Federal Agencies Should Prioritize Equity When Regulating Corporate Concentration in Health Care

On Tuesday, March 5, 2024, the Federal Trade Commission (FTC), Department of Justice (DOJ), and Department of Health and Human Services (HHS) opened public comments for their “Request for Information on Consolidation in Health Care Markets” [Docket No. ATR 102]. Next100 Policy Entrepreneur Nia Johnson submitted the following comment letter on corporate consolidation and private equity ownership in health care based on her experience as a patient advocate and economic policy researcher. This letter urges agencies to focus on reducing racial and class-based disparities exacerbated by greedy, corporate practices as part of their work to address consolidation in health care markets. This letter also calls for agencies to leverage existing authority to scrutinize private equity’s growing influence in health care markets.

Delivered via Regulations.gov
Department of Justice
Department of Health and Human Services
Federal Trade Commission

RE: “Request for Information on Consolidation in Health Care Markets” [Docket No. ATR 102]
June 4, 2024

On behalf of Next100, a think tank committed to elevating the experiences of the most impacted communities and diversifying the policy sector, I am pleased to submit these comments in response to the Federal Trade Commission’s (FTC), Department of Justice’s (DOJ) and Health and Human Services (HHS) Department’s “Request for Information on Consolidation in Health Care Markets” [Docket No. ATR 102].

I applaud the Federal Trade Commission (FTC), the Department of Justice (DOJ), and the Health and Human Services Department (HHS) for investigating the effects of corporate consolidation and ownership in health care. The corporate practice of medicine is an urgent issue for patients and workers, who are increasingly subjected to it. The corporate practice of medicine drives a wedge between patients and health care workers while entrenching the wealth of for-profit entities and private equity firms. As it stands, patients cannot trust that doctors are making decisions based on their medical judgment. The corporate practice of medicine, where private equity firms and for-profit entities not owned by health care workers prioritize profits over patients, pressures doctors to make medical judgments influenced by financial incentives and coercion. Each of these agencies has a unique role in addressing the corporate practice of medicine, which exacerbates health disparities along racial and class lines.

This comment responds to the following questions:

1. Effects of Consolidation: How has a transaction involving health care providers (including providers of home- and community-based services), facilities, or ancillary products or services conducted by private equity funds or other alternative asset managers, health systems, or private payers (e.g., a health system, a private payer, or a private equity fund buying independent ambulatory surgery centers, dialysis clinics, PBMs, GPOs, or nursing homes) affected: (i) Patients, (iii) Providers, health care workers, and support staff.

4. Need for Government Action: What actions should the Department of Health and Human Services, Federal Trade Commission, and United States Department of Justice consider taking to identify and address transactions that, due to market consolidation or corporate control issues, may have major adverse impacts on entities listed in question 1(i)-(iv)?

4.1 Should the agencies promote greater transparency and enhanced availability of information to the public on mergers, acquisitions, and other transactions involving health care facilities, providers, payers, and ancillary products or services, and if so, how?

Response

Patients

Extreme market concentration in the health care system affects health care affordability. I first became aware of market concentration and its harmful impacts in 2011, as a patient advocate for my mother who spent six years in psychiatric treatment using Zyprexa, a generic drug used to treat certain mental disorders. At the time of her treatment, Zyprexa was owned by Eli Lilly, a for-profit company that previously lied about the intended uses and side effects of Zyprexa in medical advertisements.¹ As the price of Zyprexa jumped for patients like my mother who were uninsured and paying out of pocket, the antipsychotic drug made Eli Lilly close to $5 billion per year.² In 2006, the average cost for Eli Lilly’s Zyprexa was under $400, but by 2011, Eli Lilly started charging over $1,000 for this medicine, forcing my mother to choose between stabilizing her mental health or supporting the basic needs of our family as a single, black mother of six. ³

The reason Eli Lilly was able to profit at the expense of my mother and many others in this manner is because they established market dominance over the sale of Zyprexa. Eli Lilly was granted the legal authority to monopolize Zyprexa from 2005 – 2011 via a drug patent.⁴ As a result, Eli Lilly could overcharge for this drug on top of breaking marketing laws regarding the side effects of the drug. Unfortunately, stories like my mother’s reach far beyond the context of drug pricing as the health care system grows increasingly concentrated by for-profit interests, including corporations and private equity firms.

