out to dry.
Turns out that as grown-ups, we still have imaginary friends. They are our primary care health providers, our “family doctors.” We cling to the myth that we have a provider that will be there for us, that we will be able to see when we need him or her, if not on the same day, then within two or three days at most. What are the chances?
A lot of effort is put into public health education, to advise us about when we should seek care and at what level. Which symptoms mean “wait and see.” Which should be addressed sooner rather than later. When to go to the ER as opposed to waiting for an office appointment. Broken leg? ER. Persistent cough and cold? Office. At what temperature does a fever demand more attention than an aspirin or two?
The internet is full of advice. Urgent care or walk-in clinics are an alternative when a primary provider can’t fit you in, but as one website says: “They don’t know you or your health history like your primary care does.” The reason to have a “family doctor” is to have someone who knows your medical past, whether you give an accurate medical history of a problem, whether you have a short fuse or a long one, medically speaking, and what medications you’re on.
A physician you’ve seen for years will sometimes be willing to guide you through initial treatment of a seemingly minor problem without a visit. Anyone else will want you to come in. In their defense, this is the responsible way to go about health care if you have no prior relationship with the provider.
The trouble starts when you try to reach your provider by phone. That’s rarely possible. One estimate is that a primary care practice must carry an annual census of over 2,000 patients to be financially viable. That does not leave much time for taking or returning phone calls. It’s hard to reach a live human at all. Often, it’s a voice message that promises to get back to you “by the end of the next business day.”
If you can connect, you discover that your provider doesn’t have anything available that day. Nor in the next few days. “She’s booking pretty far out…” How far is far out? Three weeks. “Would you like me to call around to the clinics and see if someone can see you?” Well, not really.
Any licensed provider should be able to render appropriate care, but we are not prepared for “any licensed provider.” We want to see “our” doctor, but he or she has become an imaginary friend. When we access health care we are still queried as to who our “regular” doctor is, even though we see little of them. An annual physical can still be scheduled with the provider of your choice if you call far enough ahead, but anything in between, not so much.
Patients loved their family doc, but the doctors themselves? They devoted mind, body and soul to their practices, available day and night, running back and forth between the office and the ER in the day and crawling out of bed to see a patient admitted to the hospital at night. They missed birthdays, anniversaries and graduations. Their marriages and children paid a price.
If the “family doctor” ideal was hard on providers, the “imaginary friend” provider is detrimental for the patients. Are these the only two options? One emerging model is the “concierge” plan where patients sign up with a physician for an annual fee and get to see that particular physician as needed. Insurance might still be needed for major illness, lab tests and diagnostic imaging; the jury is not in on the ultimate workability of this model.
Should we abandon the pretense of having a regular provider? We could enroll in a hospital-based system with one-stop shopping. Call a single number, relate the problem and a triage nurse would arrange for you to be seen at the appropriate level of care within a reasonable time. You might not know who you would see, but at least you would see someone. Relying on an imaginary friend for health care does not work. Health care delivery has become extremely frustrating for patient and provider alike. It’s time for a new model that recaptures the human element and puts the “care” back in health care.
Jill Goldthwait worked for 25 years as a registered nurse at Mount Desert Island Hospital. She has served as a Bar Harbor town councilor and as an independent state senator from Hancock County.
https://ellsworthamerican-me-app.newsmemory.com/?publink=241b42b31_134aa5e
State of Maine Column stirs up a hornet’s nest of health-care horror stories
By Jill - Ellsworth American - January 16, 2023
After a recent column that compared primary health care providers to “imaginary friends,” a phone call came that was too good not to share. An old acquaintance reported that her granddaughter had two imaginary friends, named Lucy and Plucy.
One day the woman was out in the yard pushing her granddaughter on the swing. “What ever happened to Lucy and Plucy?” she asked. “We haven’t seen them around for a while.” “Oh,” replied the granddaughter with nonchalance, “they moved to ‘Assachusetts.’” There was plenty of other feedback about that particular column, most of which was a lot less charming. It was a series of horror stories from people who tried to access primary care but in most cases without success. Patients had been told when to seek care and where, but when they made the call for an appointment, they found there was no one available to see them, at least in the near term.
One physician describes primary care as a process of writing prescriptions and making referrals rather than offering care, because the physician/patient ratio averages 2,500-3,000 patients per physician, and the duration of an office visit is expected to be about seven minutes. For the patient, who is often shuttled to someone other than their own primary care provider, it means retelling their health care history at every visit.
The American health care system has plenty of woes beyond this question of access to primary care. An opaque billing system and a bewildering array of specialists are among them. Patients are increasingly frustrated and often opt not to seek care at all. Providers are burned out, either choosing to leave the profession or drawing lines in the sand regarding their practices.
Many hospitals searching for physician staff are finding that it is a seller’s market in which doctors who used to tolerate the terms of engagement as “that’s just the way it is” are opting out of what used to be basic job requirements. They want to limit hours worked and do not want to take calls. It is not because they are not committed physicians; it is because the job has become so unpalatable that they can’t bear for it to absorb their whole lives like the old GPs did.
