Thursday, May 11, 2023

Private equity, private profit, Medicare and your health: They are incompatible

When recently scheduling a procedure with a physician, he just shook his head and told me how lucky I was to have retired, and how difficult the practice of medicine is now. Before the outpatient procedure, he had wanted me to get a consultation from a physician in another specialty, but it turned out that that group no longer saw outpatients but only did hospital consultations because they no longer had the capacity. From his perspective, the problem is lack of people, especially doctors and nurses.

 But there are other big reasons, which I have discussed in previous blog posts. There are different aspects to them, but they essentially boil down to the transformation of American healthcare into another profit-driven industry. My doctor, and the doctors he wanted to consult, and the nurses and other staff with whom they work, are all interested in providing high-quality and effective care to people. The corporations for which they work (or are forced to work with, such as hospitals) are interested in making money.

This transformation, like most, is incomplete, but it seems to have passed an inflection point from which, if something major is not done, there is no turning back. The changes have been in process for a long time, documented in books such as the Health Policy Advisory Center (HealthPAC)’s 1971 “The American Health Empire” (Barbara Ehrenreich and others), and Paul Starr’s “The Social Transformation of American Medicine” published in 1982. They document the change from a cottage industry of independent doctors to one dominated by large institutional players. In the 1980s, Physicians for a National Health Program (PHNP) was created with the goal of, if not reversing this trend, at least harnessing the system to serve all of our people through the creation of a centrally-financed single-payer health insurance system. While every other wealthy (and many non-wealthy) countries in the world have such coverage, the US is the outlier. PNHP has advocated for decades for a coverage system more like that of Canada, where provincially-run financing plans cover everyone under a set of rules set by the federal government.

At that time, and today, a huge part of the problem was, and is health insurance companies. They are the obvious predators, drawing profit from ‘managing’, which often means restricting, your access to health care. Insurance in general makes money when it takes in more than it pays out, and as customers we “win” when we lose. That is, we collect when we have a car accident, or our house catches fire, or we die. We bet against ourselves, and hope we will not need the insurance. But health care is different, because we want to receive it. To be paid by insurance may have made sense in the early days, when it covered the hopefully-unneeded hospitalization or surgery (“major medical”, it was called) and we paid doctors out of our pockets or in chickens. But it makes no sense for routine and necessary health care.

The other big abuser back then was pharmaceutical companies, which made even more than insurance companies, marking up prices to whatever the market would bear, no matter how many people were left out and could not afford them. Sadly, the news is not that the character, behavior or profit taking by insurance or pharmaceutical companies has improved; now they are both even worse! What is sad, and terrible, is that the actual health care providers have become more predatory, and more often owned and controlled by companies whose primary business is making money, and only incidentally providing health care. I have written about this sort of abuse by hospitals and corporate-controlled physician groups, and it has just scratched the surface.

Recently, the Kaiser Family Foundation Health News reported on ‘Sick Profit: Investigating Private Equity’s Stealthy Takeover of Health Care Across Cities and Specialties’, exposing once again the way in which for-profit companies, and increasingly private equity, have bought up healthcare practices and limited access or worse in the name of making money. The article leads with the story of a 2-year old child in Yuma, AZ who died of complications of anesthesia while receiving extensive dental work that, his parents say in a lawsuit, was unnecessary (it almost certain was). They charge that the dentists were pressured by the private equity firm that owns the practice to do the maximum number of procedures on children with Medicaid to maximize revenue and profit. But that is just the lede; the article documents the increasing frequency of practices owned by for-profit companies abusing and sometimes killing people, either by over or under treatment. Which one depends on which will make the most money, not on whether folks need medical care or not.

Killing children in pursuit of profit is something most of us would frown upon, but while all practices owned by private equity or other profit-making entities may not behave so badly, it would be a mistake to call those that do “bad actors” and excuse the others. It is the entire concept that YOUR health should be a source of profit, and be attractive to the venture capitalists investing in these practices because they can make so much money. The money, whether paid by you directly, or indirectly through your insurance premiums, or by the government through your taxes, should be going toward your healthcare, not their private jets.

This practice complements the impending takeover of Medicare by for-profit Medicare “Advantage"”plans, and private-equity controlled ACO/REACH plans, just recently reported on in the New York Times, “Corporate Giants Buy Up Primary Care Practices at Rapid Pace”. The article begins by noting the shortage of primary care doctors, and that it is getting worse (also something I have written about often) because they get little respect and less money (than other specialists). It would be nice to think that this evidence of the impact of family doctors and other primary care clinicians on patients was a sign of respect, but it is just a sign of greed, especially through the programs that privatize your Medicare. This represents a huge potential profit center for these companies. “That’s the big pot of money everyone is aiming at.” Yup. It’s $400 billion!

This is why most of us who are paying attention agree that we now need to go much farther than simply national universal health insurance. While that is important and good, it could end up being another vehicle for profit-taking; remember the Yuma dentists were ripping off Medicaid, a government funded program. Thus, only a truly non-profit (unlike the ostensibly “not-for-profit” hospital sector than emulates for-profit competitors to maximize revenue) is acceptable. Steffi Woolhandler and David Himmelstein, founders of PNHP, call for such a national health service in a recent interview in Jacobin, and it makes sense.

The justification cited by these companies for their rapacity is that they increase efficiency. This is of course, BS. Efficiency in generation of more money for them, perhaps, by cutting back the number of doctors, nurses, and other staff, overworking those who remain, and making them all, along with their patients, miserable. That is not efficiency in production of healthcare, and is certainly not efficacy.

Doctors and nurses are being “sped up” as if they were on an assembly line, and are burning out and leaving in droves. The people who are the “products” are getting 7 minute visits, don’t have time to even talk about their problems not to mention get adequately treated. It is bad for everyone but those few earning the profit.

The Times article says “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.” Yup. That’s what they say. Not to put too fine a point on it, it is a self-serving lie.

We need one system, well-funded, to handle all of our needs, generously paid for without a cent going to private profit.

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