Private Equity and Healthcare Don’t Mix
In a recent news article, “The emergency in emergency medicine,” two ER docs, Eric Snoey and Mark Morocco, lament the current state of hospital emergency rooms, which are overflowing, causing new patients, even some arriving by ambulance, to be seen, examined and treated in the lobby. While there are multiple factors contributing to this sad state of affairs, the authors, both seasoned physicians who train new ER docs, focus on “a collapsing system of rehab, skilled nursing or home health options” which cause “a third or more of the patients in a hospital to be on hold pending an appropriate discharge destination.” With ward beds thus full, no new patients can be admitted.(1)
What is causing the collapse of these “discharge destinations?” I believe one answer can be found in another recent news article, “Private equity snapping up disability services,” by Anna Claire Vollers, which describes how private equity firms have been acquiring group homes, skilled nursing facilities, and home health care agencies, consolidating them and selling off assets, as well as cutting staff. There have been more than 1,000 such acquisitions from 2013 – 2023.(2)
Vollers points out that nearly all of the revenue from these facilities comes from Medicaid and Medicare. In a nutshell, the private equity firms are taking money from the government, and turning it into profit for their shareholders.Who loses in this transfer of wealth? The disabled, sick and elderly patients in these facilities – as well as the ones who are waiting in the hospitals, and the rest of us who have to settle for “lobby medicine.”
Over the last decade, private equity firms have been buying up medical practices and hospital chains as well, with the same goal of turning a quick profit for their investors by taking Medicaid and Medicare funds, and selling off assets like real estate. Not only is this bad news for both patients and staff of these facilities, it has also led to the bankruptcies of two formerly private equity-backed hospital chains, whose failures caused medical facilities nationwide to close.(3)
This is the true emergency in our healthcare system, yet many people seem to be completely unaware. Everyone complains when we read about banks, oil companies, or local utilities “putting profits before people,” because common sense and our moral compass tell us this is wrong. But the takeover of our healthcare system by private equity funds, whose mission is to maximize profits for their investors, seems to me to be completely incompatible with the goals of healthcare, starting with the Hippocratic oath, to “first do no harm.”
The American Medical Association voted last year to support state-level bans on “corporate medicine.” A study published in the Journal of the American Medical Association (JAMA) in March 2024 (4) found that over 60% of surveyed physicians held a negative view of private equity involvment in healthcare, with only 10% holding a positive view. The areas viewed most negatively were physician well-being, healthcare costs, and health equity.
Even the private equity sector itself has begun to question whether healthcare represents a good investment, especially in light of recent scrutiny by the Federal Trade Commission. A article published in 2024 on an industry news site reported that FTC chair Lina Khan expressed concern about “extractive” PE practices such as “flip and strip” ownership, and strategies that serve to consolidate power and undermine competition. The article poses the question, “is the growth of private equity investment in US healthcare perpetuating health inequity?”(5)
In this article, there are various points of view offered, as well as an historical perspective and some interesting charts. One data point that jumped out at me: 25% of emergency departments in the US are staffed by PE-backed contract management groups. That made me go back and take a look at where the authors of that first article work (one is at Highland, a county hospital in Oakland, and the other at UCLA’s Medical Center).
To quote Lina Khan again, from the same article, there is increasing concern “that growing financialization in the healthcare industry can force medical professionals to subordinate their medical judgment to corporate decision-makers’ profit motives at the expense of patient health.”
On the other hand, according to this article, there are private equity firms that have built mutually beneficial partnerships with healthcare systems and physicians over several decades, funding better healthcare delivery through new technologies, improving efficiency, and allowing hospitals and medical clinics to expand their services in rural areas. (Healthcare innovation and patient access to healthcare were noted as positives in the JAMA survey.)
The US healthcare system hasn’t been functioning efficiently or effectively for many years, so I can see where PE investment may have been welcomed, and may have benefitted patients as well as their providers in some instances. And like in every industry, there are good guys and bad guys. But there’s simply no denying the incompatible goals of PE funds and good patient care.
What can we, as healthcare consumers, do here? First, we can inquire or investigate to find out who owns the medical practices, hospitals, or other healthcare organizations we use. When we have a choice, we can elect to receive our healthcare from non-PE owned establishments. Second, we can urge our Senators and Congressional representatives, at both the federal and state level, to support legislation that at least seeks to curb or monitor PE investment in our healthcare, if not block it altogether.
