Private equity is buying up health care, but the real problem is why doctors are selling

Yashaswini Singh & Christopher Whaley

The Hill

Originally published 21 Dec 23

Here is an excerpt:

But amid warnings that private equity is taking over health care and portrayals of financiers as greedy villains, we’re ignoring the reality that no one is coercing individual physicians to sell. Many doctors are eager to hand off their practices, and for not just for the payday. Running a private practice has become increasingly unsustainable, and alternative employment options, such as working for hospitals, are often unappealing. That leaves private equity as an attractive third path.

There are plenty of short-term steps that regulators should take to keep private equity firms in check. But the bigger problem we must address is why so many doctors feel the need to sell. The real solution to private equity in health care is to boost competition and address the pressures physicians are facing.

Consolidation in health care isn’t new. For decades, physician practices have been swallowed up by hospital systems. According to a study by the Physicians Advocacy Institute, nearly 75 percent of physicians now work for a hospital or corporate owner. While hospitals continue to drive consolidation, private equity is ramping up its spending and market share. One recent report found that private equity now owns more than 30 percent of practices in nearly one-third of metropolitan areas.

Years of study suggest that consolidation drives up health care costs without improving quality of care, and our research shows that private equity is no different. To deliver a high return to investors, private equity firms inflate charges and cut costs. One of our studies found that a few years after private equity invested in a practice, charges per patient were 50% higher than before. Practices also experience high turnover of physicians and increased hiring of non-physician staff.

How we got here has more to do with broader problems in health care than with private equity itself.

The info is here.

Here is my summary, which is really a warning:

The article dives into the concerning trend of private equity firms acquiring healthcare practices. It argues that while this might seem concerning, the bigger issue lies in understanding why doctors are willing to sell their practices in the first place.

The author highlights the immense financial burden doctors shoulder while running their own practices. Between rising costs and stagnant insurance reimbursements, it's becoming increasingly difficult for them to stay afloat. This, the article argues, is what's pushing them towards private equity firms, who offer immediate financial relief but often come with their own set of downsides for patients, like higher costs and reduced quality of care.

Therefore, instead of solely focusing on restricting private equity involvement, the article suggests we address the root cause: the financial woes of independent doctors. This could involve solutions like increased Medicare payments, tax breaks for independent practices, and alleviating the administrative burden doctors face. Only then can we ensure a sustainable healthcare system that prioritizes patient well-being.

Examining clinician burnout in health industries

Cynda Hylton Rushton

Danielle Kress
Johns Hopkins Magazine
Originally posted 26 Dec 19


Here is an excerpt from the interview with Cynda Hylton Rushton:

How much is burnout really affecting clinicians?

Among nurses, 35-45% experience some form of burnout, with comparable rates among other providers and higher rates among physicians. It's important to note that burnout has been viewed as an occupational hazard rather than a mental health diagnosis. It is not a few days or even weeks of depletion or exhaustion. It is the cumulative, long-term distress and suffering that is slowly eroding the workforce and leading to significant job dissatisfaction and many leaving their professions. In some instances, serious health concerns and suicide can result.

What about the impact on patients?

Patient care can suffer when clinicians withdraw or are not fully engaged in their work. Moral distress, long hours, negative work environments, or organizational inefficiencies can all impact a clinician's ability to provide what they feel is quality, safe patient care. Likewise, patients are impacted when health care organizations are unable to attract and retain competent and compassionate clinicians.

What does this mean for nurses?

As the largest sector of the health care professions, nurses have the most patient interaction and are at the center of the health care team. Nurses are integral to helping patients to holistically respond to their health conditions, illness, or injury. If nurses are suffering from burnout and moral distress, the whole care team and the patient will experience serious consequences when nurses' capacities to adapt to the organizational and external pressures are eventually exceeded.

The info is here.