Raise the subject and everyone within earshot has a story. A 14-month wait to get a dermatology appointment as a new patient. Three months before a woman diagnosed with cancer could get her initial “intake” visit at a cancer center. A man who has given up and gets no treatment for his diabetes- related foot infection because it is just so frustrating to slog through what it takes to get a doctor’s appointment. A man with a broken hip who is told he needs physical therapy but there is no one to do it.
Is this just a rural phenomenon? Is it better in larger population areas — cities — because there are more providers there? People report giving up on seeking local care and going to Boston, where they seem able to schedule an appointment and begin care. Lucky them. The cost of traveling to Boston for care puts that option out of reach for many.
This raises a broader question. Is it getting harder to be here? In Maine? It’s not just health care. Need your furnace cleaned, or a broken step fixed? Need a plumber? It’s not on. To their credit, a plumber will usually show up for a real meltdown, but for maintenance-level needs it is virtually impossible to find someone unless your plumber happens to be your son, and even then it’s not a sure thing.
There are some fundamental life needs that, once upon a time, we were able to take care of ourselves. As we became less self-sufficient, there were still the local go-to guys who could take care of our plumbing, heating and carpentry needs. Without enterprising locals willing to do that work for local people, our very ability to stay in Maine, at least north of Cumberland County, is jeopardized.
The dearth of support services is a challenge for yearround Mainers, but the inability to get basic health care when needed is more than an inconvenience. It is a factor that determines whether a born-and-raised Maine family can remain here, or a potential in-migrating family attracted by Maine’s quality of life decides to move here or not.
The tension is between “Maine: The Way Life [Used to] Be” and a Maine that attracts or supports year-round residents. When the systems that support daily life break down, rural communities all over the state face an uphill battle in retaining their population. None of these is more important than knowing basic health care can be obtained when needed. This is no longer a certainty in much of Maine.
Jill Goldthwait worked for 25 years as a registered nurse at Mount Desert Island Hospital. She has served as a Bar Harbor town councilor and as an independent state senator from Hancock County.
https://ellsworthamerican-me-app.newsmemory.com/?publink=4aee9d2b0_134aa6c
According to Medical Guidelines, Your Doctor Needs a 27-Hour Workday
Some doctors say that however reasonable guidelines may seem, their cumulative burden causes “constant frustration” to medical practice.
by Gina Kolata - NYT - February 14, 2023
The intent is admirable: Give doctors guidelines so they can be sure to cover what needs to be discussed with patients and help select options. Let’s talk about your diet and any problems you might have sleeping. Are you getting enough exercise? If not, here is some advice. You are due for colon cancer screening. Do you prefer a colonoscopy or a fecal test? Here are the pros and cons of each.
But there is a problem. There are just not enough hours in a workday to discuss and act on all the guidelines.
Suppose an American doctor wanted a gold star when seeing patients and followed all of the guidelines for preventive, chronic and acute disease care issued by well-known medical groups. That could require nearly 27 hours per day, a team of doctors wrote in a study last year for the Journal of General Internal Medicine.
No one could actually do that, so imagine a doctor shrugged off the chronic and acute care, as well as administrative work, and merely followed the preventive care checklist recommended by the U.S. Preventive Services Task Force, an independent panel of health experts. That would be 8.6 of the doctor’s hours each day, according to a study in the American Journal of Public Health.
As anyone who has been sped through a 15-minute annual wellness visit knows, doctors cannot be so exacting. That the guidelines are so thorough yet so often glossed over prompts questions about their usefulness. At the same time, doctors’ pay often depends on checking off guideline boxes.
“Is this an issue? Absolutely,” said Dr. Michael Pignone, a former member of the Preventive Services Task Force and chairman of the department of internal medicine at the University of Texas at Austin’s Dell Medical School.
“Suffice it to say that what has been incentivized isn’t always what delivers the most health or benefit,” Dr. Pignone said.
Guidelines have become “a constant frustration,” said Dr. Minna Johansson, a general practitioner in Uddevalla, Sweden, who also directs the Global Center for Sustainable Healthcare at the University of Gothenburg. She worked with doctors in other countries on an analysis of the issue that was published last month in BMJ. “A lot of guidelines may seem reasonable when considered in isolation,” Dr. Johansson said. “But the cumulative burden of all guideline recommendations combined is absurd.”
Dr. Johansson was inspired to study the issue working in a small town on Sweden’s west coast.
“I have a yearly visit with my patients,” she said. Spending that precious time discussing a lifestyle prescription that, however well meaning, is unlikely to change a patient’s habits, is of dubious value, she said. And, she added, it “crowds out more important discussions.”
“Maybe the patient smokes or has suicidal thoughts,” she said.
And, she added, many guidelines, like those for extensive discussions about improving exercise habits or diet, have not been shown to result in important health benefits.
Dr. Johansson worked with Dr. Gordon Guyatt of McMaster University in Hamilton, Ontario, and Dr. Victor Montori of the Mayo Clinic in Rochester, Minn. They argue that this problem affects medical systems throughout North America and Western Europe.
In Norway, for example, guidelines for assessing and treating high blood pressure apply to the nearly three-quarters of adults with pressures above the goal of 120/80. If the guidelines were strictly adhered to, patients would need so many regular follow-up visits that accommodating them would require more general practitioners than are currently working in Norway.
