As private equity (PE) plays a larger role in health care, we likely have a patient-centric image of who these individuals are and what these institutions do. But what does health care look like to PE, and what does health care do from their perch? While attending a housewarming party of an acquaintance who works in PE and specializes in GI clinic acquisitions, these questions were answered, and it was not what I was expecting. It was worse and degrading. Something must be done about it.
After the usual small talk that accompanies a housewarming party of a friend’s friend, I circled around to the snack table with my non-finance companion, Samantha (name changed). While we enjoyed the charcuterie plate, we struck up a conversation with another woman, Kristina. She lives in a resort city where I once worked. We spoke some, and it came up that I am an NP. The usual questions were asked of me: “Why aren’t you a doctor? How much longer until you are a doctor? What can’t you do that a doctor can?” and “Do you make as much money as a doctor?” I gave the usual answers; the most important for this post was why I chose to pursue an NP instead of an MD/DO despite less compensation.
“I chose NP because I love caring for people, and becoming an RN was the fastest way to provide patient care. The freedom of the step-wise approach to schooling in pursuit of an NP was much easier for me to fathom. I also found it difficult to handle the stress of not having enough residency spots for all graduates and the threat of matching into a specialty I did not want. The NP route avoided those, along with other stressors. I just wanted to see patients as soon and safely as possible.”
“You should have been a doctor,” Kristina said bluntly. “Because you shouldn’t be doing the same work as a doctor for less money.”
Kristina’s arrogance made me want to laugh, but I held it in because she was absolutely serious.
“I agree the pay could be more for NPs, but I am not a physician, so why would I demand their income?”
She did not seem to understand. Humility was seemingly a language she had yet to learn. I explained that NPs are in this role because there are not enough providers to care for the population, and because of that, it is not simply about money; it is about the greater good, and something has to be done about it. I also explained that physicians and other providers are being squeezed financially because of reimbursement rates, private equity, malpractice rates, and other expenses and that being a doctor is not as lucrative or as easy as people assume. Lastly, I emphasized that she is viewing it backward and that NPs are likely bringing down the value of some physician specialties.
“You know Dr. Cook, right?” said a new entrant to the conversation. She was the wife of a gentleman who works on the deal team for a PE firm that specializes in “value-based” medicine, outpatient care, and behavioral health. “Dr. Cook is buying a surgical practice, and she will be making a million dollars a year from it. She just graduated. You should have done that.”
“That is what she says,” I replied, not telling them that Dr. Cook offered me a job. “But keep in mind that, as the owner, she will be overseeing several surgeons and over a dozen other providers, including PAs and NPs. She may not get to practice medicine as she wants to in such a role. If there is a million dollars waiting for her, she will definitely be working for it and may not be able to do as much patient care as she wishes.”
“Could you ever make a million dollars as an NP?” asked this stranger.
“For me, it is not about money. I make enough. I chose this route to care for my patients, get to know them, and optimize their treatment plan.”
With that, I might as well have insulted everything these individuals believed in. They gawked at me with as much astonishment as I looked at them. What was going through their heads, I am afraid to acknowledge. What was going through me was wondering how their view would change if they were patients and their caretakers and providers were as money-hungry as they wished me to be.
“Health care-focused PE firms need people that understand the business like you do, and you could make a lot of money. Remember that when you decide you want to make money,” said Kristina to conclude our 30-minute conversation.
They both left. I remained with Samantha, who listened to the whole thing. She was pale.
“Was it just me, or did they neglect to inquire about or seem to have knowledge about patient outcomes, the difficulties that the industry is enduring, the burnout rates, severe provider shortages in hundreds of communities, and even medicine itself?”
Samantha shook her head.
While many Americans resist representative oversight of health care, these are the people who are running it. These individuals gave me the impression that they are unabashedly after money and only see health care not as a red cross or crescent but as a dollar sign. They hide in their pretty houses and resort towns, a far cry from the patients who are falling through the cracks, going bankrupt due to outrageous bills, and for whom the term ‘underserved’ is a personal problem they experience at restaurants. They gave me the impression that they do not have concerns about provider burnout, skyrocketing costs of supplies, malpractice insurance premiums, or other issues facing us, not because they do not care but because they seemingly do not even know about these issues. It does not affect their balance sheet.
Kristina is not alone; I am associated with several people in PE, and she acts and speaks like the rest of them. I live in a community composed of many financial leaders. I hear them at the coffee shop, the park, the train, walking down the street. Everywhere. I hear the conference calls they have on speakerphone about how to squeeze more profit out of Medicare Advantage plans and the strategies they use to increase their edge when buying out physician practices, no matter the deleterious effects on the practice itself or how it will hurt health care.
This conversation left me feeling as I fear many in PE view health care workers: suckers. Suckers for allowing money to flow past us in the name of the public good and a higher calling. We are like a different species. Yet they are the ones that are increasingly making the rules and policy. They are not some obscure fictional character. They work daily as we work for our patients, but instead of working for the greater good, they work to get more money out of the system and make it as impersonal as an algorithm that manages airline tickets. They cannot understand what it means to be a healer, and they should be banned from owning any company that offers health care as a service unless there is drastically increased transparency in their dealings.
PE owning health care services is not the disease but rather the symptom of health care being viewed as a commodity and market item, that being the disease. As providers, we cannot necessarily change that, but we can push for greater transparency and for deceptive practices of PE and other industries that view health care as a cash-generating machine to be publicized and more closely examined by the public and governmental agencies. There have been several positive changes in the past years, and as providers, we should educate our patients about these: why they will not be getting surprise bills anymore, that they can request reasonable estimates for care, that Medicaid may be an option for many; and services like GoodRx or Mark Cuban’s pharmacy. PE is not going to stop lying, scheming, and plotting to maximize their income by any means possible. We are among the few people who can stop them and protect our patients by teaching them about this, what has been done to protect them, and what needs to be done so the system does not break even more.
Joseph Lanctot is a nurse practitioner.
