Summary: PNHP founders Woolhandler and Himmelstein propose that progressive health reform needs updating to respond to the widespread takeover of providers by for-profit corporations. The original vision of insurance reform should be expanded to include ownership of provider organizations.
The founders of Physicians for a National Health Program put single-payer health care on the map. Now, discussing the next phase of the movement, they say even single-payer won’t be enough to fix the problems caused by continued privatization. …
Steffie Woolhandler
There’s two countervailing things going on. One is that giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP. So when we started, we were mostly up against the insurance industry and pharmaceutical industry. But now there’s all sorts of involvement by banks and for-profit ownership of health providers, so that makes things harder.
The other thing is that the health care system continues to be so dysfunctional. People with or without insurance face massive medical bills, the complete inability to afford lifesaving treatments like insulin and sometimes cancer treatments. The growing dissatisfaction among doctors is now often called burnout or sometimes moral injury. Whatever you call it, physicians recognize that the system’s not functioning very well. So the system’s own problems and dysfunctions continually create an interest in and constituency for fundamental health reform.
Giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP.
David U. Himmelstein
We need to have a deep understanding of what the problems in the current system are, and the shifts in the organization of the current system need to guide both our program and our political work. So I think we need to update what the vision of single-payer health care is from when we first conceived of it.
We thought we could control the health care system by replacing insurance companies with a single public financing system. And I think that was true as long as health care was essentially carried out by small-scale practices, mostly individual hospitals, that were not parts of large chains, not controlled by giant corporations. But at this point, we have the vertical and horizontal integration of ownership of the health care system. So for instance UnitedHealthcare employs seventy thousand doctors. Just taking away the insurance business isn’t going to be an adequate reform of the health care system.
We need to reconsider our reforms to think about how we seize ownership of health care assets from the corporations that have come to dominate them, and how patients and people doing health care work can really take ownership of this system. I don’t think it’s possible any more by just taking control of insurance. I don’t see a lot of advocacy for radical reform of the health care system, and that I think is the next phase that either PNHP or some new form will need to take up.
Comment by: David Himmelstein and Steffie Woolhandler
Looking forward rather than backward, progressives need to update the vision of health reform that we and others articulated in the 1980s. Back then, a public financing program that displaced private ownership of health insurers would have had the leverage needed to broadly transform health care. But Wall Street’s subsequent takeover of health care delivery – hospitals and nursing homes, doctors’ practices, and even hospices – necessitates reform of who owns provider resources. Communities, not corporations should control care.
We hope that by speaking out on this issue, we can encourage the health reform movement to take on the critical ownership issues.
A few comments on the mostly accurate PNHP history presented in the article. It was founded 37, not 35 years ago. We note that Ron Sable, and subsequently Quentin Young, and then Claudia Fegan took over day-to-day oversight when PNHP moved from Cambridge to Chicago. Former Executive Directors Ida Hellander and Matt Petty made important contributions to PNHP. We are currently members, but not leaders, of the organization.
Corporate Giants Buy Up Primary Care Practices at Rapid Pace
Reed Abelson - NYT - May 8, 2023
Large health insurers and other companies are especially keen on
doctors’ groups that care for patients in private Medicare plans.
It’s no surprise that the shortage of primary care doctors — who
are critically important to the health of Americans — is getting worse.
They
practice in one of medicine’s lowest paid, least glamorous fields. Most
are overworked, seeing as many as 30 people a day; figuring out when a
sore throat is a strep infection, or managing a patient’s chronic
diabetes.
So why are multibillion-dollar corporations,
particularly giant health insurers, gobbling up primary care practices?
CVS Health, with its sprawling pharmacy business and ownership of the
major insurer Aetna, paid roughly $11 billion to buy
Oak Street Health, a fast-growing chain of primary care centers that
employs doctors in 21 states. And Amazon’s bold purchase of One Medical,
another large doctors’ group, for nearly $4 billion, is another such move.
The
appeal is simple: Despite their lowly status, primary care doctors
oversee vast numbers of patients, who bring business and profits to a
hospital system, a health insurer or a pharmacy outfit eyeing expansion.
And
there’s an added lure: The growing privatization of Medicare, the
federal health insurance program for older Americans, means that more
than half its 60 million beneficiaries have signed up for policies with
private insurers under the Medicare Advantage program. The federal
government is now paying those insurers $400 billion a year.
“That’s
the big pot of money everyone is aiming at,” said Erin C. Fuse Brown,
director of the Center for Law, Health & Society at Georgia State
University, and an author of a New England Journal of Medicine article about corporate investment in primary care. “It’s a one-stop shop for all your health care dollars,” she said.
Many
doctors say they are becoming mere employees. “We’ve seen this loss of
autonomy,” said Dr. Dan Moore, who recently decided to start his own
practice in Henrico, Va., to have more say in caring for his patients.
“You don’t become a physician to spend an average of seven minutes with a
patient,” he said.
The absorption of doctor practices is part of a
vast, accelerating consolidation of medical care, leaving patients in
the hands of a shrinking number of giant companies or hospital groups.
Many already were the patients’ insurers and controlled the distribution
of medicines through ownership of drugstore chains or pharmacy benefit
managers. But now, nearly seven of 10 of all doctors are either employed
by a hospital or a corporation, according to a recent analysis from the Physicians Advocacy Institute.
The
companies say these new arrangements will bring better, more
coordinated care for patients, but some experts warn the consolidation
will lead to higher prices and systems driven by the quest for profits,
not patients’ welfare.
Insurers say their purchase of medical practices is a step
toward what is called value-based care, with the insurer and doctor paid
a flat fee to care for an individual patient. The fixed payment acts as
a financial incentive to keep patients healthy, provide more access to
early care and reduce hospital admissions and expensive visits to
specialists.
The companies say they favor the fixed fees over the
existing system that pays doctors and hospitals for every test and
treatment, encouraging doctors to order too many procedures.
Under
Medicare Advantage, doctors often share profits with insurers if the
doctors take on the financial risk of a patient’s care, earning more if
they can save on treatment. Instead of receiving a few hundred dollars
for an office visit, primary care doctors can be paid as much as $14,000
a year to manage a single patient.
But experts warn these major
acquisitions threaten the personal nature of the doctor-patient
relationship, especially if the parent company has the authority to
dictate limits on services from the first office visit to extended
hospital stays. Once enrolled, these new customers can be steered toward
chains of related businesses, like a CVS drugstore or Amazon’s online
pharmacy.
UnitedHealth Group is a sprawling example of
consolidated services. It owns the major insurer that has nearly 50
million customers in the United States and oversees its ever-expanding
subsidiary, Optum, which has bought up networks of doctors and medical
sites. Optum can send patients from one of its roughly 70,000 doctors to
one of its urgent care or surgery centers.
Senator Elizabeth
Warren, Democrat of Massachusetts, is urging the Federal Trade
Commission to take a closer look at some of these large deals, which
regulators have so far not blocked on antitrust grounds. “I fear that
the acquisition of thousands of independent providers by a few massive
health care mega-conglomerates could reduce competition on a local or
national basis, hurting patients and increasing health care costs,” she wrote to regulators in March.
This
consolidation of medical care may also run afoul of state laws that
prohibit what is called corporate medicine. Such statutes prevent a
company that employs doctors from interfering with patient treatment.
And
experts warn of the potential harm to patients, when corporate
management seeks to control costs through byzantine systems requiring
prior authorization to receive care.
For example, Kaiser Permanente, the giant nonprofit health plan that also owns physician groups, settled a malpractice case for nearly $2.9 million
last year with the family of Ken Flach, a former tennis player who
contracted pneumonia and died from sepsis after a Kaiser nurse and
doctor would not send him for an in-person visit or to the emergency
room, despite the urgent pleading of his wife. Kaiser said medical
decisions are made by its providers in consultation with their patients
and said its “deepest sympathy remains with the Flach family.”
