What does the future hold

Ethics

Two podcasts recently caught my attention. The first examined the impact of venture capital on the American economy (1). Gretchen Morgenson, the co-author of “These are the Plunders: How Private Equity Runs and Wrecks America,” was extremely critical of venture capitalism because of its impacts, which include layoffs, pressure to make important decisions based on financial criteria only and the demoralization of employees. The second podcast  explored the concept of moral injury (2). The author, Elay Press, examined how physicians are increasingly at risk for and appear to be suffering from moral injury, as a consequence of the corporate takeover of much of medical care. While interesting in their own right, what made these podcasts  stand out for me is the rapid growth in venture capital firms buying up mental health practices and starting multi state corporations to provide mental health services.

Listening to these podcasts brought to mind a comment an old friend of mine made many years ago, when we both worked for a large hospital. He referred to the physicians, who at that time, the late 1980s, were primarily self-employed, running their own practices, as “the last cowboys”  as they pretty much practiced how they wanted.  Obviously, this has changed greatly as nearly all of these practices are now owned by large hospital chains or practice groups, or increasingly by insurance companies or large corporations.  Both podcasts (1,2) and a number of articles (3) highlighted that these changes have had very negative impacts on physicians, particularly those in primary care and emergency room physicians. A shockingly large proportion of emergency room physicians are actually employees of venture capital (VC) funded or owned companies. Hospitals have apparently outsourced the staffing of ERs to these groups to save money. An even larger share of primary care physicians appear to have become employees of large practice groups or hospital chains. The result according to the authors interviewed on these podcasts is that physicians are increasingly experiencing moral injury.  Press (3.a.) explains moral injury as follows:  “Military psychiatrists use the term to describe an emotional wound sustained when, in the course of fulfilling their duties, soldiers witnessed or committed acts — raiding a home, killing a noncombatant — that transgressed their core values.”  

Press cites the work of Dean and Talbot, who originally discussed how increasing numbers of physicians were experiencing significant distress about the pressures they experienced (3.b.). These authors stress that physicians are reporting increasingly high levels of distress and dissatisfaction, that physicians have higher rates of suicide than military members and that healthcare workers (including physicians and nurses) are leaving the field in alarmingly high numbers. They attribute these realities to fact that physicians and other healthcare workers  are increasingly faced with situations where they are pressured to make medical decisions or practice in ways that they believe are wrong (1,2, 3) such as overprescribing tests, being limited to “seven minute” office visits with patients, and being pressured to discharge patients who they believe are in need of care.  The predominant theme being that profit is superseding all else. While some may find it hard to muster up a great deal of sympathy for physicians, given their high status and incomes, the impact on healthcare and on caring and well intended providers is a significant concern. If physicians leave the field we all suffer.  If physicians succumb to these pressures our healthcare may be jeopardized.  Moreover, the most vulnerable among are at the greatest risk.   

These podcasts also reminded me of a group of solo practitioners I met with many years ago. This group consisted mostly of psychologists, all of whom were in independent practice. When one of the members learned I was developing a group practice, this clinician asked me, “why would anyone want to work for you?”  This was not a personal disparagement, but a question of why would anyone want to sacrifice the freedom of independent practice. Clearly this has also changed, with many therapists either working for a group practice, or owning and running a group practice. Many years ago there were a few group practices; the majority of those were owned by psychiatrists, who had clinicians working for them.  Now there are many practices owned by psychologists, social workers, licensed professional counselors, and marriage and family therapists. The evolution of private practice from more solo practitioners to more group practices (for outpatient mental health services) is a different issue, one that we will not address in this blog. 

Even back in the days when most healthcare professionals were independent, economic pressures to place oneself in potentially morally compromising situations existed. A former colleague who worked for one private psychiatric hospital explained that the hospital  would pay for office space and other perks on the condition that clinicians hospitalize a certain number of patients a month. This certainly would have posed a moral dilemma for those who accepted this offer.  For those who are old enough to recall, prior to the rise of managed care, many hospitals had one or more psychiatric wards filled with adolescents who were hospitalized for either 29-30 days, or 59-60 days, the maximum number allowed by their insurance.  I doubt that anyone would argue that today’s adolescents are mentally healthier. However, clinicians who worked for these practices may have found themselves facing moral dilemmas to keep patients in the hospital. 