This is also true of the hospital sector, which accounts for $1.3 trillion of health care spending that everyone pays for including the government, workers, taxpayers, and most especially, patients in underserved communities.⁵ For instance, a study of hospital concentration and low-income, Medicaid patients linked hospital concentration to a decline in Medicaid patient admissions.⁶ Other research has also connected the consolidation of hospital systems to lower wages and higher health care prices. One study found that wage growth slowed by 6.8 percent in merging hospitals for nurses and pharmacy workers.⁷ The Institute for New Economic Thinking also found that nurse wages in small metropolitan statistical areas subjected to market concentration, fell behind the wages of workers not in the hospital sector by almost $4.08.⁸ When hospitals merge within close proximity, prices increase by an average of 6 percent.⁹ In the absence of market competition, monopoly hospitals which establish market dominance, charge an average of 12 percent more compared to hospitals with nearby market competition while also reducing worker wages and staffing levels.^10,11

Health care consolidation, particularly by private equity firms, has uniquely impacted the ownership and service of hospitals in communities of color. Between 1961 and 1988, the market of historically black-serving institutions severely declined with roughly 56 black-owned hospital closures, and at least 15 black-owned hospital mergers or conversions into institutions with non-black ownership.¹² This represented a significant decrease from the approximately 200 establishments that were present in 1920.¹³ By the end of the 20th century, there were only eight black-owned hospitals left, each facing mounting pressure to merge and consolidate to increase their chances of survival and financialization.¹⁴ As of today, Howard University Hospital stands as the last traditionally black-owned hospital left in America.^15,16In contrast, many of the formerly black-owned hospitals were subjected to mismanagement as they were consolidated into corporate and for-profit health networks.

L. Richardson Memorial Hospital, a historically black-owned hospital, is a prime example of a historically black-serving institution that underwent a series of management and ownership changes to become part of Apollo Global Management, the second-largest private equity firm. In the 1980s, L. Richardson Memorial Hospital shifted into management under the Hospital Corporation of America – a consortium of private equity firms led by Bain Capital Partners.¹⁷ Further consolidation led to the sale of L. Richardson Memorial Hospital to Vencor Corp. – one of the largest nursing home chains charged by the Department of Justice for knowingly submitting false claims to Medicare, Medicaid, and beyond.^18,19 Vencor later fell into bankruptcy and reemerged as Kindred Health, which Apollo has since consumed by acquiring and merging Kindred Health with LifePoint Health – a rural hospital chain.^20,21

As a private equity investor and owner in health care, Apollo has played the role of degrading the care and operational quality of health systems through service cuts, compliance violations, and more. For instance, just last year a health inspector found that Kindred Hospital Brea – located in California – failed to properly monitor and manage patient infections due to a lack of cleanliness and hand hygiene standards from January through December 2022 while under Apollo’s ownership.²² A separate inspection at Kindred Hospital South Hollywood in Florida found at least 16 rooms below maintenance standards and lacking the basic housekeeping services needed to keep things clean and comfortable for patients.²³ This is not an isolated issue. Kindred Hospital workers have also been on the front lines protesting hospital understaffing and demanding better safety precautions.²⁴ Given that Apollo’s outsized influence and harmful impacts are well reported, the situation with L. Richardson Memorial Hospital highlights the intersectional consequences of not having racial equity outcomes inform approvals or rejections of private equity transactions in health care while also allowing decades of unchecked private equity consolidation.²⁵

Private equity’s role in health care consolidation has been linked to diminished access to care. From its inception, Cerberus Capital Management identified immediate avenues to profit from the growing Steward Health Care’s hospital debt that has since been leveraged against workers and patients.²⁶ Steward Health was initially established through the purchase of six struggling Massachusetts-based hospitals and grew by way of Cerberus rolling up the health care market.²⁷ As the nation’s largest physician-owned private hospital operator that only recently separated from its private equity shackles, Steward Health Care is at risk of losing roughly 9 hospitals in Massachusetts due to Cereberus’ management. Cerberus’ was the majority stakeholder owner, loading Steward Health up with debt when Steward was involved in at least 35 lawsuits in the last year alleging issues with Steward Health ranging from unpaid bills and falsified checks to doctor kickback schemes.^28,29,30The current risk of closure that the Steward hospitals now face is directly connected to Cerberus’ purchase of these hospitals and subsequent practices. UnitedHealth Group’s proposed acquisition of Steward Health Care’s physician group warrants additional scrutiny to ensure that the new capital is directed toward supporting the long-term health of these hospitals rather than perpetuating problematic practices.³¹

