April 22, 2025 • 33 mins
In this episode of The Provider's Report, the host welcomes Dr. Betty Rabinowitz, MD to discuss the corporate side of healthcare. Covering the evolution of healthcare structures, Dr. Betty shares her extensive experience as a general internist and her venture into healthcare information technology, culminating in her role as Chief Medical Officer for NextGen Healthcare.
The conversation delves into the rise of private equity in healthcare over the past decade, highlighting both the benefits and risks of such investments. Discussion points include the definition of private equity in healthcare, its impact on efficiency and quality of care, and the ethical dilemmas it poses.
Dr. Betty also touches upon the increasing involvement of private equity in hospice care and its implications. The episode concludes with practical advice for practitioners currently navigating private equity acquisition, emphasizing patient-centered care, legal awareness, and maintaining professional integrity.
00:00 Introduction and Guest Speaker Introduction
00:38 Dr. Betty's Career Journey
01:50 Understanding Private Equity in Healthcare
05:07 Pros and Cons of Private Equity in Healthcare
08:11 Ethical Challenges and Future of Private Equity
17:30 Case Study: Private Equity in Hospice Care
28:23 Advice for Healthcare Providers in Private Equity Acquisitions
31:58 Conclusion and Final Thoughts
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rebecca (00:00):
Hello everyone and welcome back to another episode
of the Providers Report.
We are really excited here tohave a guest speaker who's going
to talk to us all about thecorporate side of healthcare and
what it looks like today, whatit used to look like, what are
some of the pros with some ofthese new structures, and what
should we be on the lookout foras providers.
So Dr.
(00:20):
Betty, thank you so much forjoining us.
Betty (00:23):
I'm very glad to be here and it's a, topic that I have
long had interest, in, And I'mexcited, for today's
conversation.
Rebecca (00:31):
only that, it looks like you have the perfect amount
of experience with this topic aswell.
Your resume is very impressive.
Could you start by telling us alittle bit about everything
you've done so far in yourcareer?
Betty (00:43):
Sure.
the core of my professional,identity is as a general
internist.
I was in practice for over 25years.
The last five years of that,career at the University of
Rochester, I was the medicaldirector for the Center for
Primary Care.
I then, left to found ahealthcare, information
(01:04):
technology company, a populationhealth company, which, was
acquired by NextGen Healthcare,which is a publicly traded, very
corporate, entity.
and, ended my career being,their chief medical officer for,
three years, have been doingconsulting work, in, retirement.
Rebecca (01:23):
I love the quote unquote retirement.
For those of you who don't havethe video accessible, quote
unquote, retirement, I feel likeis so popular amongst healthcare
providers who have done exactlywhat you've done.
We transition out of thatclinical practice, you know, we
either open up amazing companiesor we work with amazing
companies for the greater good.
it sounds like you were verymuch trying to leave your mark
(01:44):
with your professional career,so thank you for all you've
done.
Betty (01:48):
Sure, sure.
Thank
Rebecca (01:50):
Yeah.
So for those of you listening,if this topic is relatively new
for you, I did want to startwith a brief definition of what
private equity ownership lookslike in healthcare, So the
definition is really referringto.
When investment firms or othercompanies can acquire and manage
some healthcare businesses, likesome of the ones that she just
mentioned, and this can be for avariety of reasons.
(02:11):
hospitals and physician groupsand urgent care centers are some
great examples of how thisbusiness acquisition comes into
play.
so I wanted to pick your brainon why do you think this has
become so popular in healthcarethese days?
Betty (02:26):
So, let's look for a moment just at the scope of this
issue.
In, the last, 10, 12, 13 years,1 trillion with a t dollars have
flowed from private equity intoacquisitions and investments.
In, healthcare, and it'simportant to, understand that.
(02:48):
there's a specific businessmodel to private equity,
investment, which is ainvestment structure to be
relatively short term, usuallybetween four and six years of
investment.
That includes a restructuring a,Re, imagining a redesign of the
asset that has, been acquiredand a relatively short
(03:11):
turnaround to create,profitability and then, divest
that.
asset for a profit.
the reason that healthcare hasbeen so attractive and has,
garnered all of this, hugeinvestment is that it is a
source of reliable, flow ofcash.
(03:33):
Much of the, financialactivities in healthcare are
backed by Medicare and Medicaid,which are, the US government.
So there's assurance that thatflow of cash, continues if you
follow, the money, that's why,private equity has been coming
in additionally, Healthcare hasbeen a market that is still very
(03:54):
fragmented.
So there was great opportunityfor consolidation, which is one
of the, mechanisms that privateequity applies to, gain
profitability is consolidating,creating economies of scale in
their approach.
other reasons were that from aregulatory perspective, there
were very low.
(04:14):
bars to enter the market becausethere's really not much
regulation on who buys, whosells, who acquires.
And speaks to one of the biggestproblems about talking about
this area is that we don't knowexactly.
How much of this is going on,where it's going on?
There's a lot of obliqueness inthese deals.
(04:37):
and there are no rules orregulations about having to
expose or declare or, advertise,these shifts in ownership and
investment.
Rebecca (04:47):
Oof.
That is a lot.
I mean, I can definitely nowunderstand.
By hearing it from you, why itis so attractive.
You know, if you happen to besitting on millions of dollars
and you're looking forinvestment opportunities, you
want the biggest return andtypically the quickest return.
So that makes perfect sense.
do you think, I mean, let's chatabout some pros and cons.
(05:09):
I think my brain is particularlybiased.
I tend to love systems andefficiency, and I know that.
working with other companies andmanaging companies with other
organizations typically gets youthere.
So I imagine that might be oneof the major pros with, some of
this acquisition.
But in your mind, what are someof the pros and cons to working
(05:30):
with other companies like thisand agreeing to do this type of
investing?
Betty (05:35):
So let's start with the pros.
traditionally, healthcareorganizations, have not enjoyed
the.
Highest, level of, corporate,management and tools.
Many of them are smallerpractices, physician led, where
the skill sets of thosephysicians really are focused on
clinical medicine.
They excel at that, and don'tnecessarily bring, the sharpest
(05:59):
tools to, management efficiency.
Application of technology,choice of technology, deployment
of technology, finance, andfunding, which are some of the
challenges that practices facein today's healthcare
environment.
