When markets consolidate

A view from the inside

It is interesting to see how an insider in the not-for-profit sector sees this marketplace. His blog tell us about this. I have followed many of the things that Dr Sxxxxx Jxxx has said and most of the time I agree with him and like his approach. One warms to his humanity and his mission.

He now believes that operating in a Niche market and providing excellent care will carry him through. He believes that competition will allow him to do this. He may be able to survive and keep his mission alive there but he has a wider responsibility to the community and I don't think he is meeting that.

Jxxx manages not-for-profit Hxxxxxxcare.  I think he has lost the plot and I am writing this page as a direct challenge to him. He planned to write 6 blogs but I could only find four.

I don’t think he has any idea of how ruthless the marketplace can be and while he remains critical of the focus on profits he skates around the issues. At the beginning of the previous page “Not-for-profit operators” I quoted from an article by Robert Kuttner describing what happened in health care when it consolidated. Jxxx should read it.

This is what he needs to be prepared for and what Jxxx proposes will only work for niche players. If the niche is large enough or can be made more profitable then the for-profits will come after it.  But what about the rest of aged care?  It he going to desert it and leave it to the for-profits.

First lets look at what Jxxx has said on his blog:

In this blog Jxxx claims that competition will be on quality, differentiated product and price.

• Competition on quality requires a system of transparently collected data and a customer competent to assess that data and with the power to insist on what she wants.  That does not exist in aged care.  Without it a competitive market cannot work.
• A differentiated product presumably means finding special niche segments that you can be an expert in. This can work provided your niche is small enough else the big companies will come after it.
• When you compete on price those with money are served rather than those in need who don’t have it. Not quite what a faith based company with a mission should be supporting.

The two groups he sees as losers are the undifferentiated metro services and the rural services. The majority of users will go to a facility near families and friends and these will be undifferentiated services. In addition the elderly have multiple different morbidities and multiple different needs. A highly differentiated service will not serve them well.

Jxxx overlooks the fact that marketing is the most important factor for success in a competitive market and that the aged are not shoppers and do not move around. They trust others to help them. They tend to stay near families and friends and that is wise as in a marketplace you need someone you know well to watch over you. 

When a nursing home becomes a loser, the real losers are not the managers and owners, but the residents and their families.

Sadly in our society, marketing dominates and the wealthy will opt for the luxury and the “presence” that accompanies it. As a socially responsible community we need to be concerned for them too. And as far as mud is concerned, it has been flying since 2000 and the public is so disinterested that no one notices.  It doesn't hit the fan often and when it does it is soon forgotten.

As regards excellence Jxxx relies on expensive process and that has its limits.  It can discourage empathy and inhibit our humanity. What about care motivated by compassion and understanding, the sort of culture that develops in smaller and more personal groups and in the communities where aged care really belongs. When people like this are involved and engaged in what they do their humanity can become infectious. We need the sort of care that listens to people and provides them the opportunity to realise themselves in their interaction with others. In large structured entities and in a competitive market there is little space for this.

Jxxx is quite correct if this were a functioning market but he is under the illusion that this is a market that is working and has not failed. A market that fails because there is no transparency and no effective customer does the very opposite. It preys on those it should be serving.  If you look around you will see that this is happening and not only in aged care.

Jxxx looks at the investors and hopes that they will change the way they assess aged care. That credits them with humanity and that is a luxury they cannot afford.

Jxxx is telling us that there are going to be losers and lots of them. What sort of mission has he embraced. These are our vulnerable seniors, surrounded by anxious and confused family members at times of great stress. One suspects that Jxxx’s mission has slipped a bit!

What sort of new information is he talking about.  Those of us who look see conmen selling snake oil and an unreliable and complex accreditation process.

Government regulation has not worked in the face of a strongly competitive aged care market in any country. But government in Australia. is actively abandoning regulation without replacing it with any alternative.

The implication is that government should abandon its responsibility to its citizens and should simply hand it all over to the ruthless marketplace and depend on Jxxx to keep them honest. The UK government has done just this.