Doctors
also chafe at oversight that does not benefit patients. “They are
trying to run it like a business, but it’s not a business,” said Dr.
Beth Kozak, an internal medicine doctor in Grand Rapids, Mich.
Her
doctors’ group has teamed up with Agilon Health, an investor-owned
company, to work with Medicare Advantage plans. Dr. Kozak said she has
to work longer hours, not to provide better care, but to supply
additional diagnoses for patients, which increases federal
reimbursements under the Medicare Advantage program. “It’s not because
I’m giving better patient care,” she said. “It’s all tied to the
billing.”
The corporate consumption of medical care keeps growing. Walgreens Boots Alliance, one of the largest U.S. pharmacy operations, spent
$5 billion for a majority stake in VillageMD, a primary care group, and
teamed with Cigna to buy another medical group for nearly $9 billion.
And short of an outright purchase, UnitedHealth is partnering with
Walmart to offer care to older patients.
In promoting the benefits
of buying Oak Street clinics to investors, Karen S. Lynch, the chief
executive of CVS Health, said primary care doctors lower medical costs.
“Primary care drives patient engagement and positive clinical outcomes,”
she said.
Many of these companies are building chains
of clinics. On a recent tour of an Oak Street clinic in Bushwick, one of
16 centers opened since October 2020 in New York City, patients were
typically seen from 8 a.m. to 5 p.m., with a nurse available after hours
to field questions.
Ann Greiner, the chief executive of the
Primary Care Collaborative, a nonprofit group, defended the recent
forays by private companies into this field of health care, saying they
are infusing practices with sorely needed funds and may improve access
to care for people in underserved areas.
“The salaries of the folks in those arrangements are higher,”
she said. “They are providing more comprehensive care in many of those
arrangements. They are providing more tech and more team-based care.
That’s all investment.”
But these deals also risk shifting the balance from quality treatment to profits, she said.
In
recent years, some have invoked the laws banning corporate medicine to
challenge these large-scale private operations. Envision Healthcare, a
private equity-backed company that employs emergency room doctors, is
being sued in California by a unit of the American Academy of Emergency
Medicine, a professional group that supports independent practices,
accusing it of violating that state’s provisions.
“Envision
exercises profound and pervasive direct and indirect control and/or
influence over physicians practice of medicine, ” according to the lawsuit. The suit maintains that Envision controls the doctors’ billing and establishes medical protocols.
While
Envision would not comment on the litigation, it said it “follows an
operating structure that is common across the health care sector and
widely used by nonprofit, privately held and public groups as well as
hospitals and insurers.”
The big insurers find doctors’ groups
particularly attractive, although many have reported sizable losses. The
acquisition of Oak Street, which has lost more than $1 billion over the
last three years, could help CVS’s Medicare Advantage plans improve
their quality or “star” ratings and increase payments for one of its
plans.
Even small numbers of patients can translate into
significant revenue. One Medical, the company Amazon owns, is best known
for sleek clinics. The company scooped up a practice specializing in
Medicare Advantage. Only about 5 percent of One Medical’s 836,000
members are enrolled in that federal program, but roughly half of its
revenue comes from that tiny slice of patients, according to its 2022
financial statements.
Regulators are already flagging questionable methods employed by some practices. In November 2021, Oak Street disclosed that the Justice Department was investigating
sales ploys like free trips to its clinics and payment of insurance
agents for referrals. One doctor at a center described recruiting
patients with “gift cards, swag and goody bags,” according to a
shareholder lawsuit against Oak Street.
The lawsuit detailed concerns that
doctors were inflating the payments from the federal government by
overstating how sick their patients were.
Oak Street says it has not been accused of any wrongdoing by the Justice Department and says the lawsuit is “without merit.”
These private Medicare Advantage plans have been heavily criticized
for racking up enormous profits by inflating costs and exaggerating
patients’ illnesses to charge the government more than they should.
Under new rules,
the Biden administration would eliminate some of the most problematic,
overused diagnoses, and doctors and insurers could earn less.
But
other pathways to profit also explain why corporations covet these
deals. Unlike the caps on insurers’ moneymaking, where a Medicare
Advantage insurer has to spend at least 85 cents of every dollar on
patient care, there are no limits to how much profit these doctor
practices and pharmacy chains can make.
It may be too soon to
determine whether consolidated care will improve patients’ health. “So
far, when you look across the industry, the record of these acquisitions
has been mixed,” said Dr. Sachin H. Jain, the chief executive of SCAN
Group, a nonprofit based in Long Beach, Calif., that offers Medicare
Advantage plans.
And the investments may not halt the rapid
disappearance of the doctor still sought by so many people for ordinary
care, including a recent report showing
fewer medical school graduates going into the field.
“We’re
dealing with incredible levels of burnout within the profession,” said
Dr. Max Cohen, who practices near Portland, Ore. Since the pandemic, his
low-income patients have become much sicker, he said, with the level of
illness “through the roof.”
Primary Care Corporate Takeover a Challenge for Single Payer
Summary: The large-scale corporate appropriation of primary care reflects and enables the profiteering that now dominates US health care. The doctor-patient relationship suffers. Single payer financing may falter if corporations own the vast majority of providers. What are our reform options?
Why are multibillion-dollar corporations, particularly giant health insurers, gobbling up primary care practices?
The appeal is simple: Despite their lowly status, primary care doctors oversee vast numbers of patients, who bring business and profits to a hospital system, a health insurer or a pharmacy outfit eyeing expansion.
And there’s an added lure: The growing privatization of Medicare means that more than half its 60 million beneficiaries have signed up for policies with private insurers under the Medicare Advantage program. The federal government is now paying those insurers $400 billion a year.
The absorption of doctor practices is part of a vast, accelerating consolidation of medical care, leaving patients in the hands of a shrinking number of giant companies or hospital groups. Nearly seven of 10 of all doctors are either employed by a hospital or a corporation. Experts warn these major acquisitions threaten the personal nature of the doctor-patient relationship, especially if the parent company has the authority to dictate limits on services from the first office visit to extended hospital stays. [The article provides examples of how corporate control of primary care leads to abusive practices to increase revenue.]
“We’re dealing with incredible levels of burnout within the profession,” said Dr.Max Cohen, who practices near Portland, Ore.
Comment by: Don McCanne & Jim Kahn
There is not much new here in this report of the corporate takeover of our health care system except maybe for the rapidity and boundlessness with which it is taking place.
Recently single payer financing gained in popularity as people recognized how it could transform our defective insurance system to bring truly affordable, accessible, equitable care with free choices for all. But with corporations now controlling medical delivery including linchpin primary care providers, care has become less affordable and thus less accessible for many, certainly less equitable, and our choices are limited to the dictates of the corporate entity.
The complexity that this has produced was explained by Steffie Woolhandler and David Himmelstein, the founders of Physicians for a National Health Program, in a recent Jacobin interview andHJM post. Just a few years back, all we needed was a public financing program that displaced private ownership of health insurers (single payer).
But now with Wall Street’s takeover of the health care delivery system, reform of ownership of provider resources is needed. Community rather than corporate control of care seems to be what we need, but imagine the hurdle in transferring ownership of our entire health care system from the titans of Wall Street to the inhabitants of Main Street. Difficult times lie ahead, but what can we do? One thing for sure, we cannot leave control of our health care in the hands of the billionaires.
Are there any ideas out there that would actually work, short of socialized medicine (which, of course, would)? We’re contemplating this, and welcome ideashealthjusticemonitor@gmail.com.
The United States Is Crime Sick. Health Care Is the Cure.