So an influx of managementexpertise, finance expertise,
creating sensible debt,restructuring, nonsensical,
(06:23):
debt, managing assets like realestate and space and HR and
staffing and economies of scaleand purchasing and.
negotiating with healthcareinsurance companies on, better
rates.
Are all capabilities that, theseprivate equity companies, the
good ones really can contributetremendously to, practices and
(06:46):
have done so.
additionally, it, can relievephysicians of incredibly
stressful financialcircumstances.
They can find themselves,particularly the ambulatory
space where reimbursement isless lucrative than, procedure
driven inpatient, space.
(07:07):
it can provide a flux of cashthat solves, financial, problems
and also allows physicianswho've spent a career equity in
a practice allow them to,materialize or cash out, on the
value that they've built.
And I see that as fair and, andvery reasonable.
(07:28):
trouble is that it comes with aof cons.
The major and biggest one isthat physicians providers of a
variety of kinds lose.
autonomy.
So once you have sold yourpractice, you, have given over,
(07:49):
decision making power thedirection, the culture, the
requirements, the structure, theHR regulations, the focus, the
priorities of the practice tosomeone else.
for physicians we are, somewhat,control freaks.
that is a very difficult, thingto do.
(08:11):
And the second thing is that itcreates A slew of ethical
challenges that have to do withdriving priorities in healthcare
based on profitability andefficiency rather than patient
and family benefit.
That is a con that cannot bespoken away, negotiated away,
(08:33):
rationalized the way it's thereand needs to be.
faced square on, and there are,we'll talk, I'm sure later in
the conversation about ways tomitigate, these issues, but they
are real.
Rebecca (08:45):
Yeah, they're definitely real.
And I think a lot of ourlisteners definitely have a
strong affinity toward morevalue-based care,
patient-centered approaches.
And, you know, in my naivety, Ienvision a world where we're
able to do both.
I want to see high efficiency.
In our systems, in ourorganizations, our hospitals,
but at the same time, I neverwant to lose, that value-based
(09:08):
care, and I know you have tonsof experience in that world.
Long story short, do you thinkthat world exists?
Can we attain that?
Betty (09:16):
So, I'm a born optimist.
So the answer is yes, thereprobably is a best of both
worlds model, but it requiresboth sides, to apply a fair
amount of, wisdom to the waythese deals are structured and
possibly, the need forregulatory intervention, for
(09:37):
example.
Should we allow private equityto own a hundred percent of
these publicly necessary assets?
a hospital in a rural area,which is the only hospital
serving that area, should weallow private equity to, own a
hundred percent of it, or shouldwe limit ownership of private
(09:57):
equity?
Allow them to have a stake and,gain from the profitability of
their organization.
But for example, not.
Bankrupt it, not sell it, or,not run it, in ways that aren't
supportive of that community.
That is an example where youcould enjoy the best of both
(10:18):
worlds.
I think it would reduce theprofitability and the control
that private equity has andtherefore make it a bit less
attractive to them.
20% of hospital systems that,went, bankrupt
Rebecca (10:31):
Okay.
Betty (10:31):
private equity owned and the unscrupulous, private equity
companies that had, entered thespace, or even if they weren't
unscrupulous, but justunsuccessful, basically, we'll
do anything to gain the profitthat they promised their
investors, for example.
(10:51):
mortgaging or using, hospital,estate assets as leverage for
loans.
So hospitals suddenly findthemselves owing a great deal,
of money or the private equity,company owes a great deal of
money that they have borrowed topay back investors or reinvest,
(11:12):
and the collateral for thoseloans are the hospital.
real estate and if somethinggoes wrong with the deal, then
there's a big mass.
There are, examples of, hospitalsystems being saved by, and,
managing to get back to,stability because of private
equity investment.
But there are examples ofhospital systems who have.
(11:36):
not being successful in thatmodel.
There is beginning to be, Icannot say that it's common,
it's still a rarity, but,physician practices that are
buying themselves back fromprivate equity, sometimes in the
context of.
Multiple hand changes becausethere's nothing to stop a
private equity firm from sellingyou to another private equity
(12:00):
firm that then can turn aroundand sell you again.
The, these changes all entailchanges in culture, changes in
leadership, changes inmanagement, very disruptive to
the practice.
So in a few ca, there are a fewexamples.
When I looked at the literaturein preparation for today, there
are a few examples.
Of practices that have toreverse the decision to, to
(12:23):
enter into private equity,relationships.
Even though the, the, I have tobe clear, this is the minority
at this time,
Rebecca (12:31):
Yeah, that's interesting.
I recently started hearing ofthat, within the last year as
well.
And obviously the reasons forthat tend to have a lot to do
with autonomy for the providersand just.
Getting back that old schoolfeeling of a smaller practice or
a smaller hospital.
actually across the street frommy own practice, there was a
very long established primarycare facility.
(12:53):
the two providers there,practiced for almost 60 years.
and they eventually did getbought out by one of the big
hospitals in my city of GrandRapids, Michigan.
toward the end they had theoption to either.
Buy themselves back, like youmentioned, and have someone take
it over like a younger primarycare doc.
And they were kind of at thatfork in the road where the best
(13:14):
decision for them due to, youknow, being so close to
retirement was just to kind ofbe done.
All of the patients, of course,had to find a different, primary
care office within that hospitalstructure.
But it was such a strange endingand I feel like that's.
That wasn't the norm withprivate practice owners before.
you had a successor to yourpractice who carried out some of
the great, traditions that youinstilled in that facility.
(13:38):
Do you think that there's goingto be more regulation or are
there any insights as to whatthat future might be?
Betty (13:45):
Yeah.
Well, it's, it's, it's really avery complex system you think of
it.
There are also, um.
There are non-for-profitentities in healthcare.
There are for-profit entities.
So it used to be an oxymoronthat a hospital was for-profit,
but there now are very largehospital systems that are
for-profit.
And then there's the privateequity, model.
(14:08):
So in a certain way you take theprofit motive and you put it on
steroids in private equity, butthere are still for-profit
forces occurring in healthcare.
It's interesting to me thedecision whether or not to,
participate in a private equitydecision as a practitioner,
(14:29):
whether hospital owned or, stillrarely in private practices as
solo or group owners of apractice.