Private equity “gaming” the health care system disproportionately harms low-income patients and communities of color. The authority granted to the Center for Medicare and Medicaid Innovation allows CMS to develop and test new payment models continually. Accountable care organizations (ACOs) are health care organizations that receive value-based payments – which are based on the quality of care provided to Medicare patients – from the Centers for Medicare & Medicaid Services (CMS). Private equity’s incentive to maximize profits on any investments made as a byproduct of its commitment to shareholders and investors poses a significant risk to Medicare patients because private equity providers may be motivated to invest in ACOs simply to collect unearned monetary rewards or the leftover money that CMS pays to cover the cost of Medicare patient expenses rather than provide quality care to underserved communities. Steward Health Care is a prime example of this dynamic. Despite the recognition of Steward Health Care as a leading ACO by CMS, its involvement in Medicare and Medicaid kickback schemes underscores the vulnerability of value-based payment models to private equity extraction.^32,33 With more private equity firms increasingly investing in value-based care clinics for Medicare patients, urgent measures are needed to safeguard these communities.³⁴

Notably, states that are especially susceptible to private equity influence, such as Texas and Oklahoma, also exhibit pronounced racialized health disparities and low health system scores, especially for black and brown patients.³⁵ Texas, for instance, has 97 private equity hospitals, representing 18% of its private hospital market, with leading firms like Equity Group Investments owning multiple hospitals across several states, including Texas and Oklahoma.³⁶Given the presence of numerous ACOs in these states, CMS should enhance data accessibility to facilitate research on ownership trends in value-based care facilities, particularly by private equity or for-profit entities.³⁷ If applied to ACOs data in a manner where one could identify how many ACOs receive private equity investment, in which states they are concentrated, and which ACOs are explicitly owned by private equity ownership, this transparency would enable agencies to monitor and address the trends and risks posed by private equity investment in programs targeting underserved communities.

Providers, Health Care Workers, and Support Staff

Private equity erodes the quality of work environments in health care. As exemplified by St. John Emergency Room physicians’ recent protest against TeamHealth, private equity has a tendency to understaff clinics to maximize profits.³⁸ TeamHealth, the largest physician staffing firm in the US, was purchased by private equity firm Blackstone Financial Group in 2017 for $6 billion and now profits from overburdening their workers. In addition to creating staffing shortages, a report by the Americans For Financial Reform Education Fund found that private equity’s influence in health care often resulted in reliance on underqualified personnel and pressure on physicians to prioritize the unnecessarily expensive versions of services which drive up health care costs.³⁹

Private equity compromises the provider-patient relationship. As seen with the surprise billing out-of-network fiasco, in which health care providers were billing patients for exorbitant, out-of-network fees, private equity-backed providers, in particular, drove the deceptive and unfair practice of suing and garnishing the wages of poor patients. The details of private equity’s profit-maximizing scheme are what prompted the creation of the No Surprises Act.⁴⁰ As Pro Publica reported, physicians and health care workers were not the primary benefactors or decision-makers of these predatory practices and had no say in what was billed or collected under their names.⁴¹ With approximately 77.6% of physicians now employed by for-profit entities and private equity, patients and workers are rightfully concerned about the compromised patient-physician relationship and ethical conflicts.⁴² Furthermore, even after the passage of the No Surprises Act, private equity continues to drive up costs at the hospitals they own through the No Surprises dispute process. Using this dispute process, private equity-backed providers contest out-of-network fees they collect from patients if the provider deems the amount too low. Health care providers are supposed to use the No Surprises Act dispute process to get fair reimbursement, but private equity providers often use the process to exploit patients. Four private equity firms – some with a history of exploiting surprise billing – dominated dispute cases in the second quarter of 2023, securing payments nearly three times higher than typical in-network rates.⁴³ This trend underscores the urgent need for regulatory measures to ensure equitable and affordable health care access.

Government Action

The FTC, DOJ, and HHS each have a vital role in addressing the link between corporate or private ownership in health care and equity.