Burnout in healthcare: the case for organisational change

A Montgomery, E Panagopoulou, A Esmail,
T Richards, & C Maslach
BMJ 2019; 366
doi: https://doi.org/10.1136/bmj.l4774
(Published 30 July 2019)

Burnout has become a big concern within healthcare. It is a response to prolonged exposure to occupational stressors, and it has serious consequences for healthcare professionals and the organisations in which they work. Burnout is associated with sleep deprivation, medical errors, poor quality of care, and low ratings of patient satisfaction. Yet often initiatives to tackle burnout are focused on individuals rather than taking a systems approach to the problem.

Evidence on the association of burnout with objective indicators of performance (as opposed to self report) is scarce in all occupations, including healthcare. But the few examples of studies using objective indicators of patient safety at a system level confirm the association between burnout and suboptimal care. For example, in a recent study, intensive care units in which staff had high emotional exhaustion had higher patient standardised mortality ratios, even after objective unit characteristics such as workload had been controlled for.

The link between burnout and performance in healthcare is probably underestimated: job performance can still be maintained even when burnt out staff lack mental or physical energy as they adopt “performance protection” strategies to maintain high priority clinical tasks and neglect low priority secondary tasks (such as reassuring patients). Thus, evidence that the system is broken is masked until critical points are reached. Measuring and assessing burnout within a system could act as a signal to stimulate intervention before it erodes quality of care and results in harm to patients.

Burnout does not just affect patient safety. Failing to deal with burnout results in higher staff turnover, lost revenue associated with decreased productivity, financial risk, and threats to the organisation’s long term viability because of the effects of burnout on quality of care, patient satisfaction, and safety. Given that roughly 10% of the active EU workforce is engaged in the health sector in its widest sense, the direct and indirect costs of burnout could be substantial.

The info is here.

A Missed Opportunity for the Malpractice System to Improve Health Care

Aaron Carroll
The New York Times
Originally posted May 27, 2019

Here are two excerpts:

First, the good news: These doctors quit at higher rates than other physicians. And they also tend not to pick up and move somewhere else to start fresh (which many thought they’d do given that licenses and malpractice are regulated at the state level).

But the overwhelming majority of doctors who had five or more paid claims kept on going. And they also moved to solo practice and small groups more often, where there’s even less oversight, so those problematic doctors may produce even worse outcomes.

We have long known that some doctors are likelier than others to be sued. Those who practice in certain higher-risk specialties — like surgery, obstetrics and gynecology, and emergency medicine — are more likely to be sued than those in lower-risk specialties like family medicine, pediatrics and psychiatry. Men are more likely to be sued than women. Lawsuits seem to peak when doctors are around 40.

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Those who accumulated more claims were more likely to stop practicing medicine. Even though they were more likely to retire, more than 90 percent of doctors who had at least five claims were still in practice.

Physicians with more claims were also not any more likely than those with fewer or no complaints to move to another state and continue practicing. This is actually one of the reasons the practitioner data bank was created — to prevent doctors from running away from their history by moving between states. In that respect, it appears to be working.

What’s worrisome, though, is that physicians with more claims shifted their type of practice. Those with five or more claims had more than twice the odds of moving into solo practice.

The info is here.

Psychological health profiles of Canadian psychotherapists: A wake up call on psychotherapists’ mental health

Laverdière, O., Kealy, D., Ogrodniczuk, J. S., & Morin, A. J. S.
(2018) Canadian Psychology/Psychologie canadienne, 59(4), 315-322.
http://dx.doi.org/10.1037/cap0000159

Abstract

The mental health of psychotherapists represents a key determinant of their ability to deliver optimal psychological services. However, this important topic is seldom the focus of empirical investigations. The objectives of the current study were twofold. First, the study aimed to assess subjective ratings of mental health in a broad sample of Canadian psychotherapists. Second, this study aimed to identify profiles of psychotherapists according to their scores on a series of mental health indicators. A total of 240 psychotherapists participated in the survey. Results indicated that 20% of psychotherapists were emotionally exhausted and 10% were in a state of significant psychological distress. Latent profile analyses revealed 4 profiles of psychotherapists that differed on their level of mental health: highly symptomatic (12%), at risk (35%), well adapted (40%), and high functioning (12%). Characteristics of the profiles are discussed, as well as potential implications of our findings for practice, trainee selection, and future research on psychotherapists’ mental health.