It handed care over to the marketplace and then insisted they provide the cheap care they had promised by reducing their funding. Their regulator was ineffective. The government won financially by betraying the industry that they had promised to support but the industry had already betrayed them.  If it was about the economy then it was win win for the UK government. 

Elderly Britons have been left without care as companies tried to maintain profitability while they struggled to exit the sector.  There has been no win win in what they experienced.

Jxxx has some problems: He seems to have swallowed the rhetoric about markets and improvement through competition. He needs to do a fact check. Look at Richard Baldwins article and his thesis. Look at what has happened in countries that like ours have embraced a free market system in aged care.  Look at the data that has been coming out of the USA for the last 30 years.

What about the residents in the 'losers' homes?: Jxxx acknowledges that there will be 'losers' as well as 'winners'. He conveniently overlooks the consequences for the frail elderly trapped in this system.

Losers struggle and in a marketplace they are not supported by the winners who benefit from their demise.  Jxxx conveniently does not write about the consequences for the residents in the homes owned by the 'losers'. What will happen to them as their owners struggle financially and then go under.

Poor providers do not collapse overnight. They struggle on for years and during that time they struggle to contain costs. The residents are not served and may be harmed.  Few of the residents that find themselves in a facility that is a loser realised the risks they were running by admitting themselves to a home that was once committed to providing the services they needed, and not prepared to do the cost cutting required to maintain viability until too late.

Jxxx does not examine what life is like for the residents in the homes owned by the winners as they struggle to build the profits they need to be winners.   Look at what has happened in private equity owned facilities in the USA and in the UK and that reports suggest is happening in some in Australia.

Aged care should be there to provide the best care our community can to all citizens, and not for the excitement of competing, nor for one organisation to succeed at the expense of others because it can market itself better - or even to succeed by providing successful differentiated services, if this leaves others providing inferior services, because they are not in a position (eg. locality) where they can differentiate.

Better ways of getting what Jxxx wants

Rejigging the marketplace: There are ways of getting rid of poor operators without harming the residents but that would require a properly regulated market, one that regulates to meet the needs of the seniors and puts this ahead of the illusions of the economists.

If for example providers of aged care were prohibited from being owners of the facilities they managed and communities were made the customer for both owners and providers. The community would then negotiate with the owners to rent the facilities.  They would employ the operators to provide services in those facilities.

They would be able to replace any that did not provide the sort of care they wanted. The market would then operate effectively and in the best interests of the community and its older members rather than the providers.

What happens to those who believe when it doesn't work

Many aged care providers in the USA, like Jxxx, started out with the best of intentions believing the market would work. The market dictated otherwise and step by step these providers compromised rather than admit they were wrong and fail. They were trapped.  Even when faced by overwhelming evidence they were unable to acknowledge that their belief had been misplaced and that the care they were providing was substandard.

Hxxxxxxcare has been one of the really good providers in aged care. and a role model for others but can that be maintained as he tries to compete?

On the Glassdoor employment website Hxxxxxxcare has two reviews. The second makes some positive comment about the experience gained but then has some criticisms. It is only two reviews but is this a sign of this beginning to happen?

Survival

It is clear from what he has written elsewhere that Jxxx clearly feels that not-for-profits with a mission can survive this and succeed by providing good care, particularly if they specialise to provide specialised types of care. He is very positive about the benefits of competition. I hope that he is right and that he has discovered how this will work and has learned from what happened elsewhere. The information in the next two sliders illustrate what has happened in similar markets elsewhere.

Jxxx is not alone

The new chairman ACSA, the body representing not-for-profits has just published an article claiming that not-for-profits in Australia will do better that they have in other countries. It is interesting that they too have been building up strong balance sheets with the extra funding that came with the Living Longer Living Better program.  This is probably in order to protect themselves, which may be why some of them are now also being accused of not providing the sort of care that residents expect.

I note that in spite of ACSA members' strong balance sheets their CEO is mounting a campaign to get more money from government.  This was after the government blocked funding after large numbers of providers upcoded, lodging claims for extra services to which they were not entitled.

