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Private equity is eating healthcare alive · Cut & Tell

• 0:01
  Hi there, and welcome to Cut and Tell.
• 0:02
  I'm Liz Malphrus.
• 0:03
  I'm a freshly minted plastic surgeon in Philadelphia.
• 0:06
  And this season is all about arming you with the health policy knowledge that you need to advocate for your patients and just as importantly, for yourself in this crazy healthcare system.
• 0:31
  Okay?
• 0:31
  So this week we're talking private equity.
• 0:34
  If you know me, irl and you've ever made the mistake of bringing this up in front of me, you know, I got a real problem with these people, okay?
• 0:40
  And today you're going to understand why.
• 0:43
  And it's not just to clarify.
• 0:45
  This is not that I'm anti business, y' all, in any way.
• 0:47
  Remember, I am an employed private practice surgeon, and I'm in aesthetics.
• 0:52
  I'm basically the business, business kind of doctor that you can be.
• 0:56
  But today I want to show you that, that private equity, this is something different and something we need to be concerned about.
• 1:01
  It is, it is a problem.
• 1:02
  And in particular, I feel that they're accelerating that loss of trust and loss of autonomy that we've been talking about in our health care system.
• 1:11
  It's.
• 1:11
  They're again, driving the, the even a bigger wedge between patients and doctors and how, how people in America especially view the medical profession.
• 1:22
  Okay, so let's, let's go.
• 1:23
  Let's start with basics.
• 1:24
  I feel like private equity, it's one of those things that people, like people say, but.
• 1:28
  And maybe you kind of have a vague idea of what it means, but, like, do you really know what it is?
• 1:32
  So we're going to break it down first.
• 1:33
  So you probably heard people say things like, oh, they sold to private equity, or like, that's a private equity group.
• 1:38
  So basically the, the term private equity, it's really a private equity firm.
• 1:43
  That's the entity that we're talking about.
• 1:45
  So you have this business, it's a private equity firm.
• 1:48
  And what they do is they have a lot of money.
• 1:53
  So sort of think of it in a Scrooge McDuck style, like giant pit of gold coins.
• 1:57
  Like, they have a lot of money.
• 1:58
  That money comes all from institutions and wealthy individuals, private institutions and wealthy individuals.
• 2:05
  Okay?
• 2:06
  So this is money that is just like, can be used for, you know, economic things.
• 2:10
  It's not tied to any public assets or anything.
• 2:13
  So all of that money is pulled together.
• 2:15
  So it's like these, you know, crazy rich people get together, put their money all together, and then this firm, they basically say, hey, we, we're going to give you all this, this big pot of money you can use.
• 2:24
  Take that money and you go out and you turn that money into more money.
• 2:29
  Okay, so that's, that's the basic structure of how this works.
• 2:31
  This is rich people stuff.
• 2:33
  It is something that I, you know, have a doctor's level understanding of.
• 2:36
  But anyway, so the, the, the kind of playbook that these groups use, these private equity firms, they go out, they take their money, they buy a controlling stake in a business.
• 2:46
  So in this case for healthcare, we're talking about in a physician practice, in a hospital and anesthura center or whatever it is, they buy a controlling stake in that business, which means they now get to make all the
• 2:55
  rules.
• 2:56
  They go in, they restructure everything to optimize for profits.
• 3:01
  And their goal is to take that business and through their ownership of it, reap all of these profits on a three to seven year timeline so they can give those profits back into that pool of Scrooge McDuck money.
• 3:14
  So it's basically rich people saying, hey, take this money, go buy businesses, make them profitable, give us the profits and then like say goodbye.
• 3:23
  Like, just say like fudge you to them, sell them off, move along to the next project.
• 3:26
  So private equity has quickly really, over the last like 10 years, become a major player in health care, particularly in like what's changing in health care.
• 3:35
  So global private equity investment between 2018 and 2022 reached 446 billion with a B.
• 3:44
  That is a lot of gold coins.
• 3:47
  And that's more than 350 billion of that is investing in U.S.
• 3:50
  practices and hospitals and long term care and like buying up all of these institutions.
• 3:55
  So like let's just, let's take an exam.
• 3:56
  Like, you know, let's take like kind of a walkthrough of how this works.
• 3:59
  So, so if you're, say you're a dermatologist, because dermatology has been one of the kind of earliest groups affected by this.