Here is part of the Discussion:

Considering that 12% of the psychotherapists were highly symptomatic and that an additional 35% could be considered at risk for significant mental health problems, the present findings raise troubling questions. Were these psychotherapists adequately prepared to help clients? From the perspective of attachment theory, the psychotherapist functions as an attachment figure for the client (Mallinckrodt, 2010); clients require their psychotherapists to provide a secure attachment base that allows for the exploration of negative thoughts and feelings, as well as for the alleviation of distress (Slade, 2016). A psychotherapist who is preoccupied with his or her own personal distress may find it very difficult to play this role efficiently and may at least implicitly bring some maladaptive features to the clinical encounter, thus depriving the client of the possibility of experiencing a secure attachment in the context of the therapeutic relationship. Moreover, regardless of the potential attachment implications, clients prefer experiencing a secure relationship with an emotionally responsive psychotherapist (Swift & Callahan, 2010). More precisely, Swift and Callahan (2010) found that clients were, to some extent, willing to forego empirically supported interventions in favour of a satisfactory relationship with the therapist, empathy from the therapist, and greater level of therapist experience. The present results cast a reasonable doubt on the ability of extenuated psychotherapists, and more so psychologically ill therapists, to present themselves in a positive light to the client in order to build strong therapeutic relationships with them.

Health care, disease care, or killing care?

Hugo Caicedo
Harvard Blogs
Originally published October 1, 2018

Traditional medical practice is rooted in advanced knowledge of diseases, their most appropriate treatment, and adequate proficiency in its applied practice. Notably, today, medical treatment does not typically occur until disease symptoms have manifested. While we now have ways to develop therapies that can halt the progression of some symptomatic diseases, symptomatic solutions are not meant to serve as a cure of disease but palliative treatment of late-stage chronic diseases.

The reactive approach in most medical interventions is magnified in that medicine is prone to errors. In November of 1999, the U.S. National Academy of Science, an organization representing the most highly regarded scientists and physician researchers in the U.S., published the report To Err is Human.

The manuscript noted that medical error was a leading cause of patient deaths killing up to 98,000 people in the U.S. every year. One hypothesis that came up was that patient data was being poorly collected, aggregated, and shared among different hospitals and even within the same health system. Health policies such the Health Information Technology for Economic and Clinical Health Act (HITECH) in 2009 and the Affordable Care Act (ACA) in 2010, primarily focused on optimizing clinical and operational effectiveness through the use of health information technology and expansion of government insurance programs, respectively. However, they did not effectively address the issue of medical errors such as poor judgment, mistaken diagnoses, inadequately coordinated care, and incompetent skill that can directly result in patient harm and death.

The blog post is here.

Letter from the American Medical Association to McConnell and Schumer

James Madera
Letter from the American Medical Association
Sent June 26, 2017

To: Senators McConnell and Schumer

On behalf of the physician and medical student members of the American Medical Association
(AMA), I am writing to express our opposition to the discussion draft of the “Better Care
Reconciliation Act” released on June 22, 2017. Medicine has long operated under the precept of
Primum non nocere, or “first, do no harm.” The draft legislation violates that standard on many
levels.

In our January 3, 2017 letter to you, and in subsequent communications, we have consistently
urged that the Senate, in developing proposals to replace portions of the current law, pay special
attention to ensure that individuals currently covered do not lose access to affordable, quality
health insurance coverage. In addition, we have advocated for the sufficient funding of Medicaid
and other safety net programs and urged steps to promote stability in the individual market.
Though we await additional analysis of the proposal, it seems highly likely that a combination of
smaller subsidies resulting from lower benchmarks and the increased likelihood of waivers of
important protections such as required benefits, actuarial value standards, and out of pocket
spending limits will expose low and middle income patients to higher costs and greater difficulty
in affording care.