Politicians
on both sides of the aisle spent the midterms telling us that more
police and prisons will make us safer. Voters didn’t bite—and perhaps
they know better.
by Eric Reinhardt - The New Repubic - December 12, 2022
With near daily mass shootings and constant media attention to
crime in America, it has become increasingly difficult to deny that the
United States is considerably less safe than other wealthy nations.
During the lead-up to the midterm elections, lawmakers from both sides
of the aisle turned to what has long been regarded as the common sense
response: calls to increase funding for police and prisons. And for the
first time in recent memory, this electoral strategy failed.
Despite being subjected to intense political and mass media rhetoric about a supposed “crime wave” for months on end, only 11
percent of people in exit polling stated that crime was their primary
concern. Meanwhile, criminal legal reformers such as Pennsylvania’s John
Fetterman, who stood by his advocacy
for clemency in cases of people who had been convicted of violent
crimes rather than shying away from it as if a vulnerability, won
despite the fearmongering strategies of their opponents. Similar results
were seen in places as varied as California, Minnesota, andTexas.
This signals potential for a major shift in American politics, and an
opportunity to change how we as a nation conceive of crime, violence
prevention, and public safety.
Millions of Americans, including many living in criminalized Black and brown communities, have been inculcated, via decades of crime journalism, copaganda, and “tough on crime” campaign rhetoric, to reflexively support such policies in the belief it will protect them. But after a half-century of this policy playing on repeat—and endless studies of its effects from researchers—there is no good evidence that more police or incarceration reduce crime or violence. Instead, there is abundant data showing police-centric public safety policy undermines public health, harms families, makes millions of Americans sick, and leads to a plethora of long-term social and economic harms.
But
this reliance on police as the centerpiece of public safety has
nonetheless remained our default policy because most Americans,
including many well-meaning lawmakers, don’t know where else to turn in
order to address fears
of violence—as well as the real thing—in our communities. This is
largely attributable to the fact that “public safety” has historically
been reduced—in part by the influence of the police-adjacent field of
criminology—to a narrow matter of crime rates
and police tactics. In the process, the concept of public safety has
been cordoned off from the policies that best serve it: public systems
for supportive care like health care, addiction treatment, supportive
housing, and guaranteed basic income programs. These, it’s assumed, are a
matter of public health policy, not safety.
If
we want to make America safer, we need to break down this false division
and embrace what data make clear: Health policy is safety policy. A
large body of research shows that the lack of safety in our communities
is inseparable from the fact that the U.S. remains the world’s only industrialized nation
to refuse to provide universal health care as a basic public service to
its citizens. As a result of this policy choice, there are now over 31 million U.S. residents without health insurance. With the end of the federal government’s Covid-related emergency provisions, up to 15 million more people are set to join them.
Where do these people excluded from care in America’s for-profit medical landscape
end up? Millions of them fall into crisis and, as a result, commit
crimes, leading to arrest and incarceration in jails and prisons—costly
public institutions that inflict health-harming punishment rather than
providing the services people need. A recent report
illustrates this dynamic, showing that 50 percent of individuals in
state prisons as of 2016 (the most recent available data) were without
health insurance at the time of their arrest. By comparison, only 9
percent of the overall U.S. population was uninsured in that same time
period. Lack of access to health care, such findings suggest, increases
the risk of crime, violence, arrest, and incarceration.
For
many people, arrest and incarceration perversely leads to temporarily
improved health care relative to what they had received on the outside.
For example, over a quarter of people in state and federal prisons who
entered prison with a chronic condition were first diagnosed with this
condition while incarcerated. Realities like this have led some to
suggest that prisons are good for health—an idea that has also been part
of the false claim that they deter future crime.
Nothing could be further from the truth. Health care quality inside jails and prisons is notoriously deficient and inadequately regulated. Unconstitutional medical neglectruns rampant, with nearly 20 percent of people in prisons reporting
that they have not had a single medical appointment since they were
first incarcerated. While 43 percent of people in state prisons have
been diagnosed with a mental health condition, 74 percent report not
having received any mental health care while incarcerated.
This lack of care has long-term consequences, with each year of incarceration associated with a two-year reduction in life expectancy. And these harmful health effects of incarceration don’t only harm those who have been incarcerated; they also spread to their families, communities, and entirecounties.
This does nothing to deter crime nor to “rehabilitate” incarcerated
people, but it does partially explain why incarceration actually increases subsequent criminal behavior.
The
real conclusion to be drawn from the relatively better availability of
health care inside jails and prisons for some people is this: Our
for-profit health care system is failing abysmally
to provide basic care for those with the greatest need. This, in turn,
fuels interrelated cycles of poverty, trauma, addiction, crime, and
violence.
These health policy failures are a major driver of America’s failed public safety paradigm. But, despite intense political and media attention
paid to crime and public safety policy over the last two years, almost
no media or political attention has been paid to a constant stream of
research repeatedly demonstrating that expanding supportive services,
especially health care access, is an extremely effective policy for
reducing crime and improving shared safety.
In studies released this year alone, one
found that men who lose access to Medicaid eligibility are 14 percent
more likely to be incarcerated over the following two years relative to a
matched comparison group. That goes up to 21 percent for people with
histories of mental health diagnoses. A second
showed that increased access to health care through Medicaid expansion
for formerly incarcerated people substantially reduces rates of rearrest
for violent crimes and public order crimes, with 16 percent reductions
in violent crime observed over the two years after release. A third
found police arrests significantly declined after the Affordable Care
Act expanded Medicaid access, leading to a 25 to 41 percent drop in drug
arrests and a 19 to 29 percent decrease in violence-related arrests.
In 2020, twostudies
demonstrated that Medicaid expansion is associated with reductions in
burglary, vehicle theft, homicide, robbery, and assault, resulting in
significant financial returns that offset the public cost of ensuring a
right to health care. Another showed
that the 1990 Medicaid expansion, which provided increased health care
access for Black children, led to a 5 percent reduction in their rate of
incarceration by age 28, mostly due to reductions in financially
motivated crimes. And a 2021 study showed expanding outpatient mental health care offices substantially reduces crime and crime-associated costs to communities.
To finally build safety, health, and trust
in American communities, we need our lawmakers to confront the fact
that punishment cannot serve as a substitute for freedom-enabling care.
Voters, including those in Republican-run states, are showing they are ready to support those who do.
The following article about private equity firms is relevant to health care because they are aggressively moving into buying health care institutions (such as nursing homes and hospice services), but also doctor's practices, such as emergency room physician practices.
Batten down the hatches!! The "fun" has just begun.
- SPC
Opinion | Private Equity Is Gutting America — and Getting Away With It
Brendan Ballou -NYT- April 28, 2023
Mr. Ballou is an attorney and the author of the
forthcoming “Plunder: Private Equity’s Plan to Pillage America,” from
which this essay is adapted.
Sign up for the Opinion Today newsletter Get expert analysis of the news and a guide to the big ideas shaping the world every weekday morning.
“Private
equity” is a term we’ve all heard but which, if we’re honest, few of us
understand. The basic idea is simple: Private equity firms make their
money by buying companies, transforming them and selling them —
hopefully for a profit. But what sounds simple often leads to disaster.
Companies bought by private equity firms are far more likely to go bankrupt than companies that aren’t. Over the last decade, private equity firms were responsible for nearly 600,000 job losses
in the retail sector alone. In nursing homes, where the firms have been
particularly active, private equity ownership is responsible for an
estimated — and astounding — 20,000 premature deaths
over a 12-year period, according to a recent working paper from the
National Bureau of Economic Research. Similar tales of woe abound in mobile homes, prison health care, emergency medicine, ambulances, apartment buildings
and elsewhere. Yet private equity and its leaders continue to prosper,
and executives of the top firms are billionaires many times over.
Why
do private equity firms succeed when the companies they buy so often
fail? In part, it’s because firms are generally insulated from the
consequences of their actions, and benefit from hard-fought tax benefits
that allow many of their executives to often pay lower rates than you
and I do. Together, this means that firms enjoy disproportionate
benefits when their plans succeed, and suffer fewer consequences when
they fail.