• 4:05
  You're a dermatologist, you've been in practice for 30 years.
• 4:07
  You've got your thriving dermatology practice, but you're, you're the, you're a solo, solo provider.
• 4:11
  Like you're the only physician in your group.
• 4:13
  You don't have a junior part partner.
• 4:14
  You don't have, you're trying to figure out what to do, like what do you do with your practice now that you want to retire and physician.
• 4:21
  So the private equity groups know that this is a group of people who have something they want to sell and who are on a, on a timeline that they are looking to get out on like a On usually
• 4:30
  a pretty short timeline.
• 4:31
  So they come in and they say, hey, like, don't sell this practice to another surgeon, like sell it to us.
• 4:38
  We will come in, we'll make this super profitable.
• 4:40
  We'll probably give you more money than like an individual person would possibly be able to give you.
• 4:44
  And like we're going to be your gold ticket off into retirement.
• 4:49
  So if you're that, if you're that surgeon that's retiring or that dermatologist retiring, like this seems like a great deal for you.
• 4:54
  And like it's hard for me to knock it honestly.
• 4:56
  Like I get it.
• 4:57
  They come in, they got the biggest paycheck to give you.
• 4:59
  Like totally makes sense why you would go for that.
• 5:01
  The problem I think is for the next generation.
• 5:04
  So the problem is that if you're a physician who is looking to come into one of these practices, they don't owe you.
• 5:11
  The private equity group that already bought out the surgeon that owned it, they don't owe you shit.
• 5:15
  I'm a physician, I want to hire another physician who is going to grow in this practice and ultimately take over from me.
• 5:21
  Like instead of it being that where you're invested in building that talent, they're viewing you, the new doctor, a hundred percent as just an employee who is highly replaceable.
• 5:31
  And so their motivation then is how can they get you for the lowest amount of money?
• 5:36
  Because their game now is all about making this business profitable on a three to seven year timeline.
• 5:45
  Okay, but you don't have to like, you don't know.
• 5:47
  The big problem here isn't actually that like we're going to talk some about job stuff for doctors because I care a lot about that.
• 5:52
  But the bigger problem here is that private equity makes health care worse.
• 5:56
  And I got some evidence for you on that front.
• 5:58
  So the largest systematic review that we have to date actually comes from the bmj.
• 6:03
  This was a big systematic review looking at a bunch of studies on private equity.
• 6:07
  And they found that private equity ownership was most consistently associated with increased cost to patients and to payers as well as at the very, at the best the same quality, but in a lot of cases worse quality care.
• 6:21
  And there certainly are no consistently beneficial impacts really for anybody except for the people making money off the private equity company.
• 6:30
  Like all the Scrooge McDuck's back there.
• 6:31
  So it's not good for the hospital, it's not good for the patient, it's not good for the doctor, it's not even good for the insurance company.
• 6:36
  All like these people are coming in taking the money and leaving.
• 6:42
  We also see that like you might be thinking, oh this is great, this company's going to come in, they're going to modernize my practice, they're going to make it more profitable.
• 6:49
  But your, your assumption is a doctor because, because you were trained in this tradition, your assumption is that like, that the goal will be not to compromise any of the quality of the care or any of the like
• 7:01
  clinical decision making that you have.
• 7:02
  And that's the problem is a private equity group doesn't have any of that stuff.
• 7:06
  They're, they're not beholden to the Hippocratic oath.
• 7:09
  They're not concerned about, about like looking at a patient and telling them that they need something that they don't like.
• 7:15
  It's just, it's very hard for a doctor, I think, to function in this environment.
• 7:19
  So when private equity acquiescer practice, they raise prices, they raise spending.
• 7:23
  We've seen this in dermatology and gastroenterology and ophthalmology.
• 7:27
  They also tend to have shorter office visits.
• 7:29
  So your patient gets less time with you, much higher volume.
• 7:32
  And that's kind of how that works because time is finite.
• 7:35
  And then in particular what we see is like the gain of these people play is they, they, they own the company for five years or whatever and then they sell after that acquisition things only this, these problems only
• 7:46
  accelerate, these things only get worse.
• 7:47
  So let's talk about some of the specific evidence we have on, especially on safety because to me this is the clearest argument is like it is actually probably not safe for us to have private equity owning these hospitals.