And implementing all the British guidelines for improving patients’ lifestyles could require more doctors and nurses than are practicing in the entirety of Britain.
The researchers say that guideline makers should consider what the study calls “the time needed to treat” — how much time it takes to implement a guideline.
For example, they say, the British guideline on assessing a patient’s physical activity would take 15 percent of a doctor’s visit to implement, but there is no evidence it would improve long-term health. That, they say, might suggest the guideline should be jettisoned.
Dr. Carol Mangione, chair of the U.S. Preventive Services Task Force, said the task force considered the time guidelines take. And nowhere is it suggested that doctors try to tick off each guideline recommendation in a single visit.
“Clinicians do not — and would never be expected to — implement all of the suggested screenings, counseling services, and preventive medications in a single patient visit,” Dr. Mangione wrote in an email. “When caring for patients, clinicians use both their judgment and the information obtained during conversations with each patient to prioritize which preventive services should be offered during each visit.”
Even that is not easy, said Dr. Daniel Jonas, director of the division of general internal medicine at Ohio State University.
Guidelines can serve a purpose, Dr. Jonas said. “I think they’re incredibly helpful,” he added. But, he said, “deciding what to prioritize in a busy primary care practice is a big challenge.”
Dr. Montori added another complication.
“To assume that patients and clinicians can sort and prioritize recommendations over multiple visits,” he said, “wishes away the fundamental problem that many patients cannot get primary care, see the same clinician or have unhurried consultations.”
Dr. Pignone said that some of the burden should be shared with other professionals, like nutritionists, who can talk to patients about healthy diets. But, he said, that is only a partial solution. He’d like to see current recommendations prioritized by their impact on health and on their cost effectiveness. As examples, he said, childhood immunizations would rank high but existing guidelines to give tetanus boosters to adults who already had tetanus shots would rank lower.
Dr. Guyatt said guidelines should be held to the same standard as new drugs. Before they are implemented, there should be evidence that they are helpful.
“Somebody might say, ‘Oh, a new drug has side effects but what harm is there in this guideline?’” he said. “But yes, there is real harm. There is a trade-off between doing things that are actually useful and spending time on things that are useless.”
Gina Kolata writes about science and medicine. She has twice been a Pulitzer Prize finalist and is the author of six books, including “Mercies in Disguise: A Story of Hope, a Family's Genetic Destiny, and The Science That Saved Them.” @ginakolata • Facebook
https://www.nytimes.com/2023/02/14/health/doctors-medical-guidelines.html
Higher Bills Are Leading Americans to Delay Medical Care
Inflation and pressing household expenses are forcing some people to postpone health needs, an emerging trend that has health experts worried that conditions may only worsen.
by Reed Abelson -NYT - February 16, 2023
Megan Swanson has warily watched the erosion of her family’s savings as inflation chips away at a reserve for emergencies.
She often postpones any regular doctor’s appointments, including her yearly dermatology appointment, even though annual skin checks are typically recommended for residents of sunny Florida, where she lives in Naples with her husband and their three children.
“Each month we are seeing our costs go up, but not our bank account,” she said.
Ms. Swanson, 37, is a part-time student and has not worked since she was laid off during the pandemic when the local Nordstrom store closed in 2020. Her husband, Brett, 37, is employed as the director of wellness at a retirement community.
“I put the priority on the kids,” she said.
Last March, the Swansons had to come up with $8,000 to cover their share of hospital bills after their baby daughter was hospitalized with a febrile seizure. “What if something happens again in the future, and how will we afford it?” she asked.
Rising out-of-pocket costs are weighing heavily on the scale, pushing aside tests or procedures when troublesome symptoms emerge. And these days, the grocery list (and even the price of eggs) feel more pressing to many families. While some people avoided seeking medical care during the worst of the pandemic, worried about the risk of infection or unable to get an appointment because hospitals and doctors were overwhelmed, now many are finding that inflation and the uncertain economy have thrown up another barrier.
“We are starting to see some individuals who are putting off some care, especially preventive care, due to the costs,” said Dr. Tochi Iroku-Malize, the president of the American Academy of Family Physicians and the chair of family medicine for Northwell Health in New York. Choosing between going to the doctor or paying for rent and food, “the health issue is no longer the priority,” she said.
The inability to afford medical tests and treatment, a perennial concern in the United States, began emerging as a much more striking issue last year. Nearly four of 10 Americans said they had put off care in 2022 because of cost, the highest number since Gallup started asking people about delaying care more than 20 years ago. The percentage reporting they or a family member delayed health care because of cost rose to 38 percent from 26 percent in 2021.
With the prices of prescription drugs, hospital stays and other treatments expected to increase significantly this year and next, some doctors expect families to have an even harder time affording medical care. A recent report from the Commonwealth Fund found that 29 percent of people with employer-based coverage were underinsured, because they had such high out-of-pocket costs even with insurance. The coming roll back of health coverage under the state-federal Medicaid program will very likely lead many people to become uninsured.
