Private equity firms pool money from investors, ranging from wealthy people to college endowments and pension funds. They use that money to buy into businesses they hope to flip at a sizable profit, usually within three to seven years, by making them more efficient and lucrative.

Private equity is rapidly moving to reshape health care in America, coming off a banner year in 2021, when the deep-pocketed firms plowed $206 billion into more than 1,400 health care acquisitions, according to industry tracker PitchBook, and has poured nearly $1 trillion into nearly 8,000 health care transactions during the past decade.

And this might become a cost and quality control problem for workers’ compensation claim administrators.

And according to an analysis of this data and report by Kaiser Health News. these investors are buying into eye care clinics, dental management chains, physician practices, hospices, pet care providers, and thousands of other companies that render medical care nearly from cradle to grave. Private equity-backed groups have even set up special “obstetric emergency departments” at some hospitals, which can charge expectant mothers hundreds of dollars extra for routine perinatal care.

As private equity extends its reach into health care, evidence is mounting that the penetration has led to higher prices and diminished quality of care, a KHN investigation has found. KHN found that companies owned or managed by private equity firms have agreed to pay fines of more than $500 million since 2014 to settle at least 34 lawsuits filed under the False Claims Act, a federal law that punishes false billing submissions to the federal government with fines. Most of the time, the private equity owners have avoided liability.

Private equity has flocked to companies that treat autism, drug addiction, and other behavioral health conditions. The firms have made inroads into ancillary services such as diagnostic and urine-testing and software for managing billing and other aspects of medical practice.

Private equity has done so much buying that it now dominates several specialized medical services, such as anesthesiology and gastroenterology, in a few metropolitan areas, according to new research made available to KHN by the Nicholas C. Petris Center at UC-Berkeley.

New research by the University of California-Berkeley has identified “hot spots” where private equity firms have quietly moved from having a small foothold to controlling more than two-thirds of the market for physician services such as anesthesiology and gastroenterology in 2021. And KHN found that in San Antonio, more than two dozen gastroenterology offices are controlled by a private equity-backed group.

Whistleblowers and injured patients are turning to the courts to press allegations of misconduct or other improper business dealings. The lawsuits allege that some private equity firms, or companies they invested in, have boosted the bottom line by violating federal false claims and anti-kickback laws or through other profit-boosting strategies that could harm patients.

“Their model is to deliver short-term financial goals and in order to do that you have to cut corners,” said Mary Inman, an attorney who represents whistleblowers.

Federal regulators, meanwhile, are almost blind to the incursion, since private equity typically acquires practices and hospitals below the regulatory radar. KHN found that more than 90% of private equity takeovers or investments fall below the $101 million threshold that triggers an antitrust review by the Federal Trade Commission and the U.S. Justice Department.

Fund managers who back the deals often say they have the expertise to reduce waste and turn around inefficient, or moribund, businesses, and they tout their role in helping to finance new drugs and technologies expected to benefit patients in years to come.

Critics see a far less rosy picture. They argue that private equity’s playbook, while it may work in some industries, is ill suited for health care, when people’s lives are on the line.

These expansions can lead to higher prices for patients, said Yashaswini Singh, a researcher at the Bloomberg School of Public Health at Johns Hopkins University.  In a study of 578 physician practices in dermatology, ophthalmology, and gastroenterology published in JAMA Health Forum in September, Singh and her team tied private equity takeovers to an average increase of $71 per medical claim filed and a 9% increase in lengthy, more costly, patient visits.

Singh said in an interview that private equity may develop protocols that bring patients back to see physicians more often than in the past, which can drive up costs, or order more lucrative medical services, whether needed or not, that boost profits.

“There are more questions than answers,” Singh said. “It really is a black hole.”

Reserving is one of the most important aspects of claim handling. Whether it is a normal run of the mill lost time claim, or a claim with benefits payable over the remaining life of the insured worker, the goal is always the same: To accurately place the proper amount of money or reserves in the claim for the duration of the claim.

The claims examiner will typically take the periodic rate of benefits and the estimate of ongoing medical expense, and then compute the yearly estimated cost, and then multiply that by the number of years of anticipated remaining lifespan this worker is expected to have.

Life expectancy has increased in the U.S. for many decades, resulting in a lifetime reserve estimate increasing over time. A few years ago, this trend reversed, with data showing life expectancy in the U.S. was declining.

And now two annual reports released Thursday by the Center for Disease Control shows U.S. life expectancy is at a two-decade low and drug overdoses have risen five times in the last 20 years.