• 7:57
  And like I don't want, I would, if I had the choice, I would not want to send my loved one to a private equity owned institution.
• 8:04
  So we've got a good analysis from JAMA on Medicare claims where they looked at private equity hospitals versus non private equity hospitals and they found that private equity acquisition was associated with a 25% increase in hospital acquired conditions.
• 8:19
  That is a lot like these are things that really should not be happening.
• 8:22
  And we're seeing a huge increase.
• 8:24
  And if you drill down on that, and let's say they try to drill down on like what is changing, it's more falls.
• 8:30
  And if you work in a hospital, you know, if there's more falls, it's probably because there's less staffing.
• 8:34
  So we're not keeping as close a tabs on our patients.
• 8:37
  And associated with a 37% increase in Central line associated bloodstream infections.
• 8:42
  And all of that is despite the fact that these hospitals, the private equity hospitals, tend to admit younger and lower risk patients because that is who is more profitable.
• 8:51
  So despite their like, patient population being healthier, they have worse outcomes.
• 8:56
  And that is terrifying to me.
• 8:57
  The biggest, like, red flag for private equity is if you look at the like, patient satisfaction scores.
• 9:03
  So to me, when I used to work in a Nash Academies, I used to like, really dislike the, the whole like, patient satisfaction, patient experience movement in measurement.
• 9:13
  Just because first of all, like, the numbers tend to be like, it's like between 90 and 100.
• 9:17
  You know, it's like everyone is above average.
• 9:19
  It doesn't really make a ton of sense.
• 9:21
  And then also, like, to me, who has a really pleasant experience when they're sick, like, it's a little, to me, it's a little bit of an unfair number.
• 9:28
  But I digress.
• 9:29
  The point is that even these numbers, what's crazy is that they are changing significantly for private equity hospitals.
• 9:35
  So patient care experience scores like, dipped by like 5 percentage points in the private equity groups versus the non private equity groups.
• 9:44
  And like, to me, that is a huge number because we're talking about like a range that only goes from 90 to 100.
• 9:49
  So like 5 percentage points is tremendous.
• 9:51
  That is more change than we saw in these patient experience patient satisfaction numbers.
• 9:56
  And during, like Covid when, when no one was happy in the hospital.
• 9:59
  Okay, so this is like kind of insane.
• 10:01
  This is another study from jama.
• 10:02
  If you look at that and you drill down on trying to understand like, why that's happening, a lot of it actually has to do with staffing.
• 10:09
  So it's reduced nurse staffing, so the patient ratios are not as good and it's a lower nursing skill mix.
• 10:15
  So instead of having like that NP who's been there for 20 years, who was like, more expensive, they fired that person and they brought in someone brand new or they brought in an MA and decided the MA could
• 10:25
  do it.
• 10:25
  And like, that stuff matters because that is the front line of healthcare.
• 10:29
  And it also matters for doctors because, you know that the doctor is also being asked to do more.
• 10:34
  And now if there's a lower nursing staff kind of skill level, the nurses are asking the doctors more.
• 10:40
  And so the doctors are spending even more time on like a lower level of like, what they are able to do now.
• 10:45
  I should say, like, I guess, you know, I try to be fair here.
• 10:47
  Not everything is negative.
• 10:49
  Like, there are.
• 10:49
  I think there's one study that I saw that said, like, maybe for very like standard routinized type, like conditions that are treated in a very systematic way.
• 10:58
  Those they maybe are handled more efficiently.
• 11:00
  Like there's not any harm, at least maybe there's some benefit at the same time.
• 11:04
  Like, you know, private equity can be a good thing.
• 11:06
  Like bringing in a bunch of money, injecting capital into something can help with modernization.
• 11:11
  They can like make systems work better.
• 11:13
  A lot of times how they work is through rollups.
• 11:15
  So it's like taking a small practice and bringing it in, bringing it into a larger group.
• 11:19
  Like, there certainly are efficiencies that can be gained there and like just systems that can make more sense.
• 11:24
  But the problem is to me, that I don't really care nearly as much about.
• 11:29
  What I care more about is whether we're providing good care for patients or like it kind of like it doesn't matter.
• 11:33
  Like to me, that doesn't matter.
• 11:34
  All those efficiencies, if the trade is that you take worse care of patients.
• 11:38
  And of course you shouldn't just take my word for it.
• 11:40
  It's not just me.