That decision changes and variesat the age of the practitioners.
you mentioned it that thesecolleagues of yours were at the
end of their career.
(14:49):
Where they likely didn't have,if the culture turned to one
that they didn't appreciate,they didn't have a long time to
work in that environment.
So the motive for them of havingfinancial benefit from a
practice and an entity that theybuilt over their careers, and I
respect that totally, is strong.
(15:11):
Versus a young practitionercoming outta residency who has.
two, three years, five years inpractice and has another 25 to
look forward to for them.
The decision of who calls theshots, what will the shots be,
how they impact their life workbalance, how they impact the
style of practice that they can,practice in very much more
(15:33):
critical than the benefit at theend of their career from the
financial asset, even thoughthat's.
in long term, in long rangeplanning, it's important as
well.
So what you see often inpractices that have varied,
career stages in them, that whenthe deci time comes to make the
decision whether or not to gowith private equity.
(15:55):
That it's very hard to findconsensus sometimes because the
motivation and the,considerations at different
stages in your career have to beand are very, very different
when you ask what the futureholds, I am not sure that the
private equity bus, has slowedor is going to slow anytime
(16:20):
soon.
I hope, I'm not sure that in thecurrent environment that's going
to happen, but that eventuallyat the state level, possibly
there will be regulatory,requirements to, avoid some of
the debacle and disasters thathave occurred.
The other thing is that we needto continue to get better at
(16:42):
managing quality of care.
So that we can measure qualityof care across the different,
financing and ownership modelsto come out with clear
conclusions.
initial indications are thatprivate equity doesn't do so
well with quality.
the outcomes that are beingmeasured are not as good in
(17:03):
private equity owned as in not,and patient satisfaction and
physician, satisfaction are notas good in private equity,
owned.
On management efficiency,measurements, they're doing a
bit better.
So that those are areas wherethere actually is some benefit,
but the future to be successfulin this space, patient advocacy,
(17:27):
and quality will have to,prevail.
One of the things that was verydisturbing to me was reading.
The fact that there has been ahuge influx of private equity
money into the hospice space.
Rebecca (17:41):
Oh, I know nothing about that.
Enlighten us.
Betty (17:44):
Yeah.
Yeah.
So hospice is a very, unique,service.
Think about it, it's a serviceevery person will only need once
in their life.
There's no return business.
you go through hospice once.
The second thing is that it's afully cap from a Medicare
perspective, from a paymentperspective, it's a fully
(18:06):
capitated service.
whether you offer a hospicepatient, a lot of services for
your daily dollar amount, orvery few is very difficult to
manage and, control.
so a private equity company canbuy a hospice and cut back on
services, but the payment forthose hospice days doesn't
(18:30):
change.
It also encourages, unscrupulousgroup cherry pick those hospice
patients who will be in hospicefor the longest time, but need
very few services.
So, financially, privilegedpatients who can get services
from elsewhere and will rely onhospice less for everything.
(18:51):
Patients with longer prognosisand less impactful, malignancies
who are still relatively highfunctioning, but have a six
month prognosis and they getonto hospice.
And then the question is, whatregulations will be in place to
protect the non-profitablepatients?
(19:11):
What happens in terms of anequity in healthcare issue is if
we don't have enough equity andaccess issues, what happens to
those patients in hospice or inarm, ophthalmology office, or
primary care office, or anoncology office, or an
ophthalmology office?
Who for whatever reason are socomplicated, whose prognosis is
(19:33):
so complicated by their diseaseand, social determinants of
health, that they would be aburden on any system who takes
care of them when?
When an entity that iscompletely driven by for-profit,
motivation chooses not to carefor them or chooses to drop them
or make a few efforts to carefor them, and then kind of,
(19:55):
separate from them either by,just by attrition or by just not
offering the kind of surfacesthat they need.
that's part of the ethical,concerns in this space.
And I thought that for a casestudy or just for your listeners
to.
Think about the implications ofthis is to think of the hospice
(20:16):
space because it's so clear.
is so fraught with bothopportunity for compassionate,
cost effective, care on the onehand, and on the other hand,
because of its payment structureand.
The fact that there isn't returnbusiness and people don't
choose, you know, to, you don'tchoose your hospice.
You can't switch hospices easilyby that time, you're quite sick.
(20:39):
And it's a very, interesting,case study.
the entrance of, private equityinto hospice care.
On the other hand, reading aboutit, there are.
Models of primary care that havebeen more successful than other
models.
But again, there's one, nationalprivate equity company that
(21:00):
created a concierge medicine,primary care model.
The trouble with that is thatit's concierge medicine.
So what happens to people whocan't pay$2,000 a year to get
special, privileges andwonderful healthcare or what
happens, to patients who don'thave access?
(21:20):
It's not in their community anddo we want to create a two tier
or at least two tier healthcaresystem where those who have get
a bit better and those who havenot, don't.
Rebecca (21:30):
Exactly.
That is such a good examplebecause even if you're, you
know, you're listening andyou're a private practice owner
in a small rural town, maybe youdon't have any experience with
hospital structures or privateequity in general.
That example right there makessense to everyone.
it really paints the picture ofwhat this looks like and what
problems are around this modeland how we have to make sure
(21:53):
that we're not forgetting thatas we continue to grow with this
new healthcare system and howthings are developing.
yeah, I'm super passionate aboutpatient access and.
It sounds crazy, but I view itas the modern day like caste
system.
If you think about it, this isdifferent.
I mean, obviously it's pullingin socioeconomic status, but
we're literally tearing peoplewith healthcare needs.
(22:17):
in my mind, it's borderlinediabolical and I understand
that.
finances will always be there.
It's always going to be anissue, but if we lose sight of
what's important here and wechange the quality of care that
people are getting based on whatthey can afford, we're gonna
have some larger problems.
And we're already findingevidence of that in the United
States right now.
Betty (22:37):
Yeah.
Amen.
I think in the context of thisconversation, it's so important
to also maintain.
compassion and understanding forpractices that find themselves
up against the financial wall ina, rural area.
For example, a hospital systemwhere, census is down, Medicare
(23:01):
reimbursement is down.
and the community is desperateto keep a hospital open.
equity there comes in as asavior, and I understand that
and I respect that.
are some.