The FTC can leverage its expansive authorities to investigate private equity firms, utilizing Section 5 of the FTC Act to combat deceptive or unfair practices, particularly in health care roll-ups involving horizontal consolidation. As part of this process, the FTC should scrutinize UnitedHealth Group’s proposed acquisition of Steward Health Care’s physician group.⁴⁴ Given recent legal developments where a federal judge dismissed a state’s false claims case and evidence of staffing shortages, there is a need for more DOJ enforcement as well.⁴⁵The DOJ should prioritize prosecuting violators of the federal False Claims Act. This enforcement is crucial to maintaining the integrity of Medicaid and Medicare programs, especially in cases where staffing shortages and falsified records jeopardize patient care and billing accuracy.

Beyond traditional merger analysis and litigation, the FTC and DOJ should explicitly include equity considerations in their merger review process, enabling a more nuanced regulation of corporate mergers and consolidations within health care. FTC Commissioner Slaughter and other experts have already noted a need for more granular demographic data and usage of retrospective merger analysis which should be used in tandem to bolster racial and class-based justice within agency enforcement actions.⁴⁶ As highlighted in a law review published by the Washington University School of Law, detailed demographic data could be collected through civil investigative demands, pre-merger notification processes, merger investigations, and more.⁴⁷ Placing the burden of information collection on entities seeking to merge could alleviate resource capacity strains that may limit the FTC’s ability to collect comprehensive racial and class-based data. Furthermore, reviewing past merger implications and enforcement actions can shed light on the racial or class-based implications of antitrust activities as well as inform future priorities such as challenging mergers that pose the risk of exacerbating racial or class-based disparities. John Kwoka, former FTC staff and an expert on industrial consolidation has put together one of the most comprehensive merger retrospectives to date and concluded that we need more structural presumptions against mergers.⁴⁸ Firms should shoulder the burden of proof to show why their merger should be allowed and antitrust enforcers should hold the line by blocking mergers when that burden of proof isn’t met. It’s time to hold private equity and corporate firms accountable for the role they play in exacerbating disparities across racial and class-based lines.

HHS, by way of the Centers for Medicare and Medicaid Services (CMS), should also bolster accountability within the ACO Realizing Equity, Access, and Community Health (REACH) value-based payment model to thwart potential exploitation by private equity interests in ACOs.⁴⁹ One of the most significant features of the ACOs REACH test model is that it has the potential to advance health care equity.⁵⁰ The ACO REACH framework has a “health equity benchmark adjustment” that acknowledges the increased costs of caring for socioeconomically disadvantaged patients by raising spending benchmarks by $30 per month for each member in the top decile of disadvantage. However, the model also includes rewarding providers with fixed fees per patient annually, which creates opportunities for entities to retain unspent funds regardless of frontline care provision. That means private equity and other for-profit entities investing in value-based care have an incentive and opportunity to maximize profits through using the value-based care models which are supposed to help underserved communities. CMS should establish more oversight around the types of investments that providers make in response to the benchmark adjustment so that ACOs focus more on improving the care they provide rather than profit generation. This oversight should also include tracking how much money goes directly to health care workers and patient expenses compared to corporate owners.

CMS should make value-based care models such as ACO REACH, mandatory. Mandatory models would offer a structured approach to testing health equity interventions and reduce the risk of selection bias towards private equity firms, thus providing a more accurate assessment of the true impact of payment changes. While there is undoubtedly a need to improve the model and continually increase funding for clinics supporting underserved patients, this funding will be undermined by corporate interests unless CMS removes the corporate incentive to squeeze money out of Medicare.

Greater Transparency

Greater transparency is needed around private equity transactions. Currently, the National Provider Identification (NPI) number disclosed under the Freedom of Information Act (FOIA) and accessible through the NPI Registry makes it difficult for the public to determine whether an institutional provider is associated with a private equity firm or for-profit entity. Even if this requirement were dropped, the public’s capacity to effectively investigate health care organizations is undermined by the lack of integration into Care Compare, which makes it more difficult to obtain this vital information. Streamlining data presentation via CMS to enable trend analysis could help uncover shared ownership patterns and geographic distributions among institutional providers, which could be a useful addition to quality ratings for providers connected to private equity firms.

Conclusion

Protecting workers and marginalized communities disproportionately harmed by private equity practices and consolidation in health care will help address health disparities, promote health equity, and strengthen the entire health care system. That protection includes ensuring the affordability, accessibility, and quality of care while also diminishing the influence of private equity in health care. Given the substantial harm inflicted by private equity firms on the health system, simply mandating structural separations or divestment of their assets in health care would fall short of ensuring that power in the health system gets redistributed to those most impacted by health care disparities and consolidation. Instead, intervention from the FTC, DOJ, and HHS must prioritize justice-based solutions that take into account racial and socioeconomic equity if they want to reduce the harms of corporate and private equity influence in health care.