The Community Aged Care Hub

I know what Jxxx wants and we would like that too but I think a factcheck will show that while he might manage to secure a niche for himself and his company this will be by abandoning any social responsibility to the rest of the community and its seniors.

What is needed is a market that works properly. For that you need an effective customer and an effective community (civil society). That is what the proposed aged care community hub would hope to achieve. There would be some prospect of giving Jxxx the sensible functioning market be wants. We would welcome support from him and hope he will come to his senses and give it to us.

Jxxx predicts that competition will become more intense. It is clear that the share market and private equity will be the two forces driving this competitive consolidation. I examined a vast amount of material from the USA when it went through this process in the late 1980's and 1990s, first in health care, particularly hospitals and then in nursing home care. At that time private equity had not entered the sector. Its advent has increased the pressures for profit and ramped up the pressure.

The hub proposal I am suggesting has considered what happened in the USA and the UK and is specifically designed to prevent that from happening in Australia. It is intended to ensure that Jxxx and his company, as well as others like him do survive and that their mission, which I agree is important for good care, and the specialised services which I agree are needed can withstand the pressures.

The illusion I suspect he has, is that good care has anything to do with success in this marketplace. That is a common misconception. My argument is that, in the sort of competitive consolidating market we are likely to have, good care does the very opposite. It makes you vulnerable and stops you from performing well in the market.

Even if he can succeed in this marketplace, I suggest he would be even more successful in the sort of marketplace where there is a consumer backed by an informed and effective community customer (the hub), one that will recognise and support the sort of service he hopes to provide.

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Hospitals: Consolidation, acquisitions and growth

Globalisation was also a large issue in the 1990s. In 2000 I wrote a web page describing how Australia, under the Howard government, was eagerly participating. The big US companies were pushing the USA government to make health care part of the globalisation agenda. The feeding frenzy in the USA extended to acquisitions in other countries and Australia was a target. Our government was welcoming but fortunately it did not happen as they intended. It is worrying therefore that a document surfaced in Jan 2015 indicating that the Abbott government has been secretly negotiating trade agreement.  An agreement with China has now been completed and more are being negotiated. It is clear that the markets that our politicians want to exploit are those in Asia.  To do that we need large home grown corporations, both market listed and private equity, with the capacity to compete globallly.  The evidence  clearly indicates that these groups provide inferior staffing and care.

The frauds in the USA: What happened in the USA in the 1980s and 1990s was not deliberately planned wickedness. Many believed that what they were doing was acceptable - even beneficial and good for care. They were sitting in their vast offices high up in skyscrapers and either could not hear, did not acknowledge the consequences, or persuaded themselves that financial success indicated good care.

This was a hierarchical system so they remained isolated at the top - and there were always reasons that could be found to discredit critics. They strongly denied any allegations made. By the time the denial below was made the company was well down the path to a culturopathy. Within a few years its practices would appall the nation and result in a criminal conviction.

Illustrative quotes from the USA

General:

For-profit Hospitals

Not-for-profit Hospitals

Not for profits were trapped because their mission of care did not give them a competitive advantage and drained their profits. They were put under intense pressure. Either they adopted similar practices or they became easy pickings. Their acquisition by large for profit hospital chains was helped by encouraging the existing managers of the not-for-profit to sell or merge. The chains offered to retain them on a much higher salary.

The industry was well represented in parliament by the Frist family, who founded Columbia/HCA. There was intense lobbying and large political donations by all hospital and aged care corporations.

Representative Fortney Pete Stark was one of the few who tried to do something about what was happening. Over the years he succeeded in getting some restraining laws passed and is best known for the legislation prohibiting kickbacks to doctors. In the extract below he speaks to legislation to contain for profit hospitals takeover of not-for-profit hospitals.

Columbia/HCA was building its empire rapidly. The legislation was also an attempt to ensure that accreditation bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) were no longer subject to control by corporations.