Extremely thoughtful privateequity companies.
I've had the privilege to, workwith, briefly and talk to some
(23:22):
people in those environments whocare deeply about quality the
idea is to try and choosepartners that are like-minded
and, principled who don't wantto, turn a profit in two years,
that they have the longer term,four to six to seven, years.
And particularly important tochoose a partner who has a track
(23:45):
record that is a positive andsuccessful one, and avoid,
promises for, you know, pot ofgold at the end of the rainbow,
where the, the track record is,is horrendous.
important to speak to your.
and people who've gone throughit.
Rebecca (24:05):
Yeah.
Betty (24:06):
listen to your, not to, ignore the red flags, explore
the red flags, sit with them,talk to people.
Get excellent legal advicebecause how these deals are
structured can make or break,your practice's, future.
Rebecca (24:24):
Absolutely.
I wanted to use that as a seguebecause I know that you have
some experience with, I believe,selling a company that you
founded.
and you touch on the importanceof selecting partners.
And a lot of our listeners, evenif they work for a hospital
structure or a private practice,a lot of the people listening
are naturally.
Seeking other options for theircareer.
(24:45):
They will probably go on one dayto open up other companies and
work with other businesses.
I would love to talk about whatyou did and how you decided who
to partner with and what thatrelationship looked like and how
things have developed sincethen.
Betty (24:59):
So, this is kind of.
Switching gears quitesignificantly because the
company I founded and sold was ahealthcare information
technology company, a populationhealth management software,
platform that we, sold alongwith the company, of course.
and that's very different thanthe decision making process in
(25:21):
the context of, practice, butstill.
The same considerations werealive and well in that decision.
There can be a decision to doyou continue building the
business.
What timing is right for you tosell the business?
(25:42):
Will your existing customersbenefit or suffer, with an
acquisition?
will you be required to changethe area of focus of the company
and the way you have served themand the kind of customer service
that they had gotten used togetting from a startup and from
a small company becoming part ofa corporation, and does the
(26:04):
corporation view.
Healthcare technology,healthcare as a whole, the
mission of healthcare, themission of healthcare technology
in ways that you can, so can yousit in a corporate office with
them without cringing?
Now, interestingly in our case,it would be, disingenuous if I
said that we had four suitorsand we chose.
(26:29):
The most likely we had a suiter,that happened to be in the right
place at the right time in ourdevelopmental stage and their
needs as an organization, wehappened to be extremely lucky
that that partnership worked outextremely well.
Rebecca (26:44):
I love that.
Betty (26:45):
so I, felt incredibly comfortable with the mission
vision, of, NextGen when wejoined it.
and enjoyed the few yearssomewhat disrupted by, the end
of my career with COVID.
But, it happened, to work out,well, All of these decisions
(27:07):
are, often, made in a certaincontext and with certain,
limitations and pressures thatyou had.
We.
It was, it's hard to know.
You always think to yourselfwhat would've happened had we
continued as an independent,startup.
(27:27):
I think we made the rightdecision at the right time.
I don't think it would've turnedout as well for our customers,
the product, or, for myself,personally, I.
Tremendously enjoyed theopportunity to work for a
publicly traded company for thelast three years of my career.
Never dreamt that would be athing.
learned so much and metincredible people.
Traveled the country and,learned so much more about
(27:50):
healthcare than I knew from, aninsulated academic practice for
many years in Rochester, NewYork.
So.
Rebecca (27:57):
that we're ending on that because that is what I want
with this podcast, is to maybeput some ideas in our listeners'
brains that they otherwisewouldn't have thought of.
You know, some of our listeners,have never heard of private
equity getting involved withhealthcare, but you paint such
an easy picture for us withoutexperience in this part of the
industry to get that picture andunderstand, okay, this is why
(28:18):
this exists.
and I think you do a really goodjob at that.
So thank you so much.
to close, could you perhaps giveus some advice for our listeners
who are currently practicing ina hospital or facility that has
been acquired by a privateequity, maybe some advice on how
to mitigate that and navigatethose waters while still
maintaining a higher level ofpatient care.
Betty (28:42):
First and foremost is to try and connect and yourself
what were the reasons you wentinto this arrangement to start
with.
Remind yourself that there werevery strong, good reasons that
you needed to take this step,whether it were financial
pressures, whether it wasbuilding the financial future
(29:03):
for your family or retirement,whether you were concerned that
the practice would close downand your patients would have no
services if you didn't take thestep.
remember the why.
compassion.
have compassion for yourself inthat context.
there were good reasons, at thetime to do it.
remember that hanging togetherwith your colleagues, creating a
(29:26):
cohesive physician.
Voice is extremely importantdividing and conquering, is a
corporate strategy that, ispowerful and the only way to
mitigate against it is to spendthe time necessary to build a
cohesive, voice for thephysicians.
(29:46):
That is represented by thesmartest and most capable
negotiators and spokespeople foryour group.
this is the time for thesmartest and brightest
physicians to step forward intoleadership so that they can
negotiate on behalf of thewhole, physician, group and
clinical group with theacquirer, the pe, the management
(30:09):
group as, whoever they are.
The other thing is don't assumethat you know the legal
ramifications for any of thecontractual decisions that
you're being asked to make Havesteady, wise, spend the money
that's necessary for good legal.
advice.
finally, remember that yourprofessional identity will
(30:32):
benefit strongly advocating foryour patients and for what's
right.
I have said it my entire career.
good for healthcare and patientcare is good for business.
So you will not be making anymistakes from a business
perspective, advocating for yourpatients and their families and
(30:54):
their wellbeing and thefiduciary responsibility you
have as a physician, a provider,a chiropractor, a nurse
practitioner, a nurse, whateverit is to those patients, you
will never go wrong in yourdecisions if you put the patient
in the center of the decisionmaking process and make the
right decision for them.
(31:15):
you will be respected for that.
it may not work out as well asyou want, but you will always
have the respect of yourpatients, their families, your
colleagues.
and then, remember that, takingcare of yourself, finding
balance between work and homeand.
The rest of life is incrediblyimportant.
(31:36):
Burnt out, tired.
Physicians are not happy and notgood physicians.