The AMA is particularly concerned with proposals to convert the Medicaid program into a
system that limits the federal obligation to care for needy patients to a predetermined formula
based on per-capita-caps.

The entire letter is here.

Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes

Hannawa, A. F., Shigemoto, Y., & Little, T. (2016).
Social Science & Medicine, 156, 29-38.

Abstract

Rationale

This study investigates the intrapersonal and interpersonal factors and processes that are associated with patient forgiveness of a provider in the aftermath of a harmful medical error.

Objective

This study aims to examine what antecedents are most predictive of patient forgiveness and non-forgiveness, and the extent to which social-cognitive factors (i.e., fault attributions, empathy, rumination) influence the forgiveness process. Furthermore, the study evaluates the role of different disclosure styles in two different forgiveness models, and measures their respective causal outcomes.

Methods

In January 2011, 318 outpatients at Wake Forest Baptist Medical Center in the United States were randomly assigned to three hypothetical error disclosure vignettes that operationalized verbally effective disclosures with different nonverbal disclosure styles (i.e., high nonverbal involvement, low nonverbal involvement, written disclosure vignette without nonverbal information). All patients responded to the same forgiveness-related self-report measures after having been exposed to one of the vignettes.

Results

The results favored the proximity model of interpersonal forgiveness, which implies that factors more proximal in time to the act of forgiving (i.e., patient rumination and empathy for the offender) are more predictive of forgiveness and non-forgiveness than less proximal factors (e.g., relationship variables and offense-related factors such as the presence or absence of an apology). Patients' fault attributions had no effect on their forgiveness across conditions. The results evidenced sizeable effects of physician nonverbal involvement-patients in the low nonverbal involvement condition perceived the error as more severe, experienced the physician's apology as less sincere, were more likely to blame the physician, felt less empathy, ruminated more about the error, were less likely to forgive and more likely to avoid the physician, reported less closeness, trust, and satisfaction but higher distress, were more likely to change doctors, less compliant, and more likely to seek legal advice.

Conclusion

The findings of this study imply that physician nonverbal involvement during error disclosures stimulates a healing mechanism for patients and the physician-patient relationship. Physicians who disclose a medical error in a nonverbally uninvolved way, on the other hand, carry a higher malpractice risk and are less likely to promote healthy, reconciliatory outcomes.

The article is here.

Things are looking app

The Economist
Originally posted March 12, 2016

Here is an excerpt:

Constant, wireless-linked monitoring may spare patients much suffering, by spotting incipient signs of their condition deteriorating. It may also spare health providers and insurers many expensive hospital admissions. When Britain’s National Health Service tested the cost-effectiveness of remote support for patients with chronic obstructive pulmonary disease, it found that an electronic tablet paired with sensors measuring vital signs could result in better care and enormous savings, by enabling early intervention. Some m-health products may prove so effective that doctors begin to provide them on prescription.

So far, big drugmakers have been slow to join the m-health revolution, though there are some exceptions. HemMobile by Pfizer, and Beat Bleeds by Baxter, help patients to manage haemophilia. Bayer, the maker of Clarityn, an antihistamine drug, has a popular pollen-forecasting app. GSK, a drug firm with various asthma treatments, offers sufferers the MyAsthma app, to help them manage their condition.

The article is here.

UK end-of-life care 'best in world'

By Nick Triggle
BBC News
Originally posted October 6, 2015

End-of-life care in the UK has been ranked as the best in the world with a study praising the quality and availability of services.

The study of 80 countries said thanks to the NHS and hospice movement the care provided was "second to none".

Rich nations tended to perform the best - with Australia and New Zealand ranked second and third respectively.

But the report by the Economist Intelligence Unit praised progress made in some of the poorest countries.

The article and the rankings are here.

Impact of Burnout: Clinicians Speak Out

Deborah Brauser
Medscape
Originally posted February 10, 2015

Professional burnout has serious negative consequences not only for affected clinicians but potentially for patient care and outcomes as well, new research suggests.