Consider the case of the Carlyle Group and the nursing home chain HCR ManorCare. In 2007, Carlyle — a private equity firm now with $373 billion in assets under management — bought HCR ManorCare
for a little over $6 billion, most of which was borrowed money that
ManorCare, not Carlyle, would have to pay back. As the new owner,
Carlyle sold nearly all of ManorCare’s real estate and quickly recovered
its initial investment. This meant, however, that ManorCare was forced
to pay nearly half a billion dollars a year in rent to occupy buildings
it once owned. Carlyle also extracted over $80 million in transaction
and advisory fees from the company it had just bought, draining
ManorCare of money.
ManorCare soon instituted various
cost-cutting programs and laid off hundreds of workers. Health code
violations spiked. People suffered. The daughter of one resident told
The Washington Postthat
“my mom would call us every day crying when she was in there” and that
“it was dirty — like a run-down motel. Roaches and ants all over the
place.”
In 2018, ManorCare filed for bankruptcy, with over $7
billion in debt. But that was, in a sense, immaterial to Carlyle, which
had already recovered the money it invested and made millions more in
fees. (In statements to The Washington Post, ManorCare denied that the
quality of its care had declined, while Carlyle claimed that changes in
how Medicare paid nursing homes, not its own actions, caused the chain’s
bankruptcy.)
Carlyle managed to avoid any legal liability for its
actions. How it did so explains why this industry often has such poor
outcomes for the businesses it buys.
The family of one ManorCare resident, Annie Salley, sued Carlyle
after she died in a facility that the family said was understaffed.
According to the lawsuit, despite needing assistance walking to the
bathroom, Ms. Salley was forced to do so alone, and hit her head on a
bathroom fixture. Afterward, nursing home staff reportedly failed to
order a head scan or refer her to a doctor, even though she exhibited
confusion, vomited and thrashed around. Ms. Salley eventually died from
bleeding around her brain.
Yet when Ms. Salley’s family sued for
wrongful death, Carlyle managed to get the case against it dismissed. As
a private equity firm, Carlyle claimed, it did not technically own
ManorCare. Rather, Carlyle merely advised a series of investment funds
with obscure names that did. In essence, Carlyle performed a legal
disappearing act.
In this case, as in nearly every
private equity acquisition, private equity firm benefit from a legal
double standard: They have effective control over the companies their
funds buy, but are rarely held responsible for those companies’ actions.
This mismatch helps to explain why private equity firms often make such
risky or shortsighted moves that imperil their own businesses. When
firms, through their takeovers, load companies up with debt, extract
onerous fees or cut jobs or quality of care, they face big payouts when
things go well, but generally suffer no legal consequences when they go
poorly. It’s a “heads I win, tails you lose” sort of arrangement — one
that’s been enormously profitable.
But it isn’t just that firms
benefit from the law: They take great pains to shape it, too. Since
1990, private equity and investment firms have given over $900 million
to federal candidates and have hired an untold number of senior
government officials to work on their behalf. These have included
cabinet members, speakers of the House, generals, a C.I.A. director, a
vice president and a smattering of senators. Congressional staff members
have found their way to private equity, too: Lobbying disclosure forms
for the largest firms are filled with the names of former chiefs of
staff, counsels and legislative directors. Carlyle, for instance, at
various times employed two former F.C.C. chairmen, a former S.E.C.
chair, a former NATO supreme allied commander, a former secretary of
state and a former British prime minister, among others.
Such
investments have paid off, as firms have lobbied to protect favored tax
treatments, which in turn have given them disproportionate benefits when
their investments succeed. The most prominent of these benefits is the
carried interest loophole, which allows private equity executives to pay
such low tax rates. The issue has been on the national agenda since at
least 2006, and three presidents have tried to close the loophole. All
three have failed.
Most recently, in 2021, as part of his first
budget, President Biden proposed to end the benefit for people with very
high incomes. But as he made his pitch, private equity opposition
surged, and the largest firms each spent $3 million to $7 million on
lobbying that year alone. One firm, Apollo Global Management, employed
the former general counsel to the House Republican caucus, a former
senior adviser to a past speaker of the House, a former chief of staff
to another speaker and a former senator, plus more than a dozen other
former officials.
As the plan wound its way through Congress, it
grew weaker, and by the fall of 2021, the proposal to end the benefit
was no longer a part of Mr. Biden’s budget negotiations. Instead,
Congress approved an amendment
that largely exempted small and midsize companies owned by private
equity firms from a new corporate minimum tax. It was an obscure but
important consideration, and with it, private equity firms managed not
just to protect a preferred tax advantage — the carried interest
loophole, which benefited people like Blackstone’s Stephen Schwarzman,
whose income in 2022 was 50 times that of the chief executive of Goldman
Sachs — but also to win a new one.
The story further
explains why the actions of private equity firms often have such sorry
consequences for everyone except themselves. By protecting favored tax
benefits, firms receive disproportionate gains when their strategies
succeed. But, insulated from liability, they face little consequence if
those plans fail. It’s an incentive system that encourages risky, even
reckless behavior like that at ManorCare, and is designed to work for
private equity firms and no one else.
But if private equity firms are powerful, so too are ordinary people, who’ve had surprising success confronting firms regarding unaffordable prison phone calls and surprise medical bills,
among other issues. Even if we’re unlikely to fix our tax code soon,
activists and others can still push to update our laws and hold private
equity responsible for its actions. Congress can clarify that firms can
be sued for wrongs committed by companies they effectively control.
States and cities can do the same when portfolio companies are based in
their jurisdictions. By making private equity firms responsible for
their own actions, we can build a better — and fairer — economy, and
make tragedies like that at ManorCare less likely. All we need is the
courage to act.
Nearly a third of nurses nationwide say they are likely to leave the profession
By
Jaclyn Diaz - NPR - May 2, 2023
Close to a third of nurses nationwide say they are likely to leave
the profession for another career due to the COVID-19 pandemic, a new survey from AMN Healthcare shows.
This level is up at least seven points since 2021. And the survey
found that the ongoing shortage of nurses is likely to continue for
years to come.
About 94% of nurses whoresponded to the AMN Healthcare survey
said that there was a severe or moderate shortage of nurses in their
area, with half saying the shortage was severe. And around 89% of
registered nurses (RNs)said the nursing shortage is worse than five years ago.
Nurses aren't optimistic about the future, either. At least 80% of thosesurveyed expect that to get much worse in another five years, the report shows.
Unions representing nurses have long warned about the problem facing
the profession, said National Nurses United President Deborah Burger and
President of SEIU Healthcare 1199NW Jane Hopkins. Both women are also
RNs.
"It's a critical moment in our time for nurses. The country needs
nurses. We are very short and we are feeling very worried about the
future of their work," Hopkins said.
The COVID-19 pandemic certainly exacerbated problems, but short staffing was an issue even before then, Burger and Hopkins said.
"The staffing crisis didn't just happen. It's been around for years.
Unions have been sounding the alarm that organizations were putting
profits before patients," Hopkins said. Employers "had cut staffing so
bad, that there was no room for flexibility."
She said she hears from members that they rarely have time to eat lunch or use the bathroom during their shifts.
Low staffing has a dangerous trickle-down effect, Burger said. It
leads to a heavier workload, more stress and burnout for the remaining
staff, as well as a negative impact to patient care.
The AMN Healthcare survey findings indicated younger generations of
nurses were also less satisfied with their jobs compared to their older
counterparts.
But even before the pandemic, the younger generation had signaled
they were done with nursing, Hopkins said. "First and second year nurses
were leaving the profession at a higher rate because it's not what they
expected. This escalated during the pandemic," she said.