1. U.S. Department of Justice, Eli Lilly and Company Agrees to Pay $1.415 Billion to Resolve Allegations of Off-label Promotion of Zyprexa, Office of Public Affairs, January 15, 2009,  https://www.justice.gov/opa/pr/eli-lilly-and-company-agrees-pay-1415-billion-resolve-allegations-label-promotion-zyprexa.
2. Brian Till, “How Drug Companies Keep Medicine Out of Reach,” The Atlantic, May 15, 2013, https://www.theatlantic.com/health/archive/2013/05/how-drug-companies-keep-medicine-out-of-reach/275853/.
3. Jim Edwards, “How Lilly Doubled the Price of an Antipsychotic Pill Without Anyone Noticing,” CBS News, Jne 27, 2011, https://www.cbsnews.com/news/how-lilly-doubled-the-price-of-an-antipsychotic-pill-without-anyone-noticing/.
4. Eli Lilly and Company, U.S. Appeals Court Upholds Lilly’s 2011 Zyprexa Patent, Investor Press Release, December 26, 2006, https://investor.lilly.com/news-releases/news-release-details/us-appeals-court-upholds-lillys-2011-zyprexa-patent.
5. Zarek Brot-Goldberg, Zack Cooper, Stuart Craig & Lev Klarnet, “Is There Too Little Antitrust Enforcement in the US Hospital Sector?,” Yale Tobin Center for Economic Policy, April 2024, https://tobin.yale.edu/research/is-there-too-little-antitrust-enforcement-us-hospital-sector#:~:text=The%20%241.3%20trillion%20US%20hospital,enforcement%20action%20against%2013%20transactions.
6. Alan Z. Chen, Ashley Lewis, Sherry A. Glied, Sunita M. Desai, & Prianca Padmanabhan, “Hospital concentration and low-income populations: Evidence from New York State Medicaid,” Journal of Health Economics, July 2023, https://www.sciencedirect.com/science/article/abs/pii/S0167629623000474.
7. Elena Prager, Matthew Schmitt, “Employer Consolidation and Wages: Evidence from Hospitals,” Washington Center for Equitable Growth Working Paper, May 7, 2019, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3391889.
8. Sylvia A. Allegretto, Dave Graham-Squire, “Monopsony in Professional Labor Markets: Hospital System Concentration and Nurse Wages,” Institute for New Economic Thinking Working Paper, January 5, 2023, https://www.ineteconomics.org/uploads/papers/WP_197-Allegretto-HospCons.pdf.
9. Zack Cooper, Stuart V. Craig, Martin Gaynor, & John Van Reenen, “The Price Ain’t Right? Hospital Prices And Health Spending On The Privately Insured,” The quarterly journal of economics, September 25, 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7517591/.
10. Ibid.
11. Elena Andreyeva, Atul Gupta, Catherine E. Ishitani, Malgorzata Sylwestrzak & Benjamin Ukert, “The Corporatization of Independent Hospitals,” National Bureau of Economic Research, October 2023, https://www.nber.org/papers/w31776.
12. Maria Odum, “7 Black Hospitals Struggle to Find A Modern Role,” The New York Times, August 12, 1992, https://www.nytimes.com/1992/08/12/health/7-black-hospitals-struggle-to-find-a-modern-role.html#:~:text=By%201920%20there%20were%20about,no%20longer%20controlled%20by%20blacks.
13. Ibid.
14. Steve Taravella,“Black hospitals struggle to survive,” Modern Healthcare, National Library of Medicine, July 2, 1990, https://pubmed.ncbi.nlm.nih.gov/10105105/.
15. Tracie LaVette Augusta, ”A Correlational Study on Spiritual and Religious Well-Being, Social Determinants of Health, and Self-Efficacy for Appropriate Medication Use Among African American Women With Hypertension,” ProQuest: The University of Memphis ProQuest Dissertation & Theses, May 2023, https://www.proquest.com/openview/4a8547be571a0efab735a7a2591170c1/1?pq-origsite=gscholar&cbl=18750&diss=y.
16. Howard Newsroom Staff, “Howard University Takes Step to Advance Vision for Howard University Hospital,” The Dig, November 14, 2023, https://thedig.howard.edu/all-stories/howard-university-takes-step-advance-vision-howard-university-hospital.