• 11:40
  Okay, so there are surveys where they've asked physicians about, particularly physicians who have been in private equity groups, what they think about it.
• 11:49
  Surprise, surprise.
• 11:50
  60 plus percent of them viewed PE involvement negatively in a practice in particular.
• 11:55
  What's crazy is that it's been, it's especially unfavorable for physician well being, like the, the physicians who are working in these groups.
• 12:02
  It's, it's a real, it's a real serious trade off, y'.
• 12:05
  All.
• 12:05
  So we have a survey that looked at private equity employed physicians versus non private equity employed physicians.
• 12:10
  And it showed that those private equity physicians, they have lower professional satisfaction and the gap is pretty big.
• 12:16
  So we're talking 44.8% versus 74.4%.
• 12:20
  That is a big difference.
• 12:22
  The private equity physicians also reported lower autonomy.
• 12:26
  And to me, isn't that why we're all trying to be doctors is to be able to make your own decisions?
• 12:30
  So they reported lower autonomy scores, 48.3% versus 66.3.
• 12:36
  So that to me is like super concerning.
• 12:39
  They also, a lot of them were much less likely to say that they intended to stay stay with their employer.
• 12:44
  So a lot of these physicians, they're miserable.
• 12:47
  Like, when I look at this, what I see, this is a miserable position.
• 12:49
  Who is burned out, who has no control in their day, and they are looking to get out as soon as they can make it work.
• 12:54
  So what's going on?
• 12:55
  So like, why, why do they feel this way?
• 12:56
  Like, it's hard to pin down a lot of this is a little squishy in that it's like, you know, it's really hard to like, especially in a heterogeneous practice with a lot of different kind of patients, it's hard
• 13:05
  to like really make the case for this.
• 13:06
  There are some good surveys where they just do like qualitative information about like talking to people about what their experience is like.
• 13:12
  A lot of the pressures come down to basically you are, you go from being a physician who's just there to take care of patients and do the right thing for them, to now you're a physician who is there
• 13:21
  to optimize how much that patient is going to spend in your practice.
• 13:25
  So there's a real push for expanding elective procedures, like increasing like how often you offer them, encouraging patients to sign up for them, as well as any kind of ancillary services that your, the church system offers.
• 13:37
  So they sort of like they want you to be like the guy at McDonald's who's like, do you want to supersize that?
• 13:40
  Like that.
• 13:41
  I don't think any of us got into medicine to be in that position.
• 13:45
  They also, these practices tend to favor in any way they can commercially insured patients because they're going to pay better than the privately than the publicly insured ones.
• 13:54
  They also try to try to deliver more low complexity, high margin care.
• 13:58
  So they're not interested in taking care of super sick patients, super complicated patients.
• 14:02
  The push is for you to get like patients with one problem and an expensive solution in the door and to take care of those patients.
• 14:12
  There's a, there's a big push to substitute higher claw, higher cost clinicians for lower cost clinicians.
• 14:18
  So think like, instead of having your like experienced mp, you're going to have a baby nurse or you're going to have you know, like maybe this an ma.
• 14:26
  Like instead of, instead of having like a mature team with a lot of experience and a lot of like institutional knowledge, you're going to have the team that is the cheapest for them to put together while still meeting
• 14:37
  that criteria for like technically being enough.
• 14:39
  A lot of us in Covid experienced a hospital system where like a lot of like a lot of nurses left, a lot of staff left.
• 14:45
  Like we had a huge turnover at our hospital and it was palpable to me as a resident how different the nursing staff became because I really saw it in terms of like the level, like the quality of the
• 14:56
  questions that I would get would be lower.
• 14:58
  And it's like it's no one's fault.
• 15:00
  It's just that you like have a team suddenly of people who are brand new, people who trained in Covid when, like, when like the standards for teaching were way down.
• 15:07
  The problem that I see with it is if your team is not as educated, not as good, a lot more of that responsibility then falls on you.
• 15:15
  So you as a doctor then become responsible for that level of care that's kind of like missing in the system.
• 15:20
  Okay, so let's, let's talk, let's talk for a little bit about like what this means for physicians who are entering the workforce soon now, around now because this is, this is kind of how I got entered in this
• 15:29
  topic and why I ended up at one point going down a very deep Internet rabbit hole about it is because I was looking for jobs and there are a lot of these private equity groups out there and they're
• 15:37
  offering very shiny fancy deals for us.