So it's your responsibility toadvocate for yourself and your
colleagues, that the workenvironment needs to support
your needs in that regard andfight hard for that.
Rebecca (31:54):
That advice alone has given me chills, like I'm
immediately ready to tackle thisyear.
Just hearing all of that,especially from you, I mean,
you've accomplished so much inyour career, and to see people
doing that in the healthcarespace and reminding us, Hey, you
can achieve all of these things.
By doing exactly what you juststated.
Continue to put patients first,and do the right thing always.
(32:15):
So thank you so much for thatincredible wisdom, and thank you
so much for joining us here onthe Provider's report today.
Betty (32:21):
My pleasure.
Thank you.
Hello everyone and welcome back to another episode
of the Providers Report.
We are really excited here tohave a guest speaker who's going
to talk to us all about thecorporate side of healthcare and
what it looks like today, whatit used to look like, what are
some of the pros with some ofthese new structures, and what
should we be on the lookout foras providers.
So Dr.
(00:20):
Betty, thank you so much forjoining us.
Betty (00:23):
I'm very glad to be here and it's a, topic that I have
long had interest, in, And I'mexcited, for today's
conversation.
Rebecca (00:31):
only that, it looks like you have the perfect amount
of experience with this topic aswell.
Your resume is very impressive.
Could you start by telling us alittle bit about everything
you've done so far in yourcareer?
Betty (00:43):
Sure.
the core of my professional,identity is as a general
internist.
I was in practice for over 25years.
The last five years of that,career at the University of
Rochester, I was the medicaldirector for the Center for
Primary Care.
I then, left to found ahealthcare, information
(01:04):
technology company, a populationhealth company, which, was
acquired by NextGen Healthcare,which is a publicly traded, very
corporate, entity.
and, ended my career being,their chief medical officer for,
three years, have been doingconsulting work, in, retirement.
Rebecca (01:23):
I love the quote unquote retirement.
For those of you who don't havethe video accessible, quote
unquote, retirement, I feel likeis so popular amongst healthcare
providers who have done exactlywhat you've done.
We transition out of thatclinical practice, you know, we
either open up amazing companiesor we work with amazing
companies for the greater good.
it sounds like you were verymuch trying to leave your mark
(01:44):
with your professional career,so thank you for all you've
done.
Betty (01:48):
Sure, sure.
Thank
Rebecca (01:50):
Yeah.
So for those of you listening,if this topic is relatively new
for you, I did want to startwith a brief definition of what
private equity ownership lookslike in healthcare, So the
definition is really referringto.
When investment firms or othercompanies can acquire and manage
some healthcare businesses, likesome of the ones that she just
mentioned, and this can be for avariety of reasons.
(02:11):
hospitals and physician groupsand urgent care centers are some
great examples of how thisbusiness acquisition comes into
play.
so I wanted to pick your brainon why do you think this has
become so popular in healthcarethese days?
Betty (02:26):
So, let's look for a moment just at the scope of this
issue.
In, the last, 10, 12, 13 years,1 trillion with a t dollars have
flowed from private equity intoacquisitions and investments.
In, healthcare, and it'simportant to, understand that.
(02:48):
there's a specific businessmodel to private equity,
investment, which is ainvestment structure to be
relatively short term, usuallybetween four and six years of
investment.
That includes a restructuring a,Re, imagining a redesign of the
asset that has, been acquiredand a relatively short
(03:11):
turnaround to create,profitability and then, divest
that.
asset for a profit.
the reason that healthcare hasbeen so attractive and has,
garnered all of this, hugeinvestment is that it is a
source of reliable, flow ofcash.
(03:33):
Much of the, financialactivities in healthcare are
backed by Medicare and Medicaid,which are, the US government.
So there's assurance that thatflow of cash, continues if you
follow, the money, that's why,private equity has been coming
in additionally, Healthcare hasbeen a market that is still very
(03:54):
fragmented.
So there was great opportunityfor consolidation, which is one
of the, mechanisms that privateequity applies to, gain
profitability is consolidating,creating economies of scale in
their approach.
other reasons were that from aregulatory perspective, there
were very low.
(04:14):
bars to enter the market becausethere's really not much
regulation on who buys, whosells, who acquires.
And speaks to one of the biggestproblems about talking about
this area is that we don't knowexactly.
How much of this is going on,where it's going on?
There's a lot of obliqueness inthese deals.
(04:37):
and there are no rules orregulations about having to
expose or declare or, advertise,these shifts in ownership and
investment.
Rebecca (04:47):
Oof.
That is a lot.
I mean, I can definitely nowunderstand.
By hearing it from you, why itis so attractive.
You know, if you happen to besitting on millions of dollars
and you're looking forinvestment opportunities, you
want the biggest return andtypically the quickest return.
So that makes perfect sense.
do you think, I mean, let's chatabout some pros and cons.
(05:09):
I think my brain is particularlybiased.
I tend to love systems andefficiency, and I know that.
working with other companies andmanaging companies with other
organizations typically gets youthere.
So I imagine that might be oneof the major pros with, some of
this acquisition.
But in your mind, what are someof the pros and cons to working
(05:30):
with other companies like thisand agreeing to do this type of
investing?
Betty (05:35):
So let's start with the pros.
traditionally, healthcareorganizations, have not enjoyed
the.
Highest, level of, corporate,management and tools.
Many of them are smallerpractices, physician led, where
the skill sets of thosephysicians really are focused on
clinical medicine.
They excel at that, and don'tnecessarily bring, the sharpest
(05:59):
tools to, management efficiency.
Application of technology,choice of technology, deployment
of technology, finance, andfunding, which are some of the
challenges that practices facein today's healthcare
environment.
So an influx of managementexpertise, finance expertise,
creating sensible debt,restructuring, nonsensical,
(06:23):
debt, managing assets like realestate and space and HR and
staffing and economies of scaleand purchasing and.
negotiating with healthcareinsurance companies on, better
rates.
Are all capabilities that, theseprivate equity companies, the
good ones really can contributetremendously to, practices and
(06:46):
have done so.
additionally, it, can relievephysicians of incredibly
stressful financialcircumstances.
They can find themselves,particularly the ambulatory
space where reimbursement isless lucrative than, procedure
driven inpatient, space.
