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"Nurses understand the urgency of ending the disastrous policies and behavior of President Trump this November," writes Bonnie Castillo, executive director of National Nurses United. "But our work doesn't stop there; past the election, we will continue to mobilize and organize for the transformative social changes all workers, and patients, sorely need." (Photo: NNU/flickr/cc)

Nurses demand adequate Covid-19 protections for healthcare workers outside Kaiser Permanente medical center in Oakland, California on May 1, 2020. (Photo: Jaclyn Higgs/National Nurses United/flickr/cc)

National Nurses United Urges Biden Admin to Crack Down on Hospital Monopolies

"Anti-competitive behavior in the healthcare sector through market consolidation is a threat to the health and safety of nurses and other healthcare workers and is making our patients sicker."

Kenny Stancil

National Nurses United, the largest union of registered nurses in the U.S., is calling on the White House to bolster federal antitrust probes and rules to reduce the detrimental impacts of healthcare industry mergers and acquisitions on patients, workers, and communities.

"Consider any merger or acquisition in the healthcare sector, particularly hospital acquisitions, to be anti-competitive."

President Joe Biden recently ordered the Federal Trade Commission (FTC) and the Department of Justice (DOJ) to update their horizontal and vertical merger guidelines, which influence how regulators analyze potentially anti-competitive deals. As part of the revision process, the agencies have been listening to and accepting public testimony and comments through Thursday.

In comments submitted earlier this week, NNU's lead regulatory policy specialist, Carmen Comsti, wrote that "anti-competitive behavior in the healthcare sector through market consolidation is a threat to the health and safety of nurses and other healthcare workers and is making our patients sicker."

The "monopoly power of employers," said Comsti, "exacerbates problems with healthcare access and affordability" for the public. For nurses and other healthcare workers, she added, it "depresses wages and dilutes the power of workers to advocate for better working conditions and patient safety."

The FTC and DOJ, Comsti wrote, should "presumptively consider any merger or acquisition in the healthcare sector, particularly hospital acquisitions, to be anti-competitive."

In her hearing testimony, Kelley Tyler, an NNU member and RN at Mission Healthcare in Asheville, North Carolina, described how conditions at her community hospital deteriorated after corporate giant HCA Healthcare acquired it.

"Services like rural cancer care and wheelchair and seating clinics have been cut completely," said Tyler. "HCA has shuttered primary care clinics and driven out hundreds of doctors and nurses. Our more vulnerable populations have suffered, especially seniors, who are often forced to drive over an hour for needed care."

HCA, Tyler continued, has "taken its hatchet to charity care, geriatric services, security, and even hospital chaplains."

"We believe HCA uses its market domination over Western North Carolina to gut our healthcare system, then send the profits back to executives and Wall Street shareholders," she added, imploring the FTC and DOJ to "modify... procedures around mergers and acquisitions to protect communities like Asheville from companies like HCA."

NNU, drawing from Comsti's detailed comments, elaborated on its concerns in a statement released Thursday.

According to the union: "Traditional distinctions between vertical and horizontal mergers have largely evaporated due to the abuse of market power by large healthcare systems. Corporate financial interests' integration into and control of different types of healthcare facilities can incentivize interference with the professional judgment of practitioners and reduce practitioner autonomy."

Citing Comsti, NNU said that "the role of private equity ownership and its 'strong tendency... to focus on short-term profits, maximizing returns paid to investors, and minimizing liability by financing acquisitions through debt' has adversely affected patient outcomes and safety."

NNU urged the FTC and DOJ to pay particularly close attention to "the deleterious effects of private equity ownership in healthcare," which Comsti wrote "is particularly damaging and even deadly." She pointed out that healthcare facilities owned or operated by private equity firms tend to have "lower staffing levels, higher prices for care, and higher medical debt for patients."

A report published last month shed light on the private equity industry's growing foothold in the home healthcare and hospice sector.

"Healthcare market concentration is strongly associated with huge increases in predatory pricing practices by insurance companies and other payers and hospital charges," NNU noted. This has contributed to "a national scandal over medical debt and... forcing up to 40% of Americans skip needed care due to escalating costs."

According to NNU, two-thirds of hospitals now belong to multi-facility systems, up from 37% in 1994. An NNU report published in 2020 found that U.S. hospitals charge patients more than four times the cost of care, on average. The highest charge-to-cost ratios were found at hospitals owned by multi-facility systems, the vast majority of which are run by for-profit corporations.

"Healthcare market concentration is strongly associated with huge increases in predatory pricing practices."

NNU explained Thursday that "conglomeration is increasingly seen when an acute-care hospital system acquires or merges with physician practices, home health agencies, telehealth service providers, outpatient clinics, nursing homes, skilled nursing facilities, or other post-acute care facilities."

The union stressed that this "frequently results in cuts in-patient services as well as higher prices for care," leading to "the increased shift of needed care work to unpaid family caregivers or unlicensed aides, rather than RNs and other professional caregivers."

Following public testimony last week, FTC Chair Lina Kahn said that "as we've heard from several of you, sometimes that cost-cutting can come at the expense of quality of care."

On Wednesday, the Centers for Medicare & Medicaid Services (CMS) released data on mergers, acquisitions, consolidations, and changes of ownership at hospitals and nursing homes enrolled in Medicare from 2016 to 2022—the first time such information has been made public.

Echoing NNU's analysis of the harmful effects of mergers and acquisitions, CMS Administrator Chiquita Brooks-LaSure said in a statement that "hospital and nursing facility consolidation leaves many underserved areas with inadequate or more expensive healthcare options."

Comsti, for her part, also emphasized that market consolidation weakens RNs and other healthcare workers' bargaining power over terms and conditions of employment, lowering wages and leading to unsafe staffing levels.

In addition to hurting patient safety, she said, "intentional understaffing, lack of health and safety precautions, and other poor working conditions have driven nurses away from bedside nursing."

To limit the damages associated with healthcare industry mergers and acquisitions, NNU is urging the FTC and DOJ "to expand antitrust scrutiny and other guidelines in reviewing past practices of the buyers, such as higher charges to payers and patients, hospital closures and patient service cuts, adverse impacts on independent safety-net hospitals and public healthcare facilities, past anti-union behavior, and degradation of patient privacy and information sharing with technology firms."

"These measures and additional remedies in merger and acquisition guidelines," the union said, "can protect patients, workers, and communities."


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