• 15:40
  So we're going to talk about like some of the specifics that, like the specific things that I think you should consider if you're a doctor looking at opportunities for private equity just to like at least understand the specifics
• 15:50
  of your contract and like what happens in particular if they sell.
• 15:54
  But I do want to say that one of the most common things that I hear, especially from older physicians about, about this problem you is they're like, it's not, it's not private equity's fault.
• 16:03
  The problem is that young doctors don't want to own their own businesses anymore.
• 16:08
  Like that's the argument I hear all the time.
• 16:09
  And I got a problem with that.
• 16:11
  Okay.
• 16:11
  Because as we've talked about in a prior episode, the.
• 16:14
  I really think the problem comes down to that doctors today, graduating today, are in a completely different economic position than the doctors that I'm talking to are.
• 16:24
  So like if you're a doctor who fin.
• 16:26
  If you're, if you're trying to sell off your 30 year old mature practice, like you entered healthcare at a very different time with a very different set of circumstances.
• 16:35
  So now if you're, if you're a doctor now, you're coming out into practice, you got 200k in debt, you probably got kids because you're a little bit older and you got like housing is more expensive like this.
• 16:45
  Like the economic situation is totally different.
• 16:47
  And so thinking that you're going to ask that person who is fresh out of practice, who's already in debt to then potentially go into a situation that is less stable with the goal of taking on more debt.
• 16:58
  Because like a lot of times those deals are like the goal is that you would go into a practice and then ultimately become a partner and then buy in.
• 17:05
  Like the idea that you're ever going to have money to invest in something is, is kind of hard to fathom I think now for doctors today.
• 17:12
  So to me, I don't think the issue is as much about like, it's not.
• 17:15
  The doctors don't want to.
• 17:17
  I really think that it's like the economics to the math doesn't math, like you cannot just, we just can't make it work anymore.
• 17:22
  It also I think would be really hard for even like the best positioned like fresh grad to compete with a private equity firm on making an offer to buy a practice.
• 17:31
  Like, I think that's also just like a little absurd.
• 17:34
  Okay.
• 17:34
  So if you're like, I totally respect, like I know people who work for private equity who accepted private equity jobs and I get it, they're offering you a lot of money.
• 17:42
  Like it is very appealing and I think especially if you view it as a long, as like a short term kind of thing, you're just like, I'm in here to make money for a couple years, years and then
• 17:51
  I'll get out.
• 17:52
  Like, I think there's an argument for it.
• 17:53
  I do think that you need to just put a little extra scrutiny into your contract review.
• 17:57
  So let's talk specifics.
• 17:58
  I think the first and most important thing is that you should, they're not going to offer this information.
• 18:02
  So you need to find out if this is a, this is a company where it's not owned by the doctor you're talking to.
• 18:07
  You've got to find out who owns it and what is their exit horizon.
• 18:12
  So like that's sort of the lingo for it.
• 18:14
  But like you want to understand like, is this a company that has an upcoming sale?
• 18:19
  Like are they planning to sell in the next year?
• 18:21
  Because you, you need to know about that because that is going to change everything for you.
• 18:25
  And so I think you should ask directly if you're looking at one of these jobs, who owns this company, understand like where the money comes from and find out whether they are anticipating a sale anytime in the next,
• 18:37
  whatever length of time you plan to be there.
• 18:41
  You also, I think need to be extra careful about all of those like restrictive covenants and like the contract clauses about like when, like what happens if you leave, like when and where can you set up shop?
• 18:51
  Again, you gotta be extra careful with those because I think in these cases what can happen is that you sign a contract with like a certain, a Certain group, and you're like, okay, I have a non compete.
• 19:01
  These are the terms of my non compete.
• 19:03
  The problem is that company can sell to a different firm, things may go haywire and not be what you want anymore.
• 19:10
  And then that restrictive covenant that you have, that lasts so like that, that contract that you have would persist beyond a sale.
• 19:18
  And so you could very much end up trapped.
• 19:20
  I think in a situation where it's like, it's not your, like the job that you signed up for was working for you, but the job changed, restrictive covenant did not.
• 19:28
  So I would really encourage you with these jobs especially to advocate for like the most limited, the shortest duration non compete that you can possibly get.