(07:07):
it can provide a flux of cashthat solves, financial, problems
and also allows physicianswho've spent a career equity in
a practice allow them to,materialize or cash out, on the
value that they've built.
And I see that as fair and, andvery reasonable.
(07:28):
trouble is that it comes with aof cons.
The major and biggest one isthat physicians providers of a
variety of kinds lose.
autonomy.
So once you have sold yourpractice, you, have given over,
(07:49):
decision making power thedirection, the culture, the
requirements, the structure, theHR regulations, the focus, the
priorities of the practice tosomeone else.
for physicians we are, somewhat,control freaks.
that is a very difficult, thingto do.
(08:11):
And the second thing is that itcreates A slew of ethical
challenges that have to do withdriving priorities in healthcare
based on profitability andefficiency rather than patient
and family benefit.
That is a con that cannot bespoken away, negotiated away,
(08:33):
rationalized the way it's thereand needs to be.
faced square on, and there are,we'll talk, I'm sure later in
the conversation about ways tomitigate, these issues, but they
are real.
Rebecca (08:45):
Yeah, they're definitely real.
And I think a lot of ourlisteners definitely have a
strong affinity toward morevalue-based care,
patient-centered approaches.
And, you know, in my naivety, Ienvision a world where we're
able to do both.
I want to see high efficiency.
In our systems, in ourorganizations, our hospitals,
but at the same time, I neverwant to lose, that value-based
(09:08):
care, and I know you have tonsof experience in that world.
Long story short, do you thinkthat world exists?
Can we attain that?
Betty (09:16):
So, I'm a born optimist.
So the answer is yes, thereprobably is a best of both
worlds model, but it requiresboth sides, to apply a fair
amount of, wisdom to the waythese deals are structured and
possibly, the need forregulatory intervention, for
(09:37):
example.
Should we allow private equityto own a hundred percent of
these publicly necessary assets?
a hospital in a rural area,which is the only hospital
serving that area, should weallow private equity to, own a
hundred percent of it, or shouldwe limit ownership of private
(09:57):
equity?
Allow them to have a stake and,gain from the profitability of
their organization.
But for example, not.
Bankrupt it, not sell it, or,not run it, in ways that aren't
supportive of that community.
That is an example where youcould enjoy the best of both
(10:18):
worlds.
I think it would reduce theprofitability and the control
that private equity has andtherefore make it a bit less
attractive to them.
20% of hospital systems that,went, bankrupt
Rebecca (10:31):
Okay.
Betty (10:31):
private equity owned and the unscrupulous, private equity
companies that had, entered thespace, or even if they weren't
unscrupulous, but justunsuccessful, basically, we'll
do anything to gain the profitthat they promised their
investors, for example.
(10:51):
mortgaging or using, hospital,estate assets as leverage for
loans.
So hospitals suddenly findthemselves owing a great deal,
of money or the private equity,company owes a great deal of
money that they have borrowed topay back investors or reinvest,
(11:12):
and the collateral for thoseloans are the hospital.
real estate and if somethinggoes wrong with the deal, then
there's a big mass.
There are, examples of, hospitalsystems being saved by, and,
managing to get back to,stability because of private
equity investment.
But there are examples ofhospital systems who have.
(11:36):
not being successful in thatmodel.
There is beginning to be, Icannot say that it's common,
it's still a rarity, but,physician practices that are
buying themselves back fromprivate equity, sometimes in the
context of.
Multiple hand changes becausethere's nothing to stop a
private equity firm from sellingyou to another private equity
(12:00):
firm that then can turn aroundand sell you again.
The, these changes all entailchanges in culture, changes in
leadership, changes inmanagement, very disruptive to
the practice.
So in a few ca, there are a fewexamples.
When I looked at the literaturein preparation for today, there
are a few examples.
Of practices that have toreverse the decision to, to
(12:23):
enter into private equity,relationships.
Even though the, the, I have tobe clear, this is the minority
at this time,
Rebecca (12:31):
Yeah, that's interesting.
I recently started hearing ofthat, within the last year as
well.
And obviously the reasons forthat tend to have a lot to do
with autonomy for the providersand just.
Getting back that old schoolfeeling of a smaller practice or
a smaller hospital.
actually across the street frommy own practice, there was a
very long established primarycare facility.
(12:53):
the two providers there,practiced for almost 60 years.
and they eventually did getbought out by one of the big
hospitals in my city of GrandRapids, Michigan.
toward the end they had theoption to either.
Buy themselves back, like youmentioned, and have someone take
it over like a younger primarycare doc.
And they were kind of at thatfork in the road where the best
(13:14):
decision for them due to, youknow, being so close to
retirement was just to kind ofbe done.
All of the patients, of course,had to find a different, primary
care office within that hospitalstructure.
But it was such a strange endingand I feel like that's.
That wasn't the norm withprivate practice owners before.
you had a successor to yourpractice who carried out some of
the great, traditions that youinstilled in that facility.
(13:38):
Do you think that there's goingto be more regulation or are
there any insights as to whatthat future might be?
Betty (13:45):
Yeah.
Well, it's, it's, it's really avery complex system you think of
it.
There are also, um.
There are non-for-profitentities in healthcare.
There are for-profit entities.
So it used to be an oxymoronthat a hospital was for-profit,
but there now are very largehospital systems that are
for-profit.
And then there's the privateequity, model.
(14:08):
So in a certain way you take theprofit motive and you put it on
steroids in private equity, butthere are still for-profit
forces occurring in healthcare.
It's interesting to me thedecision whether or not to,
participate in a private equitydecision as a practitioner,
(14:29):
whether hospital owned or, stillrarely in private practices as
solo or group owners of apractice.
That decision changes and variesat the age of the practitioners.
you mentioned it that thesecolleagues of yours were at the
end of their career.
(14:49):
Where they likely didn't have,if the culture turned to one
that they didn't appreciate,they didn't have a long time to
work in that environment.
So the motive for them of havingfinancial benefit from a
practice and an entity that theybuilt over their careers, and I
respect that totally, is strong.
(15:11):
Versus a young practitionercoming outta residency who has.
two, three years, five years inpractice and has another 25 to
look forward to for them.