Across generations, a higher percentage of nurses also reported
dealing with a greater deal of stress at their job than in previous
years, the survey said. Four in five nurses experience high levels of
stress at work — an increase of 16 points from 2021.
Similarly, a higher level of nurses reported feeling emotionally
drained from the 2021 survey — up at least 15% in two years (62% to
77%).
One source of that stress? Nurses are also experiencing an increasing level workplace violence in the hospitals, Burger said.
"Nurses don't feel safe in many of the hospitals around the country.
And we've heard horrendous stories. That also gets tied back into short
staffing," she said.
Nurses have been fighting for better working conditions
This discontent among staff has deeper implications for hospitals and other organizations across the country.
In January, around 7,000 nurses in New York went on strike
over a contract dispute with hospitals in the city. The nurses were
looking for higher wages and better working conditions. This strike
forced several hospitals to divert patients elsewhere.
Voxreported in January
that nurses and other healthcare workers have frequently gone on strike
in recent years. In 2022, eight of the 25 work stoppages involving
1,000 or more workers in the U.S. were done by nurses.
The AMN Healthcare survey similarly recommended that health care
providers create safer working environments and broader regulatory
changes to make meaningful differences.
Burger was more direct.
"Stop studying it and start actually legislating. Congress knows that they need to do something," Burger said.
"It's concerning that there's a lot of hand wringing," she said, but nothing is being done.
Maine Legislature may restrict ‘facility fees’ charged by hospitals
The legislation was drafted after a Press Herald investigation revealed
that some health care providers add the fees without disclosure or
explanation.
by Joe Lawlor - Portland Press Herald - April 28, 2023
Maine lawmakers will consider a bill to strictly regulate – in some
cases ban – so-called facility fees that are sometimes tacked onto
medical bills and can add hundreds of dollars to the cost of routine
hospital visits.
The charges are controversial, with consumer advocacy groups arguing
that they unfairly shift costs onto patients without warning and
hospitals maintaining that the fees are needed to support an array of
uncompensated services they provide.
Senate President Troy Jackson, D-Allagash, and House Speaker Rachel
Talbot Ross, D-Portland, are sponsoring the bill, indicating it’s a
priority among Democratic leadership.
Jackson drafted the bill after a Press Herald investigation
revealed that health care providers are adding – and sometimes hiding –
surcharges called facility fees to patients’ bills, often charging
hundreds of dollars simply because an outpatient procedure or test was
performed in a hospital. The newspaper’s investigation, published last
August, reported that patients are surprised, confused and frustrated by
such charges, and that insurance companies are not covering them,
leaving patients stuck paying the bill.
In one example, a Portland patient complained of being charged a $510
facility fee for a few minutes of care for a sliced finger at Northern
Light Mercy Hospital in Portland.
Jackson said Thursday that the legislation will help make health care more affordable and accessible.
“The goal is to clamp down on so-called facility fees and protect patients from being nickeled-and-dimed
at every turn,” Jackson said. “We need to make sure that our health
care system centers patients, not profits. Prohibiting unwarranted
facility fees would mark a step in the right direction.”
A spokesman for Gov. Janet Mills did not respond to questions about
whether she supports the bill. But in comments last year, Mills said she
is “determined” to “see what more can be done to protect Maine people”
from surprise and hidden medical bills.
The bill would ban facility fees from outpatient clinics and other
non-hospital locations. For certain procedures, hospitals also would be
barred from charging facility fees.
The Maine Department of Health and Human Services would be required
to create a list of services for which patients could not be charged
facility fees. The list is not spelled out in the bill, but common
screenings such as colonoscopies, blood tests, MRIs, mammograms and
other routine care would likely be targeted. The legislation also would
require DHHS to submit to the Legislature an annual report about
facility fees.
Ann Woloson, executive director of Consumers for Affordable Health
Care, which advocates on behalf of patients before the Legislature, said
the fees are especially anti-consumer because they “are often
unknowingly charged to patients.”
“(The bill) provides an initial but measured approach to limiting
when and where facility fees can be charged, and requires reporting by
hospitals that will help policy makers better understand this particular
cost driver,” Woloson said. “If passed, the bill will also certainly
help ease a portion of health care cost burden that Maine consumers
face.”
Hospitals have contended that facility fees are needed to help recoup
the costs of operating hospitals, including treating patients who don’t
have insurance coverage or the ability to pay and Medicaid patients who
are covered at lower reimbursement rates than patients with private
insurance. Unlike hospitals, many private medical practices limit the
number of uninsured or Medicaid patients they will care for.
Jeff Austin, vice president of government affairs for the Maine
Hospital Association, said the bill would regulate rates, which the
state is not set up to do for private insurance.
“We don’t have a (public utility commission) type body set up to do
rate regulation,” Austin said. “We shouldn’t be regulating rates in
one-off bills by the Legislature.”
Austin said where the state does regulate rates, in the combined
federal-state Medicaid program, the state only pays 76% of the cost of
hospital services.
“The state has a track record of setting rates that makes us nervous,” Austin said.
Austin said hospitals provide many money-losing services that
independent outpatient centers can’t or won’t do, such as clinics in
rural areas. Limiting fees could result in reduced access in parts of
rural Maine, Austin said, as hospitals look to contain costs.
Proposals to regulate facility fees are in the early stages in most
states, if they are being proposed at all. Connecticut was the first
and, so far, only state to aggressively regulate hospital facility fees.
It was Labor Day weekend 2021 when Sara Walsh, who was 24 weeks pregnant with twins, began to experience severe lower-back pain.
On Wednesday, a few days later, a maternal-fetal specialist near her
home in Winter Haven, Florida, diagnosed Walsh with twin-to-twin
transfusion syndrome, a rare complication that occurs when fetuses share
blood unevenly through the same placenta. The doctor told her that the
fetuses were experiencing cardiac issues and that she should prepare for
treatment the following day, Walsh said.
Her OB-GYN told her that, without immediate surgery, her twins had a high chance of perinatal death, and she could also die.
Both doctors referred Walsh to a fetal surgeon about four hours away, describing him as an expert on the condition.
As Walsh prepared to leave, she received a call from the surgeon’s
practice, the Fetal Institute. Walsh said a billing representative told
her that before surgeon Ruben Quintero would see her, she needed to pay
in full for the consultation, surgery, and postoperative care — a total
estimate of $15,000.
Although Walsh had insurance, the biller said the surgeon was not in
any private insurance networks nor did he offer payment plans.
“I burst into tears,” Walsh said. “’I don’t want to lose these babies.’”
Her mother agreed to give her money, and Walsh also called her
insurer, who advised her to apply for a waiver that could allow them to
reclassify the care as in network.
Late Wednesday, Walsh and her husband checked into a hotel near the
practice’s office in Coral Gables. The next morning, she handed her
credit card and then her mother’s credit card to the clerk at the Fetal
Institute. Quintero said her case had advanced to stage 3, meaning there were problems that could cause heart failure in one or both fetuses.
He performed surgery later that day at a hospital about 90 minutes
away. On Friday morning, she traveled back to his office for a
follow-up. In the following weeks, she had two more consultations.
About five weeks after the surgery, Walsh gave birth to twin girls. They were premature but otherwise healthy.
Then she waited for her insurance reimbursement to come.
The Patient: Sara Walsh, 39, is covered by Blue Cross and Blue Shield of Texas through her employer, a national newspaper publisher.
Medical Service: Fetoscopic laser surgery for
treatment of twin-to-twin transfusion syndrome, as well as pre- and
postoperative evaluations and X-rays.
Service Provider: The Fetal Institute in Coral Gables, Florida, a practice that specializes in treating rare pregnancy complications.