17. Ran Coble, Robert Conn, William Haflett, Julie McCullough, & Elizabeth M. “Lacy” Maddox, “The Investor-Owned Hospital Movement In North Carolina,” The North Carolina Center for Public Policy Research, 1986, https://nccppr.org/wp-content/uploads/research_reports/THE_INVESTOR-OWNED_HOSPITAL_MOVEMENT_IN_NORTH_CAROLINA.pdf.
18. Cynthia De Miranda, Jennifer F. Martin, & Mary Pope Furr, Historic Architecture Eligibility Study, Environmental Analysis Unit North Carolina Department of Transportation, April 3, 2018, https://files.nc.gov/ncdcr/historic-preservation-office/PDFs/ER%2018-1311.pdf.
19. U.S. Department of Justice, Vencor And Ventas Paying U.S. $219 Million To Resolve Health Care Claims As Part Of Vencor’s Bankruptcy Reorganization Recovery Includes Largest “Failure of Care” Settlement to Date, Press Release, March 19, 2001, https://www.justice.gov/archive/opa/pr/2001/March/115civ.htm.
20. Dow Jones Newswires, “Vencor Emerges From Bankruptcy, Changes Name to Kindred Healthcare,” The Wall Street Journal, April 20, 2001, https://www.wsj.com/articles/SB987790088857927171.
21. Eileen O’Grady, “Apollo Global Management Completes Merger of Kindred Healthcare and LifePoint Health, Shifts Some Hospitals to New Company,” Private Equity Stakeholder Project, January 31, 2022, https://pestakeholder.org/news/apollo-global-management-completes-merger-of-kindred-healthcare-and-lifepoint-health-shifts-some-hospitals-to-new-company/.
22. CMS Inspection Report, August 1, 2023, https://www.medicare.gov/care-compare/inspections/pdf/nursing-home/555859/health/complaint?date=2023-08-01.
23. CMS Inspection Report, September 7, 2023, https://www.medicare.gov/care-compare/inspections/pdf/nursing-home/106109/health/standard?date=2023-09-07.
24. Kevin Smith, “Kindred Hospital Ontario nurses protest understaffing, unsafe conditions,” Daily Bulletin, May 2, 2023, https://www.dailybulletin.com/2023/05/02/kindred-hospital-ontario-nurses-protest-understaffing-unsafe-conditions/.
25. Matt Parr, New report details harm caused to healthcare industry by Apollo, Private Equity Stakeholder Project, January 11, 2024, https://pestakeholder.org/news/new-report-details-harm-caused-to-healthcare-industry-by-apollo/.
26. Office of the Attorney General, Comonwealth of Massachusetts, Reports on Steward Health Care System, December 30, 2015, https://www.mass.gov/doc/reports-on-steward-health-care-system-pursuant-to-2010-and-2011-assessment-monitoring/download.
27. Office of Attorney General Martha Coakley, Statement of the Attorney General as to the Caritas Christi Transaction, October 6, 2010, http://wayback.archive-it.org/1101/20171230170004/http://www.mass.gov/ago/docs/nonprofit/caritas/statement-of-the-attorney-general-caritas-christi-transaction.pdf.
28. Prolink Healthcare, LLC v. Steward Health Care System, LLC, et al., No. 23-2825 (Mass. Sup. Ct.  Dec. 13, 2023), https://www.documentcloud.org/documents/24488292-prolink-healthcare-llc-vs-steward-health-care-system-llc?responsive=1&title=1.
29.  Physician Services of Texas, Inc. v. The Medical Center of Southeast Texas, LP et al., No. 09-24-00034 (Tex. Ct. App. Jan. 25, 2024),   https://www.documentcloud.org/documents/24478418-steward-hni-mandamus-record?responsive=1&title=1.
30. U.S. Attorney’s Office, District of Massachusetts, “United States Files Complaint Against St. Elizabeth’s Medical Center, Steward Medical Group and Steward Health Care System,” Press Release, December 18, 2023, https://www.justice.gov/usao-ma/pr/united-states-files-complaint-against-st-elizabeths-medical-center-steward-medical-group?utm_source=Sailthru&utm_medium=email&utm_campaign=THE%20DISTRUST%20SERIES%20%20VOLUME%20CXXIX%20%20TRACKING%20THE%20KEY%20ISSUES%20%20312024-03-12T06:58:00-04:00tme&utm_term=THE%20DISTRUST%20SERIES%20%20VOLUME%20CXXIX%20%20TRACKING%20THE%20KEY%20ISSUES%20%20312024-03-12T06:58:00-04:00tme.