The decision of who calls theshots, what will the shots be,
how they impact their life workbalance, how they impact the
style of practice that they can,practice in very much more
(15:33):
critical than the benefit at theend of their career from the
financial asset, even thoughthat's.
in long term, in long rangeplanning, it's important as
well.
So what you see often inpractices that have varied,
career stages in them, that whenthe deci time comes to make the
decision whether or not to gowith private equity.
(15:55):
That it's very hard to findconsensus sometimes because the
motivation and the,considerations at different
stages in your career have to beand are very, very different
when you ask what the futureholds, I am not sure that the
private equity bus, has slowedor is going to slow anytime
(16:20):
soon.
I hope, I'm not sure that in thecurrent environment that's going
to happen, but that eventuallyat the state level, possibly
there will be regulatory,requirements to, avoid some of
the debacle and disasters thathave occurred.
The other thing is that we needto continue to get better at
(16:42):
managing quality of care.
So that we can measure qualityof care across the different,
financing and ownership modelsto come out with clear
conclusions.
initial indications are thatprivate equity doesn't do so
well with quality.
the outcomes that are beingmeasured are not as good in
(17:03):
private equity owned as in not,and patient satisfaction and
physician, satisfaction are notas good in private equity,
owned.
On management efficiency,measurements, they're doing a
bit better.
So that those are areas wherethere actually is some benefit,
but the future to be successfulin this space, patient advocacy,
(17:27):
and quality will have to,prevail.
One of the things that was verydisturbing to me was reading.
The fact that there has been ahuge influx of private equity
money into the hospice space.
Rebecca (17:41):
Oh, I know nothing about that.
Enlighten us.
Betty (17:44):
Yeah.
Yeah.
So hospice is a very, unique,service.
Think about it, it's a serviceevery person will only need once
in their life.
There's no return business.
you go through hospice once.
The second thing is that it's afully cap from a Medicare
perspective, from a paymentperspective, it's a fully
(18:06):
capitated service.
whether you offer a hospicepatient, a lot of services for
your daily dollar amount, orvery few is very difficult to
manage and, control.
so a private equity company canbuy a hospice and cut back on
services, but the payment forthose hospice days doesn't
(18:30):
change.
It also encourages, unscrupulousgroup cherry pick those hospice
patients who will be in hospicefor the longest time, but need
very few services.
So, financially, privilegedpatients who can get services
from elsewhere and will rely onhospice less for everything.
(18:51):
Patients with longer prognosisand less impactful, malignancies
who are still relatively highfunctioning, but have a six
month prognosis and they getonto hospice.
And then the question is, whatregulations will be in place to
protect the non-profitablepatients?
(19:11):
What happens in terms of anequity in healthcare issue is if
we don't have enough equity andaccess issues, what happens to
those patients in hospice or inarm, ophthalmology office, or
primary care office, or anoncology office, or an
ophthalmology office?
Who for whatever reason are socomplicated, whose prognosis is
(19:33):
so complicated by their diseaseand, social determinants of
health, that they would be aburden on any system who takes
care of them when?
When an entity that iscompletely driven by for-profit,
motivation chooses not to carefor them or chooses to drop them
or make a few efforts to carefor them, and then kind of,
(19:55):
separate from them either by,just by attrition or by just not
offering the kind of surfacesthat they need.
that's part of the ethical,concerns in this space.
And I thought that for a casestudy or just for your listeners
to.
Think about the implications ofthis is to think of the hospice
(20:16):
space because it's so clear.
is so fraught with bothopportunity for compassionate,
cost effective, care on the onehand, and on the other hand,
because of its payment structureand.
The fact that there isn't returnbusiness and people don't
choose, you know, to, you don'tchoose your hospice.
You can't switch hospices easilyby that time, you're quite sick.
(20:39):
And it's a very, interesting,case study.
the entrance of, private equityinto hospice care.
On the other hand, reading aboutit, there are.
Models of primary care that havebeen more successful than other
models.
But again, there's one, nationalprivate equity company that
(21:00):
created a concierge medicine,primary care model.
The trouble with that is thatit's concierge medicine.
So what happens to people whocan't pay$2,000 a year to get
special, privileges andwonderful healthcare or what
happens, to patients who don'thave access?
(21:20):
It's not in their community anddo we want to create a two tier
or at least two tier healthcaresystem where those who have get
a bit better and those who havenot, don't.
Rebecca (21:30):
Exactly.
That is such a good examplebecause even if you're, you
know, you're listening andyou're a private practice owner
in a small rural town, maybe youdon't have any experience with
hospital structures or privateequity in general.
That example right there makessense to everyone.
it really paints the picture ofwhat this looks like and what
problems are around this modeland how we have to make sure
(21:53):
that we're not forgetting thatas we continue to grow with this
new healthcare system and howthings are developing.
yeah, I'm super passionate aboutpatient access and.
It sounds crazy, but I view itas the modern day like caste
system.
If you think about it, this isdifferent.
I mean, obviously it's pullingin socioeconomic status, but
we're literally tearing peoplewith healthcare needs.
(22:17):
in my mind, it's borderlinediabolical and I understand
that.
finances will always be there.
It's always going to be anissue, but if we lose sight of
what's important here and wechange the quality of care that
people are getting based on whatthey can afford, we're gonna
have some larger problems.
And we're already findingevidence of that in the United
States right now.
Betty (22:37):
Yeah.
Amen.
I think in the context of thisconversation, it's so important
to also maintain.
compassion and understanding forpractices that find themselves
up against the financial wall ina, rural area.
For example, a hospital systemwhere, census is down, Medicare
(23:01):
reimbursement is down.
and the community is desperateto keep a hospital open.
equity there comes in as asavior, and I understand that
and I respect that.
are some.
Extremely thoughtful privateequity companies.
I've had the privilege to, workwith, briefly and talk to some
(23:22):
people in those environments whocare deeply about quality the
idea is to try and choosepartners that are like-minded
and, principled who don't wantto, turn a profit in two years,
that they have the longer term,four to six to seven, years.
And particularly important tochoose a partner who has a track
(23:45):
record that is a positive andsuccessful one, and avoid,
promises for, you know, pot ofgold at the end of the rainbow,
where the, the track record is,is horrendous.
important to speak to your.
and people who've gone throughit.
Rebecca (24:05):
Yeah.