About one-fourth of respondents in Gallup’s poll said they put off care last year for what they considered a “serious” condition. When Margaret Bell, 71, found that her cancer had returned four years ago, she hesitated to resume her chemotherapy because she could not afford it, and higher prices have made it even harder. She would regularly skip appointments near her home in Lancaster, S.C.
“It is impacting patients’ access to care,” Ms. Bell’s oncologist, Dr. Kashyap B. Patel, said. As the chief executive of Carolina Blood and Cancer Care Associates in Rock Hill, S.C., he recently set up a nonprofit group, No One Left Alone, to help cancer patients like Ms. Bell and to connect them with local charities. The organization is covering the cost of her treatments, and Dr. Patel has assured her that his office will find the money for her visits.
On a limited budget, “it’s been very difficult for me,” Ms. Bell said. Having her family over for dinner can be a strain because of high grocery bills, and she is faced with deciding which of her medical needs is the most urgent. She has postponed receiving a pacemaker.
A new federal report suggests fewer Americans’ health bills are being sent to collection, but medical debt still accounts for more than half of all kinds of collection debt, exceeding unpaid credit card or cellphone bills. It remains a serious issue: about a fifth of Californians said they had medical debt of at least $5,000, according to another recent survey. A little over half of those asked said they had skipped some kind of care in the last year, with half of those reporting their condition got worse as a result.
“This is about trade-offs that people have to think about that are really hard,” said Dr. Jay Bhatt, the executive director of the Deloitte Center for Health Solutions, a research unit of the consulting firm. He also sees patients at the Family Christian Health Center outside of Chicago. In a survey by Deloitte last year, 28 percent of respondents said they were less able to afford care than in the previous year.
Some of the clinic’s patients are losing their jobs and insurance, he said. “We’ve seen this before, and we are going to see it in big numbers now,” Dr. Bhatt said.
In Hammond, Ind., Tameaka Smith and her husband, Stevenson Lloyd, are coping with tighter finances and trying to save where they can. She is disabled and covered through Medicare, the federal insurance program, while her husband, who works at an auto parts factory, has private insurance through his employer.
Still, they are skimping a bit on medicines they need. Her husband takes his thyroid medication every other day, and she sometimes uses her father’s asthma medicine. “We’re self-medicating, trying to stretch it out and doctor ourselves,” Ms. Smith said.
With two children, their family has not recovered from the financial strains of the pandemic. “It’s hard catching up when you’re so pushed back,” Ms. Smith said.
Her husband also weighs the merits of going to the doctor, knowing that if he doesn’t have to pay right away during the visit, “then next month we’re getting a big bill,” she said.
Any turbulence in the economy has historically resulted in the loss of medical care for an increasing number of people, either because they no longer have health insurance or because they cannot afford their share of medical bills. During the Great Recession, millions of Americans lost their health coverage, and many people are predicting a similar wave in the coming months. Millions of people could lose Medicaid coverage as states begin the process of dropping individuals from the program now that states will no longer have to keep people enrolled and extra federal funds are going to disappear.
The cost of treatments is also likely to rise next year as hospitals, many of whom reported losses in 2022, will raise their rates, said Sean Duffy, the co-founder and chief executive of Omada Health, a company in San Francisco that provides virtual care and coaching to people with chronic health conditions like diabetes. The company’s employees were already starting to see an increase in patients wrestling with how to pay for medicine and healthy food.
“2024 is the reckoning, unfortunately,” Mr. Duffy said.
In addition to medical bills, patients often cannot afford to take off work for a doctor’s visit, let alone find the funds to cover child care or the transportation needed to get there. A colonoscopy to determine why a patient may be bleeding could result in missing a day’s work and a medical bill equal to a week’s work, said Dr. Rajeev Jain, a gastroenterologist at Texas Digestive Disease Consultants. “We’re seeing an uptick in patients canceling for those reasons,” he said.
“You have a finite number of dollars to spend on your family,” Dr. Jain said. When you’re worried about having enough food or stable housing, “at that moment, you’re not thinking of preventing something five years from now.”
In 2021, a fifth of Americans either delayed or went without medical care because of the pandemic because of a lack of available appointments and fear of infection, according to a recent analysis by KFF, a nonprofit research group. Only 5 percent cited cost alone.
The catch-up in visits and procedures by people who are now able to see the doctor and the increased number of people seeking care caused by the winter season’s respiratory illnesses could mask any recent declines in seeking out medical care.
“It’s possible that this is the calm before the storm, especially since a lot of people are going to lose Medicaid coverage,” Cynthia Cox, a vice president at K.F.F., said.
https://www.nytimes.com/2023/02/16/health/inflation-delayed-health-
Private Equity has a New Love for Cardiology $$
In Arizona, cardiologist owners of one private practice are entertaining three offers from private equity buyers. They're one of many entering this type of arrangement to be thrown a potential lifeline from the financial challenges of private practice.
One of the partners, wishing to remain anonymous, said of a potential private equity deal for his group: "It's going to happen. The question is when, how, and what price."
These are not new questions, and other specialty practices have been asking them for years, saddled with increasing competition, Medicare payment cuts, inflation, and other problems.