While this history may be somewhat interesting in its own right, the more pressing issue is the challenges mental health practitioners currently face. Probably almost all clinicians in private practice can attest to having received emails “inviting” them to join or work for a VC funded organization. I can certainly empathize with clinicians who are looking to supplement their income and/or pay off educational debt.  Offers from online mental health companies could appear tempting: at virtually no cost to the clinician the clinician can provide remote services.  All the person needs is a cell phone and a computer (something nearly all of us have).  No start-up costs, no billing, no marketing required.  However, I strongly suspect that these clinicians may find themselves facing dilemmas regarding patient care. For example, I would not want to be pressured to provide mental health care via text or chat, as some companies offer.  Recently, a patient of mine told me how his psychiatrist moved from a prestigious hospital to a new VC funded group, and that the patient was now being told he had to come in for office visits every 3 months to get one of his medications renewed (something he had not had to do before, and for a medication that he had taken for years and clearly needed to continue on).  This edict came from the practice, not the provider. The psychiatrist had never required this before. Fortunately, the patient was able to prevail upon his primary care physician to write this prescription. While this is only a minor example, that a well resourced client was able to navigate, it is likely the tip of the iceberg.  

The dilemma faced by practice owners is also salient.  Practice owners face the challenges of running an ethical practice, supporting their employees, and providing quality care while facing rising costs and for those of who take insurance, rate increases that are rare or virtually non-existent.  Increased pressures to join large VC funded groups or to sell to them also seems constant. I can testify, as I assume most other practice owners, that we have received a steady stream of emails and even calls suggesting we “partner” with these groups (partnering likely being defined as selling one’s practice to the group and working for them). Moreover, I empathize with those who have sold their practices as the cost and challenges of running a group practice are substantial.  In the first podcast (1), the host asks the author why businesses would sell to VC groups. The answer: the owner and (for larger companies) shareholders often do well. It is the employees who suffer.  I suspect that those practice owners who do sell to VC backed  corporations are often doing so to help them manage the all too often overwhelming demands and challenges of running a group practice rather than trying to get rich quickly at the expense of their employees.  Those owners who do “partner” with VC funded groups also face a number of moral dilemmas.  Many VC funded groups ask owners to stay on and “manage” their practice.  I suspect that these owners likely find themselves pressured to provide services they may not want to. For example, a colleague who sold to a VC group reported some pressure, which they were able to resist, to start providing other services in addition to outpatient therapy and psychological testing.  My fear for this clinician is that this is only the beginning. Moreover, as  Morgenson (2) notes, VC firms often sell the businesses they have bought to other VC groups, and these groups continue to focus on reducing costs and upping profit, and have a very short term focus. Moreover, the cultural shift to a sole focus on profit likely has corrosive effects for formerly independent practice owners and their former employees who find themselves now answering to a new set of demands. 

The point of this blog is not to moralize. All private practitioners and many healthcare workers are faced with moral dilemmas: what do we do when patients’ lose insurance and need care; do we turn away underinsured, poorly insured individuals; what do we when patients want to continue services that there seems little need for but which brings them some comfort; do we provide services in an area that we do not have established competencies when a new patient seeks those services and we need patients?  These are only a few of the dilemmas we wrestle with. However, the entrance and growth of VC funded entities into healthcare and into mental health are likely to make these concerns seem paltry.  Currently, those of us who are self-employed have greater freedom  to make choices based on our values.  Being owned or working for a VC funded group may remove this freedom.  The need to upsell unneeded services (such as psychological or neuropsychological testing, not to mention other treatments such as Ketamine or TMS), to pressure our staff to see more patients or patients outside of their areas of competence, are just a few of the dilemmas that we may face.  While it seems our risks are less than those faced by physicians it would be naive to assume that there will not be other pressures to maximize profit which will compromise clinical care.  Thus, we place ourselves at risk for the moral dilemmas and injury that many physicians and other healthcare professionals are currently struggling with. For those who think I may be exaggerating these risks I would strongly encourage you to read some of these articles and listen to these podcasts! 

References: 

  1. Fresh Air podcast, “How Private Equity Firms Widen the Income Gap,”  April 26, 2023.  With guest, Gretchen Morgenson, co-author of “These are the Plunders: How Private Equity Runs and Wrecks America,”  by Gretchen Morgenson and Joshua Rosner, Simon and Schuster, 2023. https://www.npr.org/2023/04/26/1172179099/how-private-equity-firms-widen-the-income-gap
  2. Daily Podcast, “The Moral Crisis of America’s Doctors,” July 16, 2023.  This podcast is basically an oral version of the New Times article, cited below, by Eyal Press. https://www.nytimes.com/2023/07/16/podcasts/the-daily/the-sunday-read-the-moral-crisis-of-americas-doctors.html
  3. Articles on Moral Injury and physicians
  4. The New York Times article: “The Moral Crisis of America’s Doctors” by Eyal Press, June 13, 2023.  https://www.nytimes.com/2023/06/15/magazine/doctors-moral-crises.html?action=click&module=RelatedLinks&pgtype=Article
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