Specialist Hospitals

The scandals that engulfed the specialist hospitals in 1991 are commonly thought to have been about psychiatric hospitals as that was where it was exposed and where most care was directed. But the same or similar things happened in substance abuse hospitals, which were included in the same fraud court cases. There were allegations of similar conduct in rehabilitation hospitals and I was aware of concerns that similar practices had occurred in one company's General Hospitals. I spoke about this to an FBI fraud investigator in 1993 and was told they were aware of this but that they simply did not have the resources to widen their investigations.

National Medical Enterprises: I was interested in one particular company, National Medical Enterprises (NME), which had entered Australia and been granted licenses to operate in NSW and West Australia. I had lodged objections and went to the USA to investigate. Many others had behaved similarly but I did not collect that material. I saw much more than I could take with me and some that never became public.

I have more information and internal documents about NME's wholly owned subsidiaries, Psychiatric Institutes of America (PIA), its psychiatric division, and Recovery Centers of America, its substance abuse subsidiary, than on any other company. They provide a wonderful insight into how large numbers of people can become highly motivated and driven when they lose touch with the real world and create an illusionary one. Incredible as it may seem and in spite of all the inconsistencies, many if not most of them thought they were so successful because they were providing good care. People who had doubts were not team players. They were not welcomed and soon went elsewhere.

This is readily apparent from internal documents. This company focused on marketing and on getting people into hospital in any way that they could. They tracked every step of the recruitment and hospitalisation on a computer program to be sure as few as possible escaped. They paid bounty hunters to go into the community to persuade anyone who could be persuaded they had a problem into hospital. The company kept them there for as long as they could and concentrated on getting as much profit from each patient each day as they could.

They had designed a 'programmatic system of care' that aimed to provide as much treatment as possible each day. Psychiatrists who were team players handed their patients over to the company's treatment program and became wealthy. Those who would not were not supported and starved.

By using the words and practices of business terminology to create a new medical world, humanitarian and ethical principles could be denigrated and abhorrent practices became legitimate. It was a very efficient system - for making money.

Stockbrokers heaped praise on this and the company was the darling of the share market.

The prosecutor in Texas told me that all of their hospitals in that state were fully accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). All the company's psychiatry hospitals were also accredited by a psychiatric accreditation body. Neither had detected the problems and seen anything amiss in what was being done.

A psychiatrist described this program of care to the US House of representatives

A hospital administrator describes the pressures in the hospital

Senator Moncrief in Texas was the chair of the first investigation carried out in that state. He gave me access to the records of his inquiry.

Television programs and mental health books were used to fan community anxieties and urged citizens to phone a company hot line manned by people whose instructions were to persuade those who phoned to come for a free mental health assessment. Untrained staff doing these assessments were required to check that the person was financial (insured) then persuade them to commit themselves to hospital for a full assessment. Once there they were trapped. The company tracked each person's "conversion rate" to assess their intake performance. The company's "golden rules" instructed the administrators who managed these employees.

I was also aware as early as 1990 of disturbing business practices and a culture where care was structured for profitability rather than high standards of care in an international general hospital that was making huge profits for this company at the time. One example of this is court evidence that I quoted in a submission I wrote to Tenet's ethics committee in 1996. It is on the Corporate Medicine web site. Go to Section E. Singapore - allegations of trading in patients. The company's International Division was a part of its General Hospital Division in the USA and was managed by that section. When I spoke about my concerns to an FBI agent in the USA in 1993 I asked about their General Hospiatal Division. The agent indicated that they were aware of issues but simply did not have the manpower to investigate.

Living in different worlds: The thing that I found so surprising and difficult to understand was that the world that these companies lived in seemed to be on another science fiction planet, yet incredibly their belief in what they were doing was real to them. They really believed in what they were doing and had no doubts.  They were able to explain away everything and if they could not they became angry and attacked the messenger.  It bore little relationship to the sort of world that most of us thought we lived in.   I will write more about this on other pages.

Rehabilitation Hospitals

In 1998 I researched rehabilitation hospital giant, HealthSouth, when it entered Australia. It had an unblemished record. It had totally dominated the rehabilitation sector acquiring all of its competitors and had not indulged in any of the practices that had tarnished almost all the other successful health care companies.