What's special is that cardiology is the big one. Marriages between private equity and cardiovascular medicine are still a fairly new phenomenon and have the potential to have an impact on larger swaths of the population. More than 20 million Americans have heart disease. This is the leading cause of death in the U.S. and costs the country upward of $200 billion a year for healthcare and lost productivity, according to the CDC.
The stakes are high in cardiology and there are many unknowns. Though private equity entered healthcare long ago, it is not clear whether these deals fundamentally change the clinical practice of medicine, cardiovascular or otherwise.
The challenge of answering this question may be related to nondisclosure agreements that limit evidence gathering. MedPage Today reached out to physicians currently in private equity-backed practices, as well as others who left to work in hospitals or other practices. All declined to be interviewed, except for the Arizona cardiologist with unsigned offers.
"The big thing of the evaluation process is, who do we want to go with and who's least likely to screw us," he said. "The fear is that the financial guys from MIT and Harvard come in who don't know a lick about what it's like talking to a 90-year-old about a procedure. The fear is they're going to take what we have and turn it into something else, when we built the practice on trust and being there for people, even at night."
What Private Equity Promises Cardiologists
Here's how private equity firms typically operate. They take a large stake in an organization, invest in boosting market share and revenue, take actions to decrease costs, and ultimately sell the practice to generate returns for investors.
For years, private equity has been drawn to certain specialties, such as dermatology and gastroenterology, for their value and future earning potential.
Only recently has cardiology caught the attention of private equity firms. Accelerated deal-making in the last 2 years has brought the total number of private equity firms investing in the cardiology sector to approximately 12 today.
"We're starting to see activity take hold. It's very early innings on this consolidation ... In the next 3 to 4 years, we'll see private equity firms partner in different practices of different size and scale," said Eric Major, managing director at investment firm Provident Healthcare Partners, who spoke at a virtual meeting hosted by the American Society of Nuclear Cardiology (ASNC).
Cardiology's attractiveness is due in part to an aging population that all but guarantees growing healthcare needs. It also tracks with the rise of ambulatory surgery centers, which have an expanding list of cardiac procedures -- implantable electronic device implants, diagnostic catheterizations, and percutaneous coronary intervention -- that are now reimbursed by Medicare.
For private equity investors, cardiology also presents opportunities in the shift toward value-based care, which rewards healthcare providers with incentive payments for providing higher-quality care to patients.
"I think it's exciting to think [that] we're finally entering a world where we can start logistically talking about the total cost of care, and the way that advanced imaging can favorably impact the total cost of care," said Tim Attebery, DSc, MBA, CEO of Cardiovascular Associates of America, the management entity formed by private equity firm Webster Equity Partners in 2021. Attebery was previously CEO of the American College of Cardiology.
"Instead of arguing about what to pay for a cardiac test, let's leverage the good information about cardiac cath to show that we can reduce the number of diagnostic errors, that we can actually save on the total cost of care. And to do that, private equity platforms are going to need to invest significantly into data collection, to be able to demonstrate them across the network, and then turn that into value-based care and risk-based care arrangements," Attebery said during the ASNC meeting.
Otherwise, smaller practices will find it difficult to transition into value-based care without the data that's needed, Major suggested.
A. George Basu, MD, of Houston Cardiovascular Associates, shared his group's experience being approached by private equity in 2019. Just over a year into the official start of the new arrangement with Ares Management, he says his practice has a PET CT program on the horizon that should be up and running in the next few months.
"Historically, especially when we were a little smaller, we would have a SPECT scan like you know, likely a false positive study. The patient would go to the cath lab, totally normal coronaries, and that ends up costing the system more," Basu said. "[When] you go to a much more functional study like a PET with the component of CT giving you flow, you're getting physiologic, anatomic information that is going to be much more cost-effective for the healthcare system."
Most cardiology practices are signing 5- to 7-year terms with private equity, after which the physician owners stand to earn more based on valuation of the practice, the Arizona cardiologist said. "It works for both sides. The physicians stay on and maintain equity in the future."
"That's very different from what used to happen, which was hospitals and large groups buying you out, and that's the end of it. That's the evaluation and there's no future in that," he told MedPage Today.
Because of state law restrictions against the corporate practice of medicine, private equity arrangements have to be carefully structured so that the firm does not acquire the private practice outright. They instead buy a majority interest and leave physician owners with a minority interest in the form of equity in the partnership investment platform.
Besides the prospect of a large payout and fancy new equipment, private equity may also promise physicians a less stressful, upgraded experience of private practice. The firms can handle a lot of the unglamorous administrative work that physicians dread doing themselves. Human resources, contract negotiation, collections -- all that can be taken over by the firm. Private equity may also bring in capital to fund new ancillary services like ambulatory surgery centers, and the money it has could help practices mitigate any future risks.
"You Have to Go in With Your Eyes Open"
The American College of Physicians acknowledges the financial incentives that may drive clinicians to private equity -- attributable in part to the difficulties of the COVID-19 pandemic -- but the group nevertheless raised caution in 2021 about the long-term implications of these arrangements.
Investors' interests in generating robust profits quickly may compete with long-term investments in safety and quality.