31. Evan Godt, “Steward to sell doc network to Optum,” Health Exec, March 28, 2024, https://healthexec.com/topics/healthcare-management/mergers-and-acquisitions/steward-sell-doc-network-optum.
32. Jeremy Tunis, “Physician-Led Steward Health Care, Nation’s Largest Accountable Care Organization, Achieves CMS’ 100% Quality Ranking,” St. Elizabeth’s Medical Center Press Release, September 24, 2021, https://www.semc.org/newsroom/2021-09-24/physician-led-steward-health-care-nations-largest-accountable-care-organization.
33. Cohen Milstein Sellers & Toll PLLC, “Steward Health Care System to Settle Medicare and Medicaid Kickback Allegations for $4.7 Million,” Press Release, June 9, 2022, https://www.cohenmilstein.com/steward-health-care-system-settle-medicare-and-medicaid-kickback-allegations-47-million/.
34. Zahy Abou-Atme , Rob Alterman, Gunjan Khanna , & Edward Levine, “Investing in the new era of value-based care,” McKinsey & Company, December 16, 2022, https://www.mckinsey.com/industries/healthcare/our-insights/investing-in-the-new-era-of-value-based-care.
35. Sara R. Collins, Neil R. Powe, Arnav Shah, David C. Radley, Laurie C. Zephyrin, “Advancing Racial Equity in U.S. Health Care,” Commonwealth Fund, April 18, 2024, https://www.commonwealthfund.org/publications/fund-reports/2024/apr/advancing-racial-equity-us-health-care.
36. Private Equity Stakeholder Project, PESP Private Equity Hospital Tracker, Accessed April 8, 2024, https://pestakeholder.org/private-equity-hospital-tracker/#hospital_tracker.
37. Centers for Medicare & Medicaid Services, Accountable Care Organizations, 2024, https://data.cms.gov/medicare-shared-savings-program/accountable-care-organizations/data?query=%7B%22filters%22%3A%7B%22list%22%3A%5B%7B%22conditions%22%3A%5B%7B%22column%22%3A%7B%22value%22%3A%22aco_service_area%22%7D%2C%22comparator%22%3A%7B%22value%22%3A%22IN%22%7D%2C%22filterValue%22%3A%5B%22TX%22%5D%7D%5D%7D%5D%2C%22rootConjunction%22%3A%7B%22value%22%3A%22AND%22%7D%7D%2C%22keywords%22%3A%22%22%2C%22offset%22%3A0%2C%22limit%22%3A10%2C%22sort%22%3A%7B%22sortBy%22%3Anull%2C%22sortOrder%22%3Anull%7D%2C%22columns%22%3A%5B%5D%7D.
38. Katy Kinner, “Strike of ER clinicians begins at Ascension St. John in Detroit,” World Socialist Web Site, April 18, 2024, https://www.wsws.org/en/articles/2024/04/19/cqxs-a19.html
39. Robert Seifert, “Doctored By Wall Street,” Americans for Financial Reform Education Fund, June 2023, https://ourfinancialsecurity.org/wp-content/uploads/2023/07/AFREF-Doctored-by-Wall-Street-PRIMARY-final.pdf.
40. Centers for Medicare & Medicaid Services, Ending Surprise Medical Bills, April 9, 2024, https://www.cms.gov/nosurprises.
41. Doris Burke, Maya Miller, Beena Raghavendran, & Wendi C. Thomas,  “This Doctors Group Is Owned by a Private Equity Firm and Repeatedly Sued the Poor Until We Called Them,” Propublica, November 27, 2019, https://www.propublica.org/article/this-doctors-group-is-owned-by-a-private-equity-firm-and-repeatedly-sued-the-poor-until-we-called-them.
42. Physicians Advocacy Institute, Avalere Health, Report on Physician Employment Trends and Acquisitions of Medical Practices: 2019-2023, Physicians Advocacy Institute, April 2024, https://www.physiciansadvocacyinstitute.org/PAI-Research/PAI-Avalere-Study-on-Physician-Employment-Practice-Ownership-Trends-2019-2023.
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