• 19:37
  You also really want to understand how the conversation works because that's where you're going to see if there's, if there's incentives in place for you to, to advocate for care that is not based solely on your clinical judgment.
• 19:48
  If you're gonna, if you're gonna work at a group and you're, you're concerned about being like asked to do things for money when you want to do things for clinical care, like you're gonna see that in the payment
• 19:57
  architecture.
• 19:58
  So you're, you'll, it'll be written down like, for sure.
• 20:01
  But I think the best way to understand it is probably going to be to talk to another physician in that group to get their inside perspective on like what pressures they feel.
• 20:10
  So ask them specifically, like, do you feel like you have to meet a certain target every month and like what kinds of things are you doing to get there?
• 20:18
  All of us in health care, I think like to imagine that we're not subject to those sorts of influences that we're immune to that like pressure to upsell.
• 20:27
  I just, I gotta tell you that you're not.
• 20:28
  And like you may not even really feel it when you're actually in the job, but I think it's, I think it's very real.
• 20:33
  And so if you're, the other thing is just that like if you were in a system like that and you refuse to, to like cooperate, like if they're pushing you to sell more and you're not doing it, you're
• 20:42
  just gonna be miserable too.
• 20:43
  Like they're not gonna be happy with you, you're gonna be miserable.
• 20:46
  It just is a bad situation.
• 20:47
  So try to understand how those forces, how those like pressures are going to operate in terms of your compensation.
• 20:54
  I also think it can be really informative to look at staffing.
• 20:58
  So if you, if you get the opportunity to, you should absolutely talk directly to whatever nursing staff is there, whoever the mas are.
• 21:05
  Like, you should talk to them and get a sense for how long they've been there, what they actually do, and like, if you can, like, whether they're planning to stay.
• 21:15
  Because I think this is one of the real harbingers of a practice that is going into a bad place is if you have a group where like, over the last year, it's like, if everyone there has been there
• 21:24
  for six months or less, or like, everyone's been there for like less than a year.
• 21:28
  That to me is a bad sign because that means there were people here before who built this thing and they're all gone now.
• 21:34
  And you're going into a situation with like a very junior group.
• 21:37
  Not a lot of institutional knowledge.
• 21:39
  It's just going to be, that's going to make a big difference in terms of how you experience your job.
• 21:44
  And then lastly, I think this is super important.
• 21:46
  If you're going to take a private equity job, you need to clarify what happens in the case of a sale.
• 21:53
  And that should really be in your contract.
• 21:54
  If it's not in your contract, they will just decide for you.
• 21:57
  They'll be like, great.
• 21:58
  But you could absolutely, you can absolutely advocate to be like, if this company sells, that triggers renegotiation at the very least.
• 22:04
  Or that like, you know, this is what happens to my compensation.
• 22:07
  It's going to be held like, you just need to look into and speak with your lawyer about what happens in case of a sale.
• 22:12
  Okay.
• 22:12
  So to close things out, I just want to take us back to the big picture because we've talked a lot about kind of the nitty gritty of how this works and why.
• 22:18
  I think the bigger issue, like setting all the money aside is this is a, this is an acceleration of the loss of trust that people are going to have in doctors and in the healthcare system.
• 22:29
  And it's, it's, again, it's kind of happening to us like these, these big entities with all this money come in, they are like stripping this industry for parts.
• 22:37
  And, and the only person in that room who the patient actually sees is that doctor.
• 22:43
  So it's going to be you.
• 22:44
  So, like, the patient is going to have a worse care experience.
• 22:47
  They're going to pay more money for it and they're going to look to you and they're going to think that it's you who's doing it.
• 22:53
  And it also, I think just the idea that we're going to increase the extent to which clinical decisions are influenced by money.
• 22:59
  This is everything that our Dr.
• 23:01
  Lee forefathers stood against.
• 23:03
  Like that is the absolute, that is, that should horrify, I think all of us, because this profession is absolutely built on the idea that we can be trust trusted to make unbiased decisions about clinical medicine that are based
• 23:15
  on the evidence and that are based on our trusting relationship with a patient, that we are on the same side trying to make them better.
• 23:22
  And I just don't think that that works well in a private equity owned situation.
• 23:26
  So what are we going to do about it?
• 23:27
  I think we have, we have pretty clear evidence honestly that I feel that private equity is not making health care better, they're making it worse and they're making it more expensive.