Total Bill: $18,610 over multiple
visits for surgery; pre- and post-surgical consultations; and two
follow-up consultations for potential complications that didn’t
ultimately require more treatment. Walsh ended up putting $14,472.35 on
her and her mother’s credit cards. Her health plan eventually paid the
Fetal Institute $5,419.44. Walsh was later partially reimbursed but
ultimately paid more than $13,000 out-of-pocket.
What Gives: Walsh’s case falls into a gray area of
medical billing between emergency and elective care. Despite being
insured, Walsh paid most of the full charges upfront and out-of-pocket
for care that three doctors said she urgently needed to save her twins.
And she knew the surgeon was an out-of-network provider.
Within 20 hours, Walsh gathered the thousands of dollars she was told
she needed to pay before the surgeon would meet with her and prepared
to undergo surgery in an unfamiliar hospital. “That 20 hours was just
insanity,” she said.
When Walsh called BCBS before her procedure, a representative told
her that Quintero was in its network at a few facilities but not at his
private practice, where he would evaluate her. Laura Kersey, a billing
representative with the Fetal Institute, confirmed to KFF Health News
that the practice accepts Medicaid — which covers nearly half of all births in Florida — but does not contract with private insurance.
“Our highly specialized practice sees patients from across the
globe,” Quintero said in a statement to KFF Health News. “It would be
impractical to join all health plans. If any patient is unable to pay in
full for a procedure, we offer them CareCredit or an alternative
payment plan, on a case by case basis.”
Neither option was available to Walsh. Approval for CareCredit, a
medical credit card, would not have come in time for her next-morning
procedure. Walsh said the Fetal Institute denied her request to pay half
the bill upfront and the rest over time.
Kersey said requiring upfront payment is the Fetal Institute’s
“normal practice.” She said they are transparent about their billing
practices and disclose them to potential patients ahead of time. If
someone cannot pay, she said, the Fetal Institute sends the person back
to the referring physician to find another option.
Walsh said the BCBS representative advised her to complete a waiver
intended for patients who receive urgently needed care from an
out-of-network provider when it is not feasible to see an in-network
provider. Walsh did not have the days or even weeks needed to undergo
the insurer’s formal preauthorization process, which could have told her in advance whether BCBS would cover the claim.
Walsh and her mother had paid the Fetal Institute nearly $13,000 related to her surgery, hopeful that BCBS would reimburse them.
In the weeks before Walsh gave birth, the specialist in Winter Haven
sent her back to Quintero twice. Both times Quintero evaluated Walsh and
sent her home without further treatment. She paid nearly $1,475 more
for those visits.
Walsh said she had trouble getting all the documentation BCBS said
she needed. In early November, she received the letter of medical
necessity explaining the diagnosis.
The letter, signed by Quintero, said that twin-to-twin transfusion
syndrome, when left untreated, results in pregnancy loss in 95% of
patients.
But Walsh’s situation didn’t count as the type of emergency that could have qualified her for federal billing protections, said Erin Fuse Brown, a law professor and the director of the Center for Law, Health & Society at Georgia State University.
Walsh sought care that was “knowingly out of network, even though
there was a figurative gun to her head,” Fuse Brown said, referring to
the potential loss of her twins or even her own life.
The federal No Surprises Act, which took effect last year, months
after Walsh’s surgery, protects patients who receive emergency services
inadvertently from out-of-network providers and only in certain settings
— particularly emergency departments and urgent care centers. It also
covers nonemergency services received from out-of-network providers, but
only at in-network facilities.
Federal laws requiring public access to emergency services
apply only to hospitals, not individual providers in their offices,
Fuse Brown said. Physicians generally can refuse new patients and charge
what they want, if they are transparent about costs, she added.
“It’s not a surprise medical bill if it’s not a surprise,” Fuse Brown said.
Only about 30 to 40 hospitals nationwide can perform fetoscopic laser surgery to treat twin-to-twin transfusion syndrome, Yale Medicine estimates.
Walsh said the specialist who referred her for a next-day surgical
appointment gave her just two options for providers in the region, only
one of whom practiced in her state. That was Quintero, who is renowned
for his work on the condition. He is credited with pioneering the procedure Walsh needed and, with his colleagues, also developed a way to assess the condition’s severity, known as the Quintero staging system.
But it turns out there was another option in Florida. Neither the
specialist nor BCBS told Walsh about the possibility of getting care at
the University of South Florida, she said. At the time, USF was the only
other facility in her state that could have performed the procedure,
according to Alejandro Rodriguez, a maternal-fetal medicine physician
and an assistant professor at the USF Health Morsani College of Medicine
in Tampa. Rodriguez said that USF accepts private insurance, Medicaid,
and Medicare and doesn’t require patients to pay upfront for care.
“There was no mention of shopping around,” Walsh said. And with her
doctors telling her the lives of her children — and potentially her own —
were urgently at stake, she said it seemed her only option was to pay
up.
“No parent should face the choice of ‘How much money can I raise in
the next 12 hours and is it enough to save the lives of my children?’”
Walsh said.
The Resolution: Walsh has spent more than a year
trying to get reimbursed by her health plan, repeatedly explaining her
complicated case as representatives tried to sort out the proper billing
codes for the rare, newer treatment. “No one understood how a doctor
charged me more than $10,000 upfront to treat me,” she said.
Walsh also reached out to a medical advocate, who she said concluded that Quintero had billed correctly.
Walsh’s insurance covered Wellington Regional Medical Center, the in-network hospital where Quintero performed the procedure.
The Fetal Institute also filed claims for Walsh’s care with BCBS,
telling her they were filing on her behalf. BCBS processed the claims —
including for Quintero’s surgical services at the in-network hospital —
as out-of-network care and reimbursed Walsh for just a fraction of the
more than $18,000 charged.
Her “explanation of benefits” documents stated that Walsh was on the
hook for the balance between what Quintero’s practice charged and the
$5,419.44 that BCBS paid.
Walsh said BCBS covered her pregnancy-related visits to other,
in-network providers, adding that her plan fully covers all diagnostic
and laboratory maternity care.
In early 2022, the Fetal Institute forwarded Walsh a check for about
$1,282. According to the practice’s records shared with KFF Health News,
the check corrected an overpayment on the full charges, totaling
$18,610 — which Walsh’s payments and BCBS’ reimbursements had together
fulfilled.
Walsh said she had not received any other reimbursement.
BCBS declined to comment on Walsh’s case, citing privacy concerns
even though Walsh waived federal health privacy protections, which would
allow the insurer to speak to a reporter about the case.
After a KFF Health News reporter contacted the insurer, Walsh said, a
BCBS representative called to inform her that her claims had been
“escalated,” but eventually determined that the reimbursement was
“appropriate” because the provider was out of its network.
The insurer said that the full amount of her balance doesn’t apply toward out-of-pocket maximums in her plan.
The Takeaway: Federal billing protections are not
designed to protect patients who choose out-of-network care, even when
they find themselves in an urgent situation with few options and little
time for comparison shopping.
And often only a handful of specialized providers can treat rare
conditions. While that dearth of options raises ethical questions about
whether it is OK for a doctor to demand payment upfront for lifesaving
surgery, it is legal to do so, experts say. Many Americans would be
challenged to raise $15,000 overnight.
“The patient did everything she could,” said Fuse Brown.
Worse, still, she said: When a patient pays upfront, there’s little
incentive for providers and insurers to negotiate a fair payment or even
cooperate to help patients get reimbursement.
The case shows how consumer protections are still lacking in many
situations. “This could still happen tomorrow,” Fuse Brown said.
Summary: Aggressive collection tactics by a large bariatric surgery practice exemplify widespread problems with our health insurance: complex payment arrangements, confusing and misleading financial contracts, widely variable prices, medical debt, expensive litigation, and rising private equity.
Wallace denies the allegations, which the bariatric practice has leveled against patients in hundreds of debt-collection lawsuits filed over the past four years, court records in New York state show.