My argument at that time, that you could not succeed in this marketplace without compromising care or indulging in fraud, seemed to have been disproven. Then in March 2003 a $4 billion accounting fraud by HealthSouth was exposed. It had been working closely with banks and auditors who all ducked for cover.

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Doctors in the USA

In the 1980s the once powerful doctors were targeted by Ronald Reagan's health adviser Joseph Califano. They were gradually forced into contracts with the hospitals, who wanted the doctors to make money for them, and the insurers, who were determined to keep the costs down. 

This was called Managed Care which meant managing the care given by the doctors in the corporate and not the patient's interests.  It is what doctors in Australia have been fighting government and insurers about since 1998. Government keeps trying as their ideology sees controlling doctors as essential for the implementation of their policies.

Doctors in the USA were trapped between the two types of corporate interest.  If they resisted they could be pushed out of the hospitals for not making money or be "delisted" by the insurers who approved or disapproved the care doctors wanted to give their patients.

Their career prospects and their financial security depended on their not confronting what was happening so they were powerless to do what Australian doctors did. Some doctors thought that if they became businessmen themselves and became involved they could influence the system for the better.  That did not work!

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Nursing Homes: Consolidation and growth

I did not go to the USA to investigate nursing homes when Sun Healthcare entered Australia in 1997. I objected to its operating hospitals here on probity grounds and Victoria eventually accepted this and blocked its ambitions there. It became bankrupt.

There was intense criticism of nursing home care in the USA at the end of the 1990s. I developed contacts who were actively pursuing these issues and they sent me vast amounts of information and I gave that, which related to Sun Healthcare, to authorities. I contributed in the USA by distilling this information into a series of web pages that I wrote in 2001. Some in the USA have since found them a useful resource.

The extracts and comments below are based on or come from my introduction to each company on these web pages. There is a vast amount of information. I used many quotes from press reports to tell each company's story. Those selected below are the major nursing homes operating in the USA at the end of the 1990s during the feeding frenzy as large company's grew, acquired and consolidated and during the collapse of this market.

There were thousands of residents in all of these company's nursing homes - expecting to get care while all this intense and stressful commercial activity was going on. It was a never ending stressful and disorienting cycle for staff with each new owner introducing another set of management strategies that it felt would generate more profit. Inevitably the only way to do this was to reduce the major costs, care staff, further. Ways of doing so and explanations were developed.

The response of the US public was to form groups that supported residents' families that had suffered and helped them take legal action. Staff often leaked damning documents. Juries were horrified and awarded massive punitive awards which judges confirmed on appeal. This made the business unprofitable in those states that did not cap the damages awarded, and several of the big for profit companies vacated those states, throwing an increased load on the not-for-profits and putting more pressure on them.

There was intense lobbying by the big companies and they succeeded in having damages capped in some of the states. The nursing homes' insurers paid most of the legal costs and the punitive damages. Insurance costs rose dramatically across the USA and all of the nursing homes including the not-for-profits struggled to make ends meet.

The rapid growth of the for-profit sector during the 1990s was based on vast profits generated from subacute and step-down care, a sector paid on a per item of service basis. This lent itself to over-servicing and rorting. The sector collapsed at the end of the 1990s when government stepped in to stop the rorting and to prosecute fraud. Many of the companies entered voluntary bankruptcy and needed assistance to survive.

At about that time I stopped tracking events in the USA but I think more and more states probably capped the amounts that could be paid in punitive damages. What seems to happen now is that the juries still award massive punitive damages indicating their displeasure at the company's conduct, but the actual amount paid is then negotiated by the parties.

There is an in depth review of what happened during the late 1990s period on a web page called Overview of Corporate Nursing Home Care At the foot of that page are links to additional pages containing representative extracts from a large volume of material published between 1996 and 2003. Much of it is confronting.

Genesis Health Ventures was a company that seemed to start with a mission but the market dictated otherwise.