Famously, the large hospital chain HCA was bought by Bain Capital and other private equity entities in 2006, and then went on to a record-breaking $4.35 billion initial public offering in March 2011. In 2015, HCA agreed to pay $215 million to settle a shareholder class action lawsuit alleging that it concealed poor growth prospects and didn't disclose that it was under federal investigation for performing unnecessary cardiac procedures.
Additionally, workplace environments may change as staff at private equity-backed practices have reportedly been subject to firings on short notice and aggressive non-compete clauses.
A common refrain is that not all private equity companies are created equal.
"The criticism is when [private equity firms] start thinking they want to come change all our processes, they become just like [the hospital buyers]," the Arizona cardiologist said. "They cannot change processes that have a human element in the business. When they do that, they lose the physicians."
Even companies with the best intentions may cause problems out of sheer inexperience.
"There's a lot of private equity firms that we run into that are interested in cardiology that don't really know what they're doing, they don't have experience partnering with physicians," Major said. "If you do the deal with an investor that maybe tells you all the things you want to hear but doesn't have a track record and tries to throw some big price in front of you, those are the deals that you should probably run away from."
"Part of your consideration as a physician is making sure you align with the right organization with the right team that you view is going to allow your practice to grow and culturally aligns with your organization," he emphasized.
Physicians are left to their own devices to figure out what is and is not a good deal for themselves and their patients. Professional societies like ACC and ASNC do not take a position on the best path for cardiologists, and cardiology fellowship directors told MedPage Today they had little knowledge on private equity to offer.
The Arizona cardiologist urged interested fellow physicians to call upon friends and people they trained with for more information before transacting.
The most anecdotes may come from the red states of the South and Southwest -- namely Texas, Florida, and Arizona -- where private equity's drum beats loudest due to geographic considerations. Private equity firms stand to gain more investing in markets with less regulation (e.g., certificate of need laws) on new ambulatory surgery centers, office-based labs, and other money-makers.
Attebery's last piece of advice is that there's no going back once private equity enters the picture.
"You go in and it's a permanent decision and you have to go in with your eyes open," he warned. "You don't go in with an unwind, there's no prenuptial [like] 'We'll just unwind this thing in 3 years.' If you're not happy, you will have to leave the area, whatever that non-compete definition is."
All the more reason for practices like the Arizona group juggling three offers to be wary of the risks associated with dancing with private equity.
"If we could do it without private equity, we would. Unfortunately we just can't with the current economic climate," the Arizona partner cardiologist said.
Why Medicare and Social Security Are Sustainable
by Paul Krugman - NYT - February 21, 2023
The G.O.P. response to President Biden’s truthful statement that some Republicans want to sunset Medicare and Social Security has been highly gratifying. In other words, the party has reacted with sheer panic — plus a startling lack of message discipline, with both Mike Pence and Nikki Haley saying that actually, yes, they do want to privatize or “reform” Social Security, which is code for gutting it.
Now Republicans are talking about slashing “woke” programs like Medicaid and food stamps. It’s going to be fun when the party realizes who depends on these programs and how popular Medicaid, in particular, is even among its own voters.
The press’s response to Biden’s remarks has, however, been less gratifying. I’ve seen numerous declarations from mainstream media that of course Medicare and Social Security can’t be sustained in their present form. And not just in the opinion pages: There’s been at least some reversion to the early 2010s practice of including anti-social-insurance editorializing in what are supposed to be straight news reports, with highly disputable claims about these programs’ futures presented as simple facts.
So let me try to set the record straight. Yes, our major social programs are on a trajectory that will cause them to cost more in the future than they do today. But how we deal with that trajectory is a choice, and the solution need not involve benefit cuts.
A good starting point on all these issues is the Congressional Budget Office report on the long-term budget outlook — a report issued every year, with the most recent report released in July. (The numbers were updated this month, but the basic picture hasn’t changed.) The C.B.O. does excellent work, without a policy agenda, and is an extremely useful resource.
The current report offers a very clear depiction of both the budget challenges facing our major social insurance programs and the sources of those challenges. Here’s my favorite figure, showing projected changes in spending over the next 30 years:
But the budget office is not necessarily always right — in fact, the ways in which it has proved wrong in the past are highly illuminating. To put this chart in context, there’s a widespread narrative to the effect that Medicare and Social Security are unsustainable because they won’t be able to handle the mass retirement of baby boomers. But as you can see right away, only about half the projected rise in spending is the result of population aging. The rest comes from the assumption — and that’s all it is, an assumption — that medical costs will rise faster than gross domestic product.
Before I get there, a word about demography. You might think that the projected aging is all about the baby boomers. But the baby boom is generally considered to have ended in 1964. So the last of us — yes, I’m one of them — will hit 65 in 2029, just six years from now. Most baby boomers are already there.
So why does the C.B.O. project continuing budget pressure from aging? Because it assumes that life expectancy, specifically life expectancy at age 65, will keep rising. That has certainly been true in the past, but given America’s mortality problems, I’m not sure that it’s safe to assume this trend will continue at past rates.
Still, let’s grant the aging bit. What about “additional cost growth” in health care?