• 23:35
  So to me there's a pretty clear argument that this is bad for a lot of people.
• 23:38
  It's bad for example, for health insurance companies, like they don't want this either.
• 23:42
  It's definitely bad for big hospitals.
• 23:44
  So if we kind of like boil it down, I think the real problem is that you're just, you're taking that decision making authority away from physicians and you're basically allowing non physicians to make all the rules in physician
• 23:54
  practices.
• 23:55
  So to me the best place to look is honestly dental medicine.
• 23:59
  So like dentists, they're, they've done such a good job of protecting their industry.
• 24:03
  Like there are, there are laws at multiple levels that say that non dentists cannot own dental practices.
• 24:10
  Like can you imagine if we had that in healthcare?
• 24:12
  If like you couldn't have a hospital that wasn't, that wasn't directed by a physician, like a physician had to be in a leadership position, like that would be huge.
• 24:20
  And I think that's kind of what we need in this scenario is we need, we, we really need whatever rules we can get.
• 24:26
  It's so hard today in the US because our system is so dysfunctional, but we need protections for like clinical practices to be at least in some form informed and run by physicians.
• 24:39
  Like I think to me that is the answer at least by clinicians because I really think that this, this kind of shift that we're seeing, like turning health care into like a bunch of McDonald's is, is not going
• 24:49
  to be good because it's optimizing for something totally different than what all of us got into this for.
• 24:53
  And so if you're, if you're a resident, especially like I, I totally get it.
• 24:56
  Like you should like for sure look at that private equity job, like take a look at what they're offering you.
• 25:01
  Explore it.
• 25:02
  But I Think.
• 25:03
  I think ultimately what we can see in the numbers is that if you take one of those private equity jobs, you're not going to be happy.
• 25:10
  Like, maybe you're going to have more money in the short term, but you're not going to be happy.
• 25:14
  And the other thing is that, like, right now, I think a lot of these firms, as they're growing, they offer bigger paychecks to, like, the first people who come in because they're really eager to, like, get somebody in
• 25:24
  and get things started.
• 25:25
  The problem is they're not going to give you more money once they got you, because they got you on a contract.
• 25:29
  They're like, they're not going to give you more money.
• 25:31
  And ultimately they will come for that physician salary, too.
• 25:34
  So maybe it's not you, but it's going to be that junior partner that they hire.
• 25:38
  They're not going to make the offer that that's going to get that person in the door that you want to work with.
• 25:42
  They're going to be.
• 25:42
  They're going to be offering as little as possible.
• 25:44
  You know, in residency, you're so accustomed to sort of being beholden to all these systems.
• 25:48
  And, like, why do you want to accept that in this context?
• 25:52
  Like, why do you want to go from having, like, you know, your residency dictating everything about your life to just having a corporation detecting, dictating everything about your life?
• 26:00
  I really think if you're a physician who's looking for jobs in the near future, I just would really take a hard look at whether you.
• 26:07
  Whether you really want to be a part of this.
• 26:08
  Like, do you want to be a part of a system like this?
• 26:11
  Are you genuinely going to be happy in a system where you're ultimately going to be pressured to upsell?
• 26:17
  Is that.
• 26:17
  Is that what you got into this for?
• 26:21
  And then ultimately, I think we really need to advocate in every way we can to build back in, to regain those rules around physician ownership.
• 26:31
  Because if we don't, I really feel that that that trust we have with patients will continue to erode, and it's not going to be good for any of us.
• 26:38
  This is another, like, another dark and kind of negative one.
• 26:41
  But it has made me think I probably.
• 26:42
  I kind of would love to do.
• 26:43
  I have a lot of respect for the dental industry.
• 26:45
  I do think that they've.
• 26:46
  They've, like, can show us the way in terms of how to protect our industry from others.
• 26:50
  You also can look for, like, lawyers have been similarly really good at protecting their profession.
• 26:54
  So maybe we'll do an episode on that.
• 26:56
  And in general, if there's anything, if you have topics that you're curious to know more about, like there's so much to talk about in this arena, so just send me a message.
• 27:04
  I would love to hear what you think.
• 27:15
  Foreign.
• 27:20
  Thank you for listening to Cut and Tell.
• 27:22
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• 27:24
  Rate us five stars.
• 27:25
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• 27:29
  And then please, as always, check out our all of our content and our other shows@hippocratic-collusive.com.