Mariner Health Group in contrast was a purely business venture by businessmen intent on profit. They started with a company called Grancare that had a very poor record for care. They operated by merging into other companies and assuming their names so repeatedly escaping their bad reputations for care. Mariner was simply the last of these. They spent vast sums with the intention of securing market dominance over large areas and then capitalising on that monopoly to make money. It built up a very large debt.

Sun Healthcare is the US company that came to Australia and I will use later as an example to illustrate culturopathy. Its charismatic founder persuaded politicians in the USA and Australia that you did not need well trained expensive staff to care for the frail elderly. That had consequences for both countries making it legitimate to replace nurses with untrained carers.

Beverly Healthcare was the largest health care chain at the time. In the 1960s and 70s it had gone on a acquisitions spree ending with 1000 nursing homes but in financial trouble. It survived that by selling some but then built up its empire again. During this period it was using a number of strategies to maximise profits from its empire and pay down debt. It paid large fraud fines but was not as heavily leveraged as the other chains and survived the government's crackdown on dysfunctional practices in the late 1990s

Vencor was a very successful company that crashed when politicians stepped in and fraud investigators looked at the company

Integrated Health Services (IHS) was another nursing home that pursued innappropriate strategies and like Sun Healthcare exploited Post Acute Care and came unstuck when government stepped in to stop the rorting.

Extendicare was a Canadian company that jumped on the bandwagon in the USA and retreated back to Canada when it all came unstuck. One of its claims to distinction is the massive punitive damages awarded by juries angered at its nursing home practices.

Fault Lines - Elderly Incorporated (YouTube 20 Sep 2013) introduced as "Fault Lines investigates the business of elderly care, and what happens when corporations put profits ahead of care". I was sent similar video clips and was aware of what was happening in the late 1990s. Politicians in Australia were told but they were focussed on their economic agenda and were not listening.

And the game is still to grow by acquiring not-for-profits and making them profitable. In Philadelphia for example for-profits ownership of nursing homes increased from 49% in 2010 to 63% in 2016.

• For-profits are snapping up nursing homes The Inquirer Daily News 26 June 2016
  
  

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How Australian Health Care Escaped

Australian health care escaped the worst of the US health corporate onslaught and was able to contain the practices of the local companies. This was due to two factors.

The first was the state probity provisions, which although imperfect did the best they could when supplied with information collected from the USA. It made it very difficult for the US companies as they all had poor track records by Australian standards and they got a vast amount of negative publicity as a result.

The second was the independence of the medical profession in Australia and protection given to them by the Australian constitution. They knew what government was planning and warned them in 1996.

The Australian constition prevented the Howard government from forcing doctors to enter into contracts with insurers and hospitals. In 1998 they resisted pressure and refused the contracts offered. Doctors had seen what happened in the USA and were not going to follow that path. They also opposed the entry of some of these companies into Australia.

When Australia's largest hospital corporation, Mayne Health attempted to introduce unethical practices that harmed care, doctors revealed themselves as the real customers and took their patients elsewhere. The company's finances collapsed. It sold all its hospitals and broke up. Having really effective customers whose interests were aligned with those of their patients and who were prepared to use their market power redefined the sort of market we had in health care in Australia. Success now depended on providing the sort of facilities and the sort of staffing that the doctors needed to provide good care. This did not solve all of the problems in the corporatisation of our health system but it was a major factor in keeping them at bay.

Relevance for the proposed hub

I had been worried that Australia would follow the USA, but I had not recognised the key difference in the context here and in the USA - that the doctors had power to act as customer and stop it in its tracks by deciding who wins in health care.

The proposed hub builds on the insight of this experience and it is intended to do in aged care exactly what the doctors did in hospitals, ie change the context within which the market has to operate by creating an effective customer whose interests are aligned with the consumer of the care. This should ensure that ethical conduct and good humanitarian care become the deciding factors in determining who wins and who fails in this marketplace.

I am not suggesting that people in the community and doctors do not act in their own interests, and are not human and vulnerable. It helped that in Australia doctors interests coincided with those of their patients and the community. Hopefully in the proposed hub there would be a balance of interests.

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