Well, historically health spending has risen faster than G.D.P. — largely, we think, because doctors can now treat many more things than in the past, and this effect has outpaced cost savings from improved technology. But excess cost growth has slowed considerably since around 2010 — perhaps in part because of cost-reduction aspects of the Affordable Care Act. In any case, the leveling off is unmistakable. Here’s national health spending as a percent of G.D.P.:
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This health-cost slowdown has, as it should, affected budget projections. Back during the early 2010s, the heyday of the Very Serious People who insisted that Medicare and Social Security were unsustainable, C.B.O. projections assumed that health spending would grow at historical rates. This meant that under current policies long-run projected spending was indeed enormous, and obviously unsustainable.
But that has changed, a lot. I don’t know if people still repeating the old slogans about the need for entitlement reform realize just how much projections of future spending have come down. But here’s a comparison between projected Medicare spending as a percent of G.D.P. from the 2009 long-term budget outlook and the most recent projection:
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A side note: The C.B.O. used to do 75-year projections, but apparently realized at some point that these are of little value, because nobody has any idea what the world may look like in 75 years. I used to joke that long before we got there, Skynet would have killed us all, but now we know better: Bing’s chatbot will do us in. In any case, the projections now go only 30 years ahead.
Anyway, C.B.O. projections now show social insurance spending as a percentage of G.D.P. eventually rising by about 5 points, which is still a lot but not unimaginably large. And here’s the thing: Half of that is still the assumed rise in health care costs. And there are things we can do to control costs that don’t involve cutting off Americans’ benefits. Bear in mind both that U.S. health care is far more expensive than that of any other nation — without delivering better results — and that since 2010 we’ve already done quite a lot to “bend the curve.” It’s not at all hard to imagine that improving the incentives to focus on medically effective care could limit cost growth to well below what the C.B.O. is projecting, even now.
And if we can do that, the rise in entitlement spending over the next three decades might be more like 3 percent of G.D.P. That’s not an inconceivable burden. America has the lowest taxes of any advanced nation; given the political will, of course we could come up with 3 percent more of G.D.P. in revenue.
So no, Social Security and Medicare aren’t inherently unsustainable, doomed by demography. We can keep these programs, which are so deeply embedded in American society, if we want to. Killing them would be a choice.
https://www.nytimes.com/2023/02/21/opinion/medicare-social-security.html
Which hospitals are suing patients? Investigation reveals hospital billing practices
By Judith Garber - Lown Institute Newsletter - February 17, 2023
We’ve been following stories over the past few years of hospitals taking egregious actions to recoup medical bills, such as suing patients, garnishing wages, taking their tax refunds, and sending patients to debt collections. Some of these hospitals even made it on the Shkreli Awards, our annual list of the worst examples of profiteering and dysfunction in healthcare.
While these billing practices are widespread, it’s hard to know exactly how many hospitals or which ones have engaged in them. As of now, there isn’t a national database of hospital billing practices or lawsuits, making it difficult for patients to know if they are at risk of financial harm.
However, a recent analysis by Kaiser Health News as part of their “Diagnosis Debt” campaign provides a step forward in transparency on this issue. Their team spent a year investigating billing and financial aid at a sample of 528 hospitals across the country. Among the hospitals sampled, they found that more than two-thirds sue patients or take other legal action against them. The majority of hospitals also allow for the hospital to report patients with outstanding bills to credit rating agencies. A smaller number (about 25%) sell patients’ debts to debt collectors and about 20% deny nonemergency care to people with outstanding debt.
More than two-thirds of hospitals in the sample sue patients or take other legal action against them.
Among hospitals that with egregious billing actions are some of the largest and most prestigious hospitals in America. Twelve of the 20 hospitals on the US News honor roll have the practice of reporting patients to credit bureaus, selling patient debt, suing patients for medical debt, or denying emergency care to patients with debt—including powerhouses like the Mayo Clinic, Cedars-Sinai Medical Center, and New York-Presbyterian Hospital. Many of these hospitals are part of health systems with large fair share deficits, according to the Lown Institute. However, other prestigious hospitals including Houston Methodist, Johns Hopkins Hospital, Stanford, and UCSF do not allow any of these billing practices, indicating that continuing egregious billing practices is a policy choice.
It’s unconscionable that so many hospitals (especially nonprofits) are suing patients for medical debt, sending debt to collections, or refusing to treat patients with medical debt. While it should be standard across the nation, it’s worth noting that some hospitals that are already taking a stand and not allowing these practices. Among the top hospitals on the Lown Index, several stand out for not engaging in any of the harmful billing practices measured by Kaiser Health News.
Hospitals leading on social responsibility
The Lown Institute Hospitals Index is the first to measure hospital social responsibility using 50+ metrics across health equity, value, and outcomes. The hospitals below all received A grades in Social Responsibility on the Lown Index and have policies disallowing egregious billing practices according to Kaiser Health News’ investigation.
Are you a Top Hospital? Learn how to share your performance!