(cut)

In addition, those who reported higher levels of depersonalization were significantly more likely to report that burnout affected their interaction with patients.

Interestingly, emotionally exhausted clinicians were significantly less likely to report an impact on patient outcomes.

The entire article is here.

Burnout Rates Soar Among Family Physicians

By Diana Philips
Medscape
Originally published January 28, 2015

Nearly half of family physicians younger than 35 years feel burned out, according to a new survey conducted by Medscape. In the 2015 Family Physician Lifestyle report, which updates a previous report on physician lifestyle and burnout, 43% of family physicians in this age group responded that they had burnout, defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. This is a substantial increase over the rates documented in the 2013 report, in which fewer than 10% of the youngest family physicians said they felt burned out.

The entire article is here.

Mental health workers don't recognise their own burnout

British Psychological Society
Press Release
Originally published January 9, 2015

Some mental health workers find it difficult to recognise their own burnout and even when they do they struggle to admit it to others says a study presented today at the British Psychological Society Division of Occupational Psychology annual conference in Glasgow.

The study was undertaken by PhD student Ms Marieke Ledingham and colleagues Associate Professor Peter Standen (Edith Cowan University, Australia) and Associate Professor Chris Skinner (University of Notre Dame, Australia).

Ms Ledingham explained: “Burnout has long been a problem in mental health workplaces and remains so despite much research and considerable knowledge of it amongst professional employees. Despite working in this sector employees struggle to avoid burnout and we wanted to study how work places could improve support.”

The entire pressor is here.

New test measures doctors' ability to deliver patient-centered care

University of Missouri-Columbia
News Release
Originally released December 29, 2014

When health care providers take patients' perspectives into consideration, patients are more likely to be actively engaged in their treatment and more satisfied with their care. This is called patient-centered care, and it has been the central focus of the curriculum at the University of Missouri School of Medicine since 2005. Recently, MU researchers have developed a credible tool to assess whether medical students have learned and are applying specific behaviors that characterize patient-centered care.

The researchers first worked with real patients to identify a list of specific behaviors that demonstrated physicians were providing patient-centered care. By defining these detailed, specific patient-centered behaviors, the researchers have been able to tailor the educational experience at the MU School of Medicine to help students gain these skills.

MU medical students now are assessed on their ability to deliver the care in ways the patients expect; students must perform at a satisfactory level on the patient-centered care exam to graduate from the MU School of Medicine.

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From this authentic assessment, researchers learned students were picking up on many key factors in patient-centered care. Most MU medical students had strong, effective communication skills, didn't use medical jargon, actively listened to the patient, showed empathy and were in charge of the situation when they needed to lead a critical conversation.

The entire press release is here.

Episode 14: Ethics and Quality Enhancement Strategies

In Episode 14, John welcomes Dr. Sam Knapp back to the podcast.  Sam was fresh off his Lifetime Achievement Award in Ethics Education from the American Psychological Association.  After John's first attempt at listener mail, the topic moves toward ethics education and ways to contemplate positive ethics.  Rather than looking at remedial ethics or the ethical floor, John and Sam give examples about striving for the ethical ceiling.  The focus on quality enhancement strategies grew out of risk management strategies.  From a quality enhancement perspective, Sam and John give several examples of what may trigger the need for quality enhancement strategies.  They also review four quality enhancement strategies: 1) consultation, 2) empowered collaboration, 3) documentation, and 4) redundant protections.  Sam and John also talk about psychologists' emotional reactions to patients.

At the end of this podcast, the listener will be able to:

1. Outline three quality enhancement strategies,
2. Describe how to prepare for a helpful consultation, and,
3. List the reasons why redundant protections are helpful in clinical practice.

Click here to earn one APA-approved CE credit

Find this podcast on iTunes

Or listen directly below

Resources for this podcast

Ethical Issues With Patients at a High Risk for Treatment Failure 

Samuel J. Knapp and John Gavazzi

Can Checklists Help to Reduce Treatment Failure?