Oregon lawmakers recently approved a bill that will block private equity firms from establishing a controlling interest in medical practices. The legislation “is based on a simple principle: that medical decisions should be made by medical professionals” and not financial investors (3). Four states, Massachusetts, New Mexico, Indiana and Washington, have passed laws strengthening state oversight of corporate medical takeovers, with other states considering such measures. But here in California, our Governor vetoed a similar bill last year. (6)
Notes:
4. Zhu JM, Zeveney A, Read S, Crowley R. Physician Perspectives on Private Equity Investment in Health Care. JAMA Intern Med. 2024;184(5):579–580. doi:10.1001/jamainternmed.2024.0062 Link
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Empathy in the Crosshairs
The #1 Bestselling non-fiction paperback for the last few weeks was On Tyranny by Timothy Snyder. In second place was Bessel van der Kolk’s classic book on trauma, The Body Keeps the Score. What does that tell you? It tells me that Americans want to know how to stand up to authoritarianism, and at the same time, are feeling traumatized.
No surprise, given what the principal architect of Project 2025 said, after he was given the keys and passwords to the federal Office of Personnel Management (which is like the fox guarding the henhouse, but amplified 100,000 times): “we want the bureaucrats to be traumatically affected.” How’s that for inspiring leadership?
This week, the new head of the Department of Health & Human Services cut 10,000 jobs and eliminated dozens of programs, including safety net stalwarts Head Start and Meals on Wheels, as well as HIV prevention, Alzheimer’s research, and the Suicide Crisis Hotline. Many of those who lost their jobs found out when they tried to badge in and couldn’t.
Then there’s the man in black who appears to be in charge – you know, the chainsaw-brandishing guy who claims Social Security is a Ponzi scheme – and who has said “empathy is the fundamental weakness of Western civilization.” Our government has been taken over by a band of sociopaths! And I mean that in the most accurate clinical sense.
As a mental health expert, I know how dangerous it is to have sociopaths in charge. With empathy in the crosshairs, the most vulnerable members of our society – children, the elderly, people with disabilities and special needs – are the first to lose essential services. Next are all of the hard-working, dedicated public servants, from national park rangers to school nurses. All of us who are compassionate and have built our lives around being helpers are now regarded as weak, irrational, and out of touch with reality.
Earlier this week I heard a discussion on the radio about empathy, and realized that some people don’t actually know what it is. At least they’re using the word incorrectly, equating it with “getting all emotional,” and making decisions based on emotions rather than logic, as in “people with empathy want to open the borders to everyone without limits.” This is not true, in fact, being empathetic better informs sound and rational decision-making.
Fundamentally, empathy is being able to put yourself in someone else’s shoes, to sense or imagine what their life is like, and to see things from their perspective. Dictionary.com gives this definition: “the psychological identification with or vicarious experiencing of the emotions, thoughts, or attitudes of another,” and offers this sentence: Having faced many of the same challenges, Nyala has empathy for immigrants and what it feels like to go through those challenges.
Some people confuse empathy with sympathy, but here’s the key difference: having empathy for others means feeling their pain, while having sympathy means feeling sorry for them. With empathy, you’re on equal footing, whereas sympathy is looking down on others.
Going back to my statement representing the current administration as “a band of sociopaths,” I’d like to clarify that I’m not just name-calling people whose actions I disagree with, and explain why I believe it’s an accurate description.
Let’s start with what Dictionary.com says. It defines “sociopath” as “a person with a psychopathic personality whose behavior is antisocial, often criminal, and who lacks a sense of moral responsibility or social conscience.” One of the example sentences it offers is: After he dropped out of the race in August, Kennedy endorsed Trump, a man he had previously labeled a likely “sociopath.” (Talk about the pot calling the kettle black! Or as my sister would say, takes one to know one!)
Let’s unpack that definition a bit. First, what is a “psychopathic personality”? And what’s the difference between a psychopath and a sociopath, which many people use interchangeably to describe several members of the administration?