The drop was primarily due to increases in COVID-19 and drug overdose deaths. The data are featured in two new reports from CDC’s National Center for Health Statistics (NCHS).

The first report is “Mortality in the United States: 2021” which features the public release of final mortality data for 2021, and the report documents that there were 3,464,231 total deaths in the United States during 2021 – 80,502 more than the total reported in 2020.

The death rate for the entire U.S. population increased by 5.3% from 835.4 deaths per 100,000 population in 2020 to 879.7 in 2021. As a result, life expectancy at birth for the U.S. population decreased from 77 years in 2020 to 76.4 years in 2021.

The 10 leading causes of death in 2021 were largely unchanged from 2020, except chronic liver disease and cirrhosis became the 9th leading cause of death in 2021 while influenza and pneumonia dropped from the list of 10 leading causes. Heart disease remained the leading cause of death in the United States, followed by cancer and COVID-19.

Males’ life expectancy decreased slightly more than females by a difference of 5.8 years. Non-Hispanic American Indian or Alaska Native (AIAN) females had the highest death rate increase at 7.3%, with non-Hispanic white males coming in second at 7.2%, with AIAN males and black men still ranking at the top for overall deaths in 2021.

A second report, “Drug Overdose Deaths in the United States, 2001-2021,” showed that overdose deaths, which account for more than a third of all accidental deaths in the United States, have risen five-fold over the past two decades.

The official number of drug overdose deaths among residents in the United States for 2021 was 106,699, nearly 16% higher than the 91,799 deaths in 2020.

The CDC’s second report showed an increase in drug overdoses in all age categories of adults 25 and over between 2020 and 2021. Adults aged 34-44 had the highest rates at 53.9 per 100,000 but the 65 and over category saw the largest overall increase from 2020 to 2021 by 28%.

The rate of drug overdose deaths involving synthetic opioids other than methadone (drugs such as fentanyl, fentanyl analogs, and tramadol) increased 22% from 17.8 in 2020 to 21.8 in 2021.

From 2020 to 2021, the rate of drug overdose deaths involving cocaine increased 22% (from 6.0 to 7.3) and the rate for deaths involving psychostimulants with abuse potential (drugs such as methamphetamine) increased 33% (from 7.5 to 10.0).

The rate of drug overdose deaths involving heroin decreased 32% from 4.1 in 2020 to 2.8 in 2021.

A Saratoga, California man has been charged with posing as a doctor to perform an unlicensed Botox injection on a woman, which comes on the heels of him avoiding a jail sentence after he was prosecuted for similar acts in Miami, according to authorities and court records.

The Mercury News reports that 37 year old Brody Amir Moazzeni faces one felony count of practicing medicine without certification. The case was filed in Santa Clara County, and he was arraigned December 14, and faces a maximum sentence of a year in county jail if convicted on the charge.

Deputy District Attorney Ann Huntley said the charge is based on an allegation by a 26-year-old Stockton woman who met Moazzeni – who in the South Bay criminal complaint has listed aliases of Amir Moazzeni and Gianni Muzzati – through the Bumble dating app.

According to the investigation, the woman said she knew the defendant as Gianni Muzzati, and that he told her he was a doctor opening his own cosmetic clinic. The two began a romantic relationship, and on Sept. 25, 2021, they met at a Sunnyvale hotel where Moazzeni allegedly offered to give her free Botox injections in her face and other injections in her torso.

Huntley said that a few weeks later, the woman noticed her right eyelid was drooping and saw an ophthalmologist who told her her procedure was not done properly. After she got her eyelid treated, Moazzeni continued to pressure her into letting him do more cosmetic work, leading her to question his qualifications.

He was implicated in a similar case in March 2021 when he was charged with practicing unlicensed medicine and sexual battery involving a woman in Miami Beach, Florida, according to court records there.

Court records show that Miami-Dade prosecutors initially filed at least seven felony and misdemeanor charges against Moazzeni, but ultimately pursued two felony counts and one misdemeanor count, all involving the unlicensed medicine accusations. Those same records show that Moazzeni was allowed to participate in a pretrial diversion program to avoid a potential conviction and jail time, and that his charges were dropped Sept. 23 after he completed the program.

That was two days before the reported Botox encounter in Sunnyvale that led to his criminal charge in Santa Clara County. The new alleged offense has no consequence for his case in Florida since it was dismissed, according to the Miami-Dade State Attorney’s Office.

Still, that overlap has Huntley and investigators concerned there could be other women who received unlicensed cosmetic work from Moazenni and suffered health problems as a result.