In about 60 cases, the lawsuits demanded $100,000 or more from patients. Some patients were found liable for tens of thousands of dollars in interest charges or wound up shackled with debt that could take a decade or more to shake. Others are facing the likely prospect of six-figure financial penalties, court records show. …
[Wallace] said she turned over checks from her insurer to the bariatric group and was stunned when the medical practice hauled her into court citing an “out-of-network payment agreement” she had signed before her surgery.
“I really didn’t know what I was signing,” Wallace told KFF Health News. “I didn’t pay enough attention.” …
The bariatric group has cited these out-of-network payment agreements in at least 300 lawsuits filed against patients from January 2019 through 2022 demanding nearly $19 million to cover medical bills, interest charges, and attorney’s fees, a KFF Health News review of New York state court records found. …
In most cases, the medical practice had agreed to accept an insurance company’s out-of-network rate as full payment for its services — withcaveats, according to court filings.
In the agreements they signed,patients promised to pay any coinsurance, meeting any deductible, and pass on to the medical practice any reimbursement checks they received from their health plans within seven days.
Patients who fail to do so “will be held responsible for the full amount charged for your surgery, plus the cost of legal fees,” the agreement states.
That “full amount” can be thousands of dollars higher than what insurers would likely pay, KFF Health News found — while legal fees and other costs can layer on thousands more. …
Wallace, the Brooklyn legal assistant, was billed $60,500 for her lap sleeve gastrectomy, though how much her insurance actually paid remains to be hashed out in court.
Michael Arrigo, a California medical billing expert at No World Borders, called the prices “outrageous” and “unreasonable and, in fact, likely unconscionable.” …
Private Equity Arrives …
In August 2019, the private equity firm Sentinel Capital Partners bought 65% of the MSO for $156.5 million, according to Garber’s affidavit. The management company is now known as New You Bariatric Group. The private equity firm did not respond to requests for comment.
1) Complex payment arrangements:Scores of public insurance programs (Traditional Medicare with and without direct contracting, Medi-gap policies, Medicare Advantage and Medicaid plans in profusion) and thousands of private insurance plans from work and ACA exchanges. Out-of-network payments regulated by ambiguous laws. All of this contributes hugely to more than $600 billion per year in excess administrative costs.
2) Confusing and misleading financial contracts with patients:The patients of this bariatric surgery practice were told that it would accept out-of-network payments offered by insurers … except if … here’s the fine print … they failed to take care of all tasks within 7 days, in which case their obligation would shift to “the full amount charged for your surgery, plus the cost of legal fees”. And, it seems, the practice charged very high prices.
3) Widely variable prices:Which brings us to prices. It turns out that prices listed by different practices for these standard surgeries vary widely in nearby areas. This is generally true of medical prices: the amount “charged” (aka “billed”, aka “chargemaster”) is entirely discretionary, and varies hugely across providers. Insurers typically negotiate much lower “allowed” charges. Discerning a truly fair local price is impossible. This surgical practice aims high, which means the sued patients are on the hook for amounts far in excess of actual costs.
4) Medical debt:Which leads to medical debt. As detailed in the article, this is the result for many sued patients. And, as covered in HJM, estimates of the current prevalence of medical debt are in the range of 40-50%, with a median debt of $2,500 or more.
5) Expensive litigation:Collections lawyers are happy to line up when liabilities of tens of thousands of dollars are in the offing from poorly-represented patients who didn’t read the fine print in their contracts, and the lawyers will keep 1/3 of the yield. That adds to administrative costs. And the litigation clogs the courts and traumatizes patients.
6) Rising private equity:As the last excerpted paragraph notes, the surgery practice payment lawsuits accelerated once private equity entered the scene. Private equity is rapidly expanding its role in provider ownership, as reported in HJM. Pursuit of income and profit as their guiding light.
Single payer would solve problems 1, 2, 3, 4, and 5. And greatly mitigate 6.
'To Save the NHS,' Nurses Strike in Half of English Hospitals
Kenny Stancil - Common Dreams - May 01, 2023
Nurses and other National Health Service workers walked off the job
in half of England's medical facilities on Sunday night amid an ongoing
fight for higher pay and better patient safety in the United Kingdom.
The latest NHS strike comes after Royal College of Nursing (RCN) and Unite union members voted to reject
the right-wing U.K. government's most recent pay offer, decrying the
proposed 5% raise for this year and next as insufficient to offset the
soaring prices that have resulted in real pay cuts and a devastating cost-of-living crisis.
Carrying signs with messages such as "strike to save the NHS," healthcare workers marched in London and other cities on Monday.
"I'm striking because claps and applause don't pay our wages."
RCN's
work stoppage, which affects half of England's hospitals, community
health sites, and mental health centers, is slated to last until
midnight.
Ahead of the 28-hour action, a critical care nurse named Charlotte explained
that she has "been so torn" by RCN's decision to strike. However, she
said, "I know that this is the right thing to do for our patients, their
loved ones, for ourselves, for our colleagues, and for the future of
the NHS."
"I'm striking because claps and applause don't pay our
wages," she continued. "They don't provide incentives for people to come
into the profession, they don't improve staffing or patient safety."
"We
are a kind, caring, and compassionate profession. We don't want that
light to fade," she added. "We're striking and fighting to keep that
compassion alive for our patients and for our NHS."
NHS England warned
patients to expect "disruptions and delays to services," noting that
staffing levels in some areas would be "exceptionally low, lower than on
previous strike days," including the massive walkouts in December, January, and February.
According toBBC News,
the current strike marks the first time RCN members have "walked out of
all areas, including intensive care," but the union has agreed on "some
last-minute exemptions so nurses could be pulled off the picket line to
ensure life-preserving care was provided."
As the outlet reported:
Around
a quarter of trusts involved in the strike have been given extra
exemptions for services such as transplant and cardiac care—to allow
them to call in some striking nurses because they have not been able to
find other staff to fill the rotas.
This is to ensure a minimal level
of cover—not normal staffing—as the RCN has to abide by trade union
rules to ensure life-preserving care can be provided during a walkout.
In previous walkouts, services such as intensive care, chemotherapy, and dialysis have been excluded from strike action.
RCN
general secretary Pat Cullen lamented that a strike was necessary and
placed the blame squarely on the shoulders of Prime Minister Rishi Sunak
and his fellow Tories.
"Only negotiations can resolve this and I urge ministers to reopen formal discussions" with RCN, Cullen said
Sunday in a statement. "Nursing staff are looking for a fair settlement
that shows the government values and understands their profession."
"We appear a long way from that currently, but I remind ministers it is entirely in their gift," the labor leader added.
The
current strike comes ahead of a key Tuesday meeting between several
healthcare workers' unions, cabinet ministers, and NHS administrators.
While RCN and Unite have condemned the government's offer as inadequate,
other unions have voted to accept it, with Unison leader Sara Gorton
recently calling the proposed 5% wage increase "the best that could be achieved through negotiation."
Given that some nurses have been forced to rely on food banks, RCN is demanding
a pay hike of 5% above inflation. Meanwhile, Britain's Enough Is Enough
campaign against neoliberalism on Monday tweeted that lawmakers on the
receiving end of "a 32% pay rise since 2010" and subsidized meals are
"in no position to lecture a nurse who, since 2010, earns £5,000 less in
real-terms about pay restraint."
\u201cIf
you're an MP who's had a 32% pay rise since 2010, and have your meals
subsidised by the taxpayer, you're in no position to lecture a nurse
who, since 2010, earns \u00a35,000 less in real-terms about pay
restraint. There's plenty of money; it's just going to the wrong
places.\u201d
RCN's walkout was supposed to continue through Tuesday night, but a High Court judge ruled last week that the union's original plans would be unlawful due to the expiration of its six-month mandate for action.