Turning to the DSM-5, the Diagnostic and Statistical Manual of Mental Disorders, used by mental health professionals everywhere, it may surprise you to know there is no “psychopathic personality disorder,” nor “sociopathic personality disorder.” What we find instead is that psychopathy and sociopathy are mentioned multiple times in the descriptions of both “antisocial personality disorder” and “narcissistic personality disorder.”
For example: “The essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others,” (p 659), while “The essential feature of a narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy” (p 670). We read that “Lack of empathy, inflated self-appraisal, and superficial charm are features that have been commonly included in traditional conceptions of psychopathy” (p 660), and furthermore, “Individuals with antisocial personality disorder and narcissistic personality disorder share a tendency to be tough-minded, glib, superficial, exploitative, and lack empathy” (p 662).
Notice that there’s a lot of overlap here, and that “lack of empathy” is a core feature of both personality disorders. Which brings us back to why I believe empathy is “in the crosshairs” of this administration. Because they lack the capacity to put themselves in another’s shoes, or to see another person’s needs as valid, it is easy for them to exploit others for their own needs. Empathy is equivalent to having a moral or social conscience, which narcissists, psychopaths and sociopaths all lack. Understanding this makes their actions comprehensible, although reprehensible.
When you can put yourself in someone else’s shoes, and understand their point of view, it allows you to build respect and trust, which can lead to collaboration and creative problem-solving, to finding solutions that benefit all rather than only one individual or group. This is an essential feature of a civilized and democratic society. So no, Elon, empathy is not our greatest weakness. Empathy is actually our superpower!
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Mindfulness in Turbulent Times
In the past few months I have witnessed tremendous increases in anxiety, irritability, depression, and fear about what’s happening in our country and the world, in my mindfulness students and therapy clients (as well as among friends, family, neighbors and most everyone I interact with). At the same time, I’ve heard more people questioning the value of mindfulness practice in these crazy, chaotic times.
How can we make sense of the current political climate in the U.S., and particularly the constant assault on our Democratic institutions and dedicated public servants, from a mindfulness perspective? And more importantly, how can mindfulness help us to manage the anxiety we’re feeling? Here are some thoughts:
1) Mindfulness is not an escape from reality, but rather an embracing of reality that offers true refuge, as the American Buddhist teacher Tara Brach’s book of the same name explains. It gives us a solid ground to stand on, unlike the false refuge of our various addictive behaviors and ways we all have of numbing ourselves or checking out. When we are truly mindful, we can see clearly what is happening, without getting overwhelmed, and we’re less likely to be fooled by those who seek to manipulate our emotions.
2) When we learn to stop, take a breath, and observe what’s happening, both around us and within us, before we act/speak, then we begin to see the full range of choices available in how we respond, to any situation we face. We can choose our response carefully, rather than act/speak reactively. This is a fundamental freedom that no one can take from us, as Viktor Frankl, the Austrian psychiatrist and concentration camp survivor, said so eloquently in his book, Man’s Search for Meaning. Mindfulness practice teaches us response-ability.
3) Mindfulness asks nothing more, and nothing less, of us than deep and honest self-reflection. While the guiding principles of mindfulness are fairly simple, it is not easy to practice, because it requires that we acknowledge all of our thoughts, emotions, actions, and reactions, even the ones we’re not so proud of. It holds us accountable for our words and deeds, asking that we speak wisely, and choose skillful action, in ways that are not harmful to ourselves or others. In other words, the opposite of what’s been playing out in the political arena over the past months!
4) Mindfulness increases our capacity to tolerate strong negative emotions and difficult situations. Another of my favorite American Buddhist teachers, Pema Chodron, says, in her book When Things Fall Apart, that things are always falling apart and coming back together again, that much of our suffering comes from our resistance to this inevitable process of change, and that “the healing comes from letting there be room for all of this to happen: room for grief, for relief, for misery, for joy.”
5) There are two opposing forces in the universe, chaos and rigidity. We can see rigidity in how the current occupant of the White House tries to impose his will on others: that’s authoritarianism. We can see chaos in the impulsive and cruel actions of his unelected hatchet man: that’s nihilism. Neither extreme is good. And all of humanity’s struggles can be understood as a quest to find balance between these two forces, both in the world and within our own minds. Dan Siegel, the interpersonal neurobiologist, discusses these ideas in his book, Mindsight. Mindfulness meditation practice can lead us to that balance, a “middle way.”