Sam Knapp and John Gavazzi

Quality Enhancement Strategies - PowerPoint

John Gavazzi, PsyD ABPP

Episode 8: The Dark Side of Ethics - False Risk Management Strategies 

Therapists' Anger, Hate, Fear, and Sexual Feelings: National Survey of Therapist Responses, Client Characteristics, Critical Events, Formal Complaints, and Training

Ken Pope and Barbara G. Tabachnick

Medicare considers funding end-of-life talks

By Pam Belluck
The New York Times
Originally published August 31, 2014

Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year.

Bypassing the political process, private insurers have begun reimbursing doctors for these “advance care planning” conversations as interest in them rises along with the number of aging Americans.

The entire article is here.

Editorial note: Politics will continue to affect health care delivery in the United States.  It is critical that healthcare providers cite foundational ethical principles when advocating for changes in our healthcare system, and not become immersed in sloganeering or bumper sticker politics to support one political party or the other.  High quality health care and informed patient choice are paramount.

Second VA doctor blows whistle on patient-care failures

By Dennis Wagner
The Republic
Originally published May 2, 2014

Here is an excerpt:

Both physicians, as well as other VA employees who asked not to be named for fear of retribution, said the Phoenix VA leadership disdains internal criticism and retaliates against those who speak out. In interviews and a written statement, Mitchell told The Republic she can no longer remain silent.

"I am violating the VA 'gag' order for ethical reasons," she wrote. "I am cognizant of the consequences. As a VA employee I have seen what happens to employees who speak up for patient safety and welfare within the system. The devastation of professional careers is usually the end result, and likely is the only transparent process that actually exists within the Phoenix VA Medical Center today."

The entire story is here.

15-Minute Visits Take A Toll On The Doctor-Patient Relationship

By Roni Caryn Rabin
Kaiser Health News
Originally published April 21, 2014

Here is an excerpt:

“Doctors have one eye on the patient and one eye on the clock,” said David J. Rothman, who studies the history of medicine at Columbia University’s College of Physicians and Surgeons.

By all accounts, short visits take a toll on the doctor-patient relationship, which is considered a key ingredient of good care, and may represent a missed opportunity for getting patients more actively involved in their own health. There is less of a dialogue between patient and doctor, studies show, increasing the odds patients will leave the office frustrated.

The entire story is here.

In Health Care, Choice Is Overrated

By Ezekiel J. Emanuel
The New York Times
Originally posted March 5, 2014

Here is an excerpt:

Second, we need more transparency. Insurance companies should have to publish the measures they use to select their “high performing” or “efficient” networks. This will discourage them from looking at price alone. And consumers should be able to easily find which doctors and hospitals are included in a network. The size of a plan’s network should be as transparent as its premium.

Third, we need more reliable ways of measuring the quality of networks and the doctors and hospitals within them. The N.C.Q.A. or Consumer Reports could develop a grading system, from A to F. When comparing different plans, no one should have to rely on U.S. News and World Report’s flawed rankings or hearsay from acquaintances.

The entire story is here.

Podcast: A Conversation about Positive Ethics

In this podcast, John Gavazzi and Sam Knapp talk positive ethics.  What is different about positive ethics as compared to presentations on ethics?  We focus on how psychologists can anchor their professional conduct and decision making on overarching and foundational ethical principles. By focusing on the moral foundations of behavior, psychologists can upgrade their quality of patient care and decision making.

At the end of the podcast, the listener will be able to:

1. Describe positive ethics
2. Explain the concept of a culture of safety
3. Identity one way to apply positive ethics to daily practice

Positive Ethics by Ethics_And_Psychology on Mixcloud

For further reading:

Sam Knapp and Leon VandeCreek: Practical Ethics for Psychologists: A Positive Approach

Click here to earn CE credits for this podcast

Listener feedback can be sent to John Gavazzi