Hospitals with “A” grades in Social Responsibility and high billing quality
In alphabetical order
- Eden Medical Center, Castro Valley, CA
- The Johns Hopkins Hospital, Baltimore, MD
- Ochsner Medical Center—Northshore, Slidell LA
- OHSU Hospital and Clinics, Portland OR
- Ronald Reagan UCLA Medical Center, Los Angeles CA
- St. Anthony Community Hospital, Warwick NY
- St. Joseph Hospital, Eureka CA
- Stanford Health Care —Valleycare, Pleasanton CA
- UCSF Medical Center, San Francisco CA
- United Medical Center, Washington DC
- University of Mississippi Medical Center, Jackson MS
- UPMC Bedford Memorial, Everett PA
- UPMC Jameson, New Castle PA
- Chambersburg Hospital, Chambersburg PA
- Good Samaritan Hospital, Lebanon PA
Maine’s hospital systems are working to recover from a tough financial year
Maine hospitals endured a tough year in 2022, according to a variety of recent data and financial disclosures.
The picture has somewhat improved for them in recent months, but it will be hard for them to fully bounce back from the deep-rooted problems that have driven many into the red since the start of the pandemic, including staffing gaps, inflated costs for labor and supplies, and drops in revenue resulting from a variety of industry-wide challenges.
Maine’s bigger hospitals have borne more of the brunt for treating sick people during the pandemic and, in general, aren’t reimbursed as well as small, rural hospitals. That’s clear from the heavy operating losses sustained by the state’s two biggest health care organizations, MaineHealth and Northern Light Health, which each run some of the biggest hospitals in the state.
Similar challenges have been faced by hospitals throughout Maine and the rest of the country. About two-thirds of Maine hospitals reported negative operating margins during the first half of 2022, according to the Maine Hospital Association.
And according to data analyzed by the firm Franklin Trust Ratings — which provides health care insights to a range of clients — the median operating profit margin for many Maine hospitals was negative 17.74% in the most recently reported fiscal year, down from negative 11.1% in the prior year.
Hospital officials and experts point to a variety of reasons for the troubles, including a shrinking of Maine’s hospital workforce from a recent high of more than 34,000 in 2017, down to 31,000 by early 2021, according to state labor data.
At MaineHealth, president and CEO Andy Mueller says two of the biggest financial challenges have been wage increases that the system offered to keep up with inflation and the need to hire more clinical workers from private staffing agencies — so-called travel nurses — to fill in gaps, often at much higher rates than they once charged.
“Those two things together really conspired to raise costs,” Mueller says.
Other challenges included expenses that outpaced reimbursement rates, and ongoing nursing home staff shortages that have made it harder to discharge hospital patients and admit new ones, Mueller says. Besides making patients wait longer for necessary care, those backlogs have cut into the revenue that hospitals collect from admitting new patients.
John Morrow, a veteran hospital analyst who serves as managing director of Franklin Trust Ratings, says the picture is not entirely grim. Despite the slew of financial setbacks, he notes that the state’s two biggest hospitals — Maine Medical Center in Portland and Northern Light Eastern Maine Medical Center in Bangor — have each made notable improvements on a variety of quality, safety and health measures that his company analyzes.
"Both organizations are to be recognized for their progress during tough clinical and financial times,” Morrow says. “It shows that in spite of economic headwinds and a public health emergency, progress is being made to improve care in our communities.”
The financial and operating challenges for Maine hospitals might be ebbing slightly. The rates charged for travel nurses have dropped, and fewer hospitals had negative margins during the last quarter, according to Jeffrey Austin, a lobbyist at the Maine Hospital Association.
That easing is being felt at Northern Light Health. It was hit especially hard by the challenges of last year, losing $131.7 million in the fiscal year that ended last September and recently seeing a downward shift in its assessment by two credit rating agencies. But those agencies noted that Northern Light performed more strongly than expected in the first quarter of the current fiscal year.
To improve their financial picture further, Maine hospitals say they will need to strategically reduce costs, recruit more workers and find better ways to meet the pent-up demand for patient care, among other measures.
One of the ideas MaineHealth is now considering to improve the flow of patients is converting some of its acute care hospital beds to offer more long-term care, which could help deliver care to more sick patients, according to Mueller.
Northern Light has recently reduced costs by outsourcing laboratory and administrative functions to a pair of outside companies, Quest Diagnostics and Optum. It has also hired a consulting firm to guide its business decisions going forward.
Cutting administrative costs is an easy decision for a hospital group that’s trying to improve its financial standing, according to Morrow, the hospital analyst.
He says that a group such as Northern Light might now be considering how to improve its care delivery even further, and whether there are health services such as obstetrics that are becoming too expensive to keep offering at its smaller, more rural hospitals.
Northern Light has recently scaled back some of its other services, including closing a primary care practice in Orono and a specialized rehab program at EMMC. And some other Maine hospitals have already downsized their own maternity services, including most recently Rumford Hospital.
“Will they eliminate the emergency room? No,” Morrow says. “But it’s harder to keep some of those high-risk, high-cost services out in the field.”
Asked whether Northern Light might be considering other big operating changes in the coming months, spokesperson Suzanne Spruce said that, “In the course of any year, it is not unusual for there to be changes in offerings, providers, or locations, etc. But I am not aware of any larger scale opportunities like with Quest Diagnostics or Optum.”
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