6) Finally, Mindfulness invites us to acknowledge our common humanity, to recognize the fundamental truth that most people want the same things – to be able to take care of themselves and their loved ones, to have financial security, to enjoy basic rights and freedoms, and to be happy. As the television producer Norman Lear used to say, “I am just another version of you.” When we look for the common humanity in each other, we build bridges to understanding and compassion, rather than building walls and more hatred.
In closing I would like to offer a couple of mindfulness practices for these challenging times. The first one is called The Mountain Meditation, adapted from the Mindfulness-Based Relapse Prevention curriculum, and originally published by Jon Kabat-Zinn in his book, Wherever You Go, There You Are. The second one is a brief practice, borrowed from my colleague Renee Burgard, LCSW, called the Mindful Self-Compassion Break. Both can be found on this website, on the Guided Meditation audio files page. Password is “patience”.
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Alcohol Is Not a Health Food
Here’s yet another reason for “Dry January,” if not “dry indefinitely”: US Surgeon General Vivek Murthy says alcohol consumption causes cancer, that it is responsible for 100,000 cases of cancer and 20,000 cancer deaths annually.
“The direct link between alcohol consumption and cancer risk is well-established for at least seven types of cancer including cancers of the breast, colorectum, esophagus, liver, mouth (oral cavity), throat (pharynx), and voice box (larynx), regardless of the type of alcohol (e.g., beer, wine, and spirits) that is consumed. For breast cancer specifically, 16.4% of total breast cancer cases are attributable to alcohol consumption.”
Do we need warning labels on every bottle, as he’s proposing? Setting aside the fact that it won’t happen due to pushback from the alcoholic beverage industry, I think it would probably be a waste of time and money, because it’s not likely to change anyone’s behavior. Most people who drink already know that alcohol can be harmful to the body, because they’ve had one or more harmful experiences, or “negative consequences” as we say in healthcare, and yet they keep drinking anyway. But that’s the cynic in me talking.
The optimist in me says, Yes, even if it only moves the needle 10%, that could save 200 lives! More, given the many ways that drinking can lead to death. While most people don’t heed warning labels, some do, and although it won’t help the folks who are committed to drinking regardless of risk, it may get the attention of those who are concerned about their health and want to increase their chances of living a long and healthy life.
His advisory has already got our attention – I’ve seen half a dozen news articles on the topic in the past week – and talking about it could lead to behavior change. We can’t change that which we are unaware of, so the first step in change is awareness.
If you’re skeptical of this news, that’s not surprising. After all, hasn’t the medical community been telling us for decades that moderate drinking is safe, even a healthy habit?
Here’s what I know, based on my training as a substance abuse counselor, over 40 years of experience counseling adults who drink too much, and my own personal experience. In a nutshell:
* Alcohol is both an intoxicant and a toxin
* Its addictive potential is strong
* In small amounts, it produces some pleasant benefits, like relieving social anxiety and stress
* But it comes with serious risks, including painful illness and death, which are not always proportionate to the amount consumed.
* It is so ubiquitous in our society that if you don’t drink you’re considered odd, and if you do, it’s very easy to consume too much.
How much is too much? That’s a key question. Do you know that before the 1980’s, a standard drink was considered to be 1 oz of spirits, or 4.2 oz of wine? You could get six drinks from one bottle of wine. But drinks, like food, got supersized, so that now the standard drink is 1.5 oz spirits, 12 oz beer and 5 oz wine. Many restaurants offer 6 or 8 oz pours of wine, while craft beers and hard seltzers have a higher alcohol content. Right there you can see how easy it is to overdrink, and how common it’s become. (Here’s a standard drink chart for reference.)
The notion that moderate drinking is healthy originally came from Scandanavian health survey data, which showed a correlation between “moderate” alcohol consumption and low rates of disease. First, correlation is not causation. Moderate drinkers might have good genes, or a healthy lifestyle, or get health checkups more often. Second, it turns out that “moderate” drinkers in those surveys were those who drank “more than none,” anywhere from 1-2 drinks a year up to 1 drink a day. From this data, our American healthcare experts extrapolated that it must be healthier to have a drink a day than none at all!