“Given the sensitive nature of how he manipulates women,” Huntley said, “these women might feel used and bamboozled because of the way they were taken advantage of.”

To this point, Huntley said, there is no evidence that the defendant ever asked for payment for the procedures.

Moazzeni is currently out of jail custody and is scheduled to return to court Feb. 28. Anyone with information about the case, or other people who might have received unlicensed medial procedures from the defendant, can contact Santa Clara County DA Investigator Krissi Durant at 408-792-2567.

The Labor Commissioner’s Office collected $1,331,682 in wages and penalties, resulting from a prevailing wage assessment against Bakersfield-based subcontractor Grant Construction, Inc.

The wages collected will compensate 27 workers for unpaid prevailing wages while working on a farmworker housing construction project in the City of Wasco in Kern County.

The public works investigation determined that wage theft had occurred in the form of kickbacks and non-reporting of all hours worked. It found that a Grant Construction crew leader would collect the paychecks of the 27 workers, sign and cash them, and then pay the workers significantly less than the amount listed on their checks.

“The law requires that workers on construction projects with $1,000 or more public funds must be paid no less than the prevailing wage,” said Labor Commissioner Lilia García-Brower. “These workers held Grant Construction accountable for cheating them out of their legal wages.”

The City of Wasco hired Wallace & Smith Contractors as the prime contractor to build a $42 million farmworker housing complex with 66 apartments. Wallace & Smith Contractors hired subcontractor Grant Construction, Inc., to bring in carpenters and siding workers for the job.

The Labor Commissioner’s Office opened its investigation in February 2019 after a complaint of public works violation was filed by a worker claiming underpayment of wages and non-payment of travel and subsistence. The worker stated he was paid in cash for work performed on the project.

The investigation also confirmed that Grant Construction, Inc. failed to report all the workers and hours worked on the Certified Payroll Reports (CPR) and falsified the CPRs, paychecks, and paystubs.

The Labor Commissioner’s Office cited Grant Construction, Inc., in June 2020, for underpayment of prevailing wages to 27 workers, civil penalties, and training funds. The company was not required to pay liquidated damages because it timely deposited the full assessment amount in August 2020. However, the company requested a review of the assessment, and the hearing was held in May 2021.

The Department of Industrial Relations Director issued a decision upholding the assessment in May 2022. A judgment was entered on the decision of the Director in August of 2022 for a total of $1,389,395, including interest.

The Department of Industrial Relations’ Division of Labor Standards Enforcement, also known as the California Labor Commissioner’s Office, combats wage theft and unfair competition by investigating allegations of illegal and unfair business practices.

All workers employed on public works projects must be paid the prevailing wage determined by the Director of the Department of Industrial Relations (DIR), according to the project’s type of work and location. Failure to comply with public works requirements can result in civil penalties, criminal prosecution, or both. Employees with questions about their rights may call the Labor Commissioner’s Office at 833-LCO-INFO (833-526-4636).

The Labor Commissioner’s Office launched the Reaching Every Californian interdisciplinary outreach campaign in 2020. The campaign amplifies basic protections and builds pathways to affected populations, so workers and employers understand legal protections, obligations, and the Labor Commissioner’s enforcement procedures. Californians can follow the Labor Commissioner on Facebook and Twitter.

3-2 decision, in a closely followed employment law case, the National Labor Relations Board reinstated its prior 2011 standard, which applied a more expansive right of off-duty contractor employees to access publicly accessible areas of the primary employer’s workplace, for the purpose of engaging in organizing activity. The new decision overturns Bexar County I, 368 NLRB No. 46 (2019)

In this newest case, (Bexar County II) the San Antonio Symphony leases performance space from the Bexar County Performing Arts Center Foundation d/b/a Tobin Center for the Performing Arts.

On the evening of February 17, 2017, about a dozen Symphony employees sought to peacefully leaflet on the sidewalk in front of the main entrance to the Tobin Center. The Symphony employees had been distressed to learn that Ballet San Antonio had opted to use recorded music, rather than live music, for its production of Tchaikovsky’s Sleeping Beauty. The use of recorded music denies the Symphony employees the opportunity to work at the performance by playing the score. Because of financial difficulties, the Symphony had already had to furlough the Symphony employees for 3 weeks during the 2016–2017 season.

To raise awareness among Ballet San Antonio’s patrons about the use of recorded instead of live music, the Union decided to leaflet before the performances.

Event staff and San Antonio police officers at the Respondent’s direction immediately informed the Symphony employees that they could not distribute the leaflets anywhere on the