"It
is the darkest day of this dispute so far—the government taking its own
nurses through the courts in bitterness at their simple expectation of a
better pay deal," Cullen said
in response to the ruling. "Nursing staff will be angered but not
crushed by today's interim order. It may even make them more determined
to vote in next month's reballot for a further six months of strike
action."
Unite, meanwhile, is not facing the same legal constraints.
On
Monday, Unite members at the Yorkshire ambulance service and Guy's and
St. Thomas' NHS Trust in central London walked off the job, with the
latter demonstrating in the capital, BBC News reported. On
Tuesday, Unite members at South Central, South East Coast, and West
Midlands ambulance trusts as well as workers at the Christie NHS
Foundation Trust and Pathology Partnership, East Lancashire Hospitals
NHS Trust, and Sandwell and West Birmingham NHS Trust plan to strike.
Unite leader Onay Kasab told BBC that if U.K. Health Secretary Steve Barclay tries to impose the government's pay offer, the union will take further action.
"We
will ballot, and where we have current mandates—some of them lasting up
to September—then we will continue taking action, and we will
escalate," said Kasab.
The struggle over the future of the NHS comes as the House of Lords proceeds
with its third and final reading of the Tories' so-called Strikes Bill.
The legislation, already approved by the House of Commons, threatens to take away the right of nurses, ambulance workers, teachers, firefighters, rail workers, and others to strike.
Progressive critics argue
that the proposal to fire striking public sector workers who refuse
to comply with a mandatory return-to-work notice amounts to a "pay cut
and forced labor bill" and would constitute a "gross violation of
international law."
During a recent speech denouncing the anti-strike legislation, left-wing Labour Party MP Zarah Sultana said
that the bill is about "shifting the balance of power: weakening the
power of workers and making it easier for bosses to exploit them and for
the government to ignore them."
Enough Is Enough, for its part, has stated:
"You're either with nurses, teachers, firefighters, and frontline
workers. Or you're with the Tory government. It's time for everyone to
pick a side."
Have you had difficulty finding care with a primary care clinician? If so, you’re not alone - it’s become more difficult to establish with primary care all across the country. Last summer in the Upper Valley where I live, after a million dollar rebranding, Dartmouth Health announced it was unable to accept new patients for primary care. 98 million now Americans live in a primary care shortage area, often in rural regions.
Access and continuity with high-quality primary care is the bedrock of high-functioning health care systems. Primary care teams assure immunization, screenings for lead poisoning in children or cancer in adults, address health habits, mental health and numerous conditions like hypertension and diabetes, while coordinating care for an aging population. The National Academies of Sciences concluded that primary care is the only medical specialty of which more practitioners improves longevity, equity and the health of a population. Broad societal solutions are required to remedy such social determinants of health as racism, inadequate housing, food insecurity and the opioid epidemic. However, improving primary care access is the sole responsibility of any effective medical system.
US adults are least likely among developed nations to have regular primary care. The Association of American Medical Colleges projects a shortfall of 55,000 primary care clinicians in 10 years. Physician retirement accelerated from rising administrative burdens and after-hours spent on unwieldy electronic medical records. US surveys report poor work/life balance, stress and burnout among primary care doctors. Fewer doctors, nurse practitioners and physician assistants are electing to enter the field. Most other developed nations dedicate more expenditure on primary care services and work to integrate such services within communities. The US spends a declining 5-8% of total health dollars on primary care, while other nations allocate 14%. Many other nations compensate generalists on par with hospital-based subspecialists, and their primary care clinicians deal with much less administrative burden. Here, career compensation for primary care/pediatrics remains half that earned by “proceduralists.” You get what you pay for:primary care docs constitute 45% of practicing physicians in France and 26% in the UK, versus 12% in the US. Better health outcomes, reduced mortality amenable to medical care and greater longevity are related consequences.
There are many reasons US primary care has become secondary. A “Relative Value Scale Update Committee” (RUC) is convened by the AMA to set specialty reimbursement. The RUC has 32 voting members, of which 27 represent medical specialties, and recommendations of the RUC are implemented by Centers for Medicare and Medicaid Services (CMS.) The AMA is beholden to specialist societies and conflict of interest are rife within RUC. Importantly, health insurers are allowed to negotiate, behind closed-doors, with hospital-multi-specialty practices to set payment for services. The consolidated mega-hospital systems strive to increase “market share” of “covered lives” in their regions, so to command higher payments from insurers in such negotiations. (Higher costs of hospital service do not trouble the insurers - they make profit off a percentage of the premiums they set, so, when hospitals charge more, they just raise premiums to cover the costs, keeping a steady 20% for overhead and profit.) According to the Urban Institute, commercial insurance compensation for specialty services range 10% to 330% higher than Medicare rates, whereas rates for cognitive services via family medicine or psychiatry are barely above the CMS-set rates. Hospitals make the most revenue from elective surgical procedures. Hence, all the ads for knee replacements. The hospital-multi-specialty megaliths view primary care as a “loss leader” and may value primary care accordingly.
“Moral injury” as well as salary issues has impaired American primary care. With the rise of HMOs in 1990s, primary care docs were positioned in a professionally untenable role of “gatekeepers.” Group practices received fixed yearly reimbursement per patient from HMOs, so conflict of interest arose to limit care or procedures. That has abated, but Medicare Accountable Care Organizations are now piloted to be managed by private equity, which will recreate perverse incentives, but this time among patients who aren’t even aware they are enrolled in a Medicare ACO. Healthcare organizations have also misapplied business principles to transform doctors into efficient producers of healthcare “product lines.” Highly trained clinicians with fiduciary advocacy for their patients are morphed into “providers” clicking off check-boxes and diagnostic codes during abbreviated visits with increasingly older and complex patients.
Of interest, the wordprovideris extracted from commerce. It’s first medical usage was in 1965 Medicare legislation, referring to vendors delivering health-related products or services. “Provider’ makes no reference to professionalism. Teachers and lawyers aren’t labeled as knowledge “providers” nor legal expertise providers, and we go to a barber, not a hair-shortening provider. The highly profitable medical-industrial complex aims to transform healthcare from a public good to a commodity. In doing so, doctors became “providers” to support an engagement in a commercial transaction, rather than within a trusted, longterm, therapeutic doctor-patient relationship.
Short of Medicare for All, here’s some options: Congress should legislate that CMS set fees based on advice from transparent public agencies that meet societal needs, rather than needs of over represented specialty groups in the AMA. So recommends the Government Accountability Office. Congress can shut the revolving door of administrators leaving CMS to become health industry lobbyists and back again. Insurance “intermediaries” that market Medicare, Medicaid, employee-sponsored insurance, ACA and other tax-supported “products” must develop uniform forms and policies to lessen burden on practices and patients, and pay for community-integrated primary care teams rather than “providers delivering services.” Un-taxed hospital-megaliths can be mandated to provide robust, equitable, high-quality primary care for the communities they serve. Incentives and tuition-reimbursement should be enhanced for clinicians who wish to enter primary care, especially in rural areas.
Lastly, statehouses can learn about our rampant “pricing failure” in health care and consider emulating Maryland’s all-payer system. This transparent, state-wide negotiation sets uniform payments for hospital services from all types of insurances, such as Medicaid, Medicare and private insurance intermediaries, and involves all hospitals, big or small, urban or rural, profit or non-profit within the state. Via global budgets, it incentivizes improving outcomes within a health system’s community rather than promoting excess revenue for hospitals. According to the Maryland Hospital Association, it has also protected staffing during the pandemic, since global budgets are less subject to wild variations. It also protects those rural hospitals which cannot offer more lucrative specialty programs and serve relatively less-well reimbursed Medicare and Medicaid patients. We can ask our Congressional and state representatives, as well as local hospital board members, to research such actions, and fortify primary care - our health depends on it.