To be clear, alcohol is not a health food, and there is no universe in which it’s healthier to drink alcohol than to abstain. Doctors who have “prescribed” a drink a day, or assured their patients that “moderate drinking is perfectly safe” are either uninformed, afraid to offend their patients, or in denial about their own alcohol consumption. But we can’t just blame doctors; most people want to believe that 1 to 2 drinks a day is okay.
In reality, for most people most of the time, drinking is a pleasant experience. Alcohol is an effective mood enhancer, at least initially, and it can anesthetize physical pain as well as numb emotional pain. Because it lowers anxiety and inhibitions, it serves as a “social lubricant” for many people. Many people like the taste, and enjoy trying different drinks.
Can something be both good for you and bad? Sure, consider acetominophen (Tylenol). It’s available over the counter, so it must be safe, right? Yes, if you take 325 – 1,000 mg every 4-6 hrs, as the label directs. But wait – just 4,000 mg over 24 hrs can cause liver damage! The same is true of ibuprophen (Advil), which is safe for pain relief if taken as directed, but can destroy your stomach lining if you take it in large quantities. There’s a fine line between a safe amount and a risky amount, just as with alcohol. (And fentanyl, which I had for a recent surgery, but obviously wasn’t given a 12-pack to take home!)
The comparison with fentanyl is more apt than with acetominophen, because of the potential for addiction. Nobody gets addicted to Tylenol. Why? It’s not an intoxicant, it doesn’t give you a buzz or mellow feeling. So understanding the addictive potential of alcohol is also an important factor in deciding whether it’s safe for you to drink.
For many years, people thought it was perfectly safe to smoke cigarettes, and they smoked in restaurants, offices, airplanes, even hospitals! We now know that for many years the tobacco companies spent lots of money to suppress the research that showed smoking causes cancer, and that nicotine is addictive. Now these are well-known facts, and yet, some people still choose to smoke. (Another US Surgeon General warned about smoking and cancer back in 1964, but smoking behavior didn’t change for decades.)
The risks associated with alcohol consumption are also known, and the alcoholic beverage industry has also tried to hide that research, but mostly, it just spends millions of dollars every year on marketing campaigns to convince you that everyone drinks (not true), and that drinking alcohol will make you happier, sexier, and a lot more popular!
These days, it’s a safe bet that most people who drink are drinking too much, and should drink less or quit, for their own good. So why don’t they? The most common reason people have trouble changing their drinking habits is simply that a habit can be difficult to change, especially when there’s so much encouragement for drinking in our society, and when it’s so readily available and relatively inexpensive.
Most people can drive over the speed limit without getting a ticket or having an accident, and we usually don’t even think of that as “risky” behavior. In the same way, we don’t tend to think about drinking as risky, and any negative consequences from drinking may seem so rare or unlikely to happen that they’re easy to dismiss as “it’ll never happen to me.” (By the way, that’s the title of a classic book about children of alcoholics, and ironically, if you have a parent who is or was an alcoholic, your odds of developing alcoholism increase by 50%.)
Another reason some people drink too much is they believe “everyone drinks like this, and that’s just how it is.” They think of drinking as a super fun activity to do with friends, which makes them feel sexy and no longer shy, and so what if they black out or have a terrible hangover the next day, doesn’t everyone? This thinking is common among people who may have started out with binge drinking in high school or college, and don’t know any other way to consume alcohol. (Binge drinking is defined as 5 or more drinks on one occasion.)
I have counseled hundreds of adults who have experienced “negative consequences” (blackouts, DUIs, relationship problems, health issues, job jeopardy) from drinking, and would like to learn how to avoid future negative consequences. None of them have wanted to quit completely, and most didn’t believe they needed to quit, because “I’m not an alcoholic, I just enjoy [the taste, the way it relaxes me, the social aspect]”. So we start with a treatment goal of drinking less, not quitting.
My experience has confirmed what the research shows: indeed, some people can learn to drink less, so that they lower their risks of negative consequences. Usually it’s younger people, who have been drinking for fewer than 10 years, who don’t have a family history of alcoholism. Occasionally it’s an older person who just needed to learn a few tips, like to drink only occasionally, not drink on an empty stomach, alternate alcohol with drinking water, stick to 1 or 2 drinks, and to say a firm “no thanks” to another one.