Betty (24:06):
listen to your, not to, ignore the red flags, explore
the red flags, sit with them,talk to people.
Get excellent legal advicebecause how these deals are
structured can make or break,your practice's, future.
Rebecca (24:24):
Absolutely.
I wanted to use that as a seguebecause I know that you have
some experience with, I believe,selling a company that you
founded.
and you touch on the importanceof selecting partners.
And a lot of our listeners, evenif they work for a hospital
structure or a private practice,a lot of the people listening
are naturally.
Seeking other options for theircareer.
(24:45):
They will probably go on one dayto open up other companies and
work with other businesses.
I would love to talk about whatyou did and how you decided who
to partner with and what thatrelationship looked like and how
things have developed sincethen.
Betty (24:59):
So, this is kind of.
Switching gears quitesignificantly because the
company I founded and sold was ahealthcare information
technology company, a populationhealth management software,
platform that we, sold alongwith the company, of course.
and that's very different thanthe decision making process in
(25:21):
the context of, practice, butstill.
The same considerations werealive and well in that decision.
There can be a decision to doyou continue building the
business.
What timing is right for you tosell the business?
(25:42):
Will your existing customersbenefit or suffer, with an
acquisition?
will you be required to changethe area of focus of the company
and the way you have served themand the kind of customer service
that they had gotten used togetting from a startup and from
a small company becoming part ofa corporation, and does the
(26:04):
corporation view.
Healthcare technology,healthcare as a whole, the
mission of healthcare, themission of healthcare technology
in ways that you can, so can yousit in a corporate office with
them without cringing?
Now, interestingly in our case,it would be, disingenuous if I
said that we had four suitorsand we chose.
(26:29):
The most likely we had a suiter,that happened to be in the right
place at the right time in ourdevelopmental stage and their
needs as an organization, wehappened to be extremely lucky
that that partnership worked outextremely well.
Rebecca (26:44):
I love that.
Betty (26:45):
so I, felt incredibly comfortable with the mission
vision, of, NextGen when wejoined it.
and enjoyed the few yearssomewhat disrupted by, the end
of my career with COVID.
But, it happened, to work out,well, All of these decisions
(27:07):
are, often, made in a certaincontext and with certain,
limitations and pressures thatyou had.
We.
It was, it's hard to know.
You always think to yourselfwhat would've happened had we
continued as an independent,startup.
(27:27):
I think we made the rightdecision at the right time.
I don't think it would've turnedout as well for our customers,
the product, or, for myself,personally, I.
Tremendously enjoyed theopportunity to work for a
publicly traded company for thelast three years of my career.
Never dreamt that would be athing.
learned so much and metincredible people.
Traveled the country and,learned so much more about
(27:50):
healthcare than I knew from, aninsulated academic practice for
many years in Rochester, NewYork.
So.
Rebecca (27:57):
that we're ending on that because that is what I want
with this podcast, is to maybeput some ideas in our listeners'
brains that they otherwisewouldn't have thought of.
You know, some of our listeners,have never heard of private
equity getting involved withhealthcare, but you paint such
an easy picture for us withoutexperience in this part of the
industry to get that picture andunderstand, okay, this is why
(28:18):
this exists.
and I think you do a really goodjob at that.
So thank you so much.
to close, could you perhaps giveus some advice for our listeners
who are currently practicing ina hospital or facility that has
been acquired by a privateequity, maybe some advice on how
to mitigate that and navigatethose waters while still
maintaining a higher level ofpatient care.
Betty (28:42):
First and foremost is to try and connect and yourself
what were the reasons you wentinto this arrangement to start
with.
Remind yourself that there werevery strong, good reasons that
you needed to take this step,whether it were financial
pressures, whether it wasbuilding the financial future
(29:03):
for your family or retirement,whether you were concerned that
the practice would close downand your patients would have no
services if you didn't take thestep.
remember the why.
compassion.
have compassion for yourself inthat context.
there were good reasons, at thetime to do it.
remember that hanging togetherwith your colleagues, creating a
(29:26):
cohesive physician.
Voice is extremely importantdividing and conquering, is a
corporate strategy that, ispowerful and the only way to
mitigate against it is to spendthe time necessary to build a
cohesive, voice for thephysicians.
(29:46):
That is represented by thesmartest and most capable
negotiators and spokespeople foryour group.
this is the time for thesmartest and brightest
physicians to step forward intoleadership so that they can
negotiate on behalf of thewhole, physician, group and
clinical group with theacquirer, the pe, the management
(30:09):
group as, whoever they are.
The other thing is don't assumethat you know the legal
ramifications for any of thecontractual decisions that
you're being asked to make Havesteady, wise, spend the money
that's necessary for good legal.
advice.
finally, remember that yourprofessional identity will
(30:32):
benefit strongly advocating foryour patients and for what's
right.
I have said it my entire career.
good for healthcare and patientcare is good for business.
So you will not be making anymistakes from a business
perspective, advocating for yourpatients and their families and
(30:54):
their wellbeing and thefiduciary responsibility you
have as a physician, a provider,a chiropractor, a nurse
practitioner, a nurse, whateverit is to those patients, you
will never go wrong in yourdecisions if you put the patient
in the center of the decisionmaking process and make the
right decision for them.
(31:15):
you will be respected for that.
it may not work out as well asyou want, but you will always
have the respect of yourpatients, their families, your
colleagues.
and then, remember that, takingcare of yourself, finding
balance between work and homeand.
The rest of life is incrediblyimportant.
(31:36):
Burnt out, tired.
Physicians are not happy and notgood physicians.
So it's your responsibility toadvocate for yourself and your
colleagues, that the workenvironment needs to support
your needs in that regard andfight hard for that.
Rebecca (31:54):
That advice alone has given me chills, like I'm
immediately ready to tackle thisyear.
Just hearing all of that,especially from you, I mean,
you've accomplished so much inyour career, and to see people
doing that in the healthcarespace and reminding us, Hey, you
can achieve all of these things.
By doing exactly what you juststated.
Continue to put patients first,and do the right thing always.
(32:15):
So thank you so much for thatincredible wisdom, and thank you
so much for joining us here onthe Provider's report today.
Betty (32:21):
My pleasure.
Thank you.
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