But most of my clients who have experienced one or more negative consequences from drinking haven’t been successful at moderation. They quit counseling instead, or in some cases, come to the decision that it might actually be easier to abstain completely, because it seems to require too much self-discipline to drink less.
Frankly, one major reason some people continue to drink too much despite negative consequences is that they’re already addicted and just don’t know it, because alcohol use and abuse exist on a spectrum, where the lines between “moderate drinking,” “risky or problem drinking,” and “alcoholism” are difficult to discern. If addiction has already taken hold, chances of learning to drink moderately are slim, no matter how much willpower a person has.
I believe it’s still worth trying to reduce a dependence on alcohol, so I support “Dry January,” and “Sober Curious,” and encourage you to consider other experiments in abstinence. Keep a log or journal of thoughts and feelings that arise when you’re choosing to not drink, and pay attention to what your mind and body tell you – it might be very informative!
If you’d like help figuring out your relationship to alcohol and whether it needs to change, please feel free to reach out to me. I’m not taking new patients for long-term therapy, but I am available for short-term consultation, assessment, and referral. I also recommend checking out the ReThinking Drinking website.
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Did the Election Kill Our Hopes and Dreams for a Better World?
“Hope is being able to see that there is light despite all of the darkness.” Desmond Tutu
Well, I was hoping to retire in 2025, but after the election, it looks like my services are needed more than ever, and may be for years to come. So this is my first post in a long time, but it won’t be the last.
These are challenging times. The emotions people have described to me run the gamut, including afraid, angry, anxious, despairing, disillusioned, grieving, heartbroken, and sad. I tell them, these are all normal reactions to an abnormal set of circumstances, and it is entirely appropriate to feel like mourning, or crawling under the covers, or seeking a way to numb yourself. If you are having thoughts of harming yourself or others, however, it is imperative that you let your therapist or me know right away.
It is also a very strange time. Many of us are feeling like we’re at a funeral, or sitting shiva, while on the other side of the street, people are shouting for joy and turning cartwheels. It feels surreal. It’s hard to be on social media right now, let alone out in the world. You may not feel safe, and you may in reality no longer be safe, if you’re a member of one of the groups that the incoming administration despises.
You may be feeling alone right now. It’s as if the majority of the country has turned in a totally different direction than the one you had believed we were all heading toward. And maybe your friends, the ones who believe in what you believe in, are too distraught to even talk about it. But you’re not alone, I assure you. There are millions of Americans who still believe that a kinder, more tolerant, more equitable and more socially just world is possible.
I am not an economist, historian, or political analyst, so I’m not going to try to explain what happened, or why. I intend to stay in my lane here, by speaking from both personal and professional experience about pathological narcissism and its toxic effects. In my family of origin, I was the one who first confronted mistreatment, and called out the lies and distortions of reality, and for that I was scapegoated. So I have always supported the victims of bullying behavior, and I learned at an early age to judge people’s character by their actions, not their empty promises.
I am a psychotherapist by training, a social worker by education, and a lifelong observer of people, so I’ve learned a lot about human nature, both its positive or “prosocial” side, which I believe is our true nature, as well as its dark, antisocial side. I’m not religious, but have come to believe in the existence of evil.
And while I’m not a Buddhist, I am a student of Buddhism, which refers to those darker impulses of human nature as “greed, hatred and delusion.” So I will say that it looks like greed, hatred and delusion have won this time, vanquishing the benevolent forces of generosity, kindness, and tolerance of differences. But if they’ve won the battle, I refuse to believe they’ve won the war, because there are simply too many of us on the other side.
So if you’re having a hard time coping right now, if your anger or fear or sorrow or despair are getting the best of you, please, please, please reach out. I am here and I want to help, whether to take you on as a psychotherapy patient, or as a member of one of my mindfulness groups, or by finding another therapist or support group for you. Together we can help you get grounded, find your voice and inner strength, and perhaps then figure out what role, if any, you want to play in what I’m going to call “the resistance movement.”
Thank you for reading – may you be safe and free from harm.
As another astute observer of human behavior once said, this wannabe dictator’s ideology is “purposeful, vindictive chaos,” and “it is going to take relentless stamina, vigilance, and every institutional check and balance this great country can muster” to stop his destruction. “No one action will be adequate, all actions will be necessary.” (Jon Stewart on the Stephen Colbert show, 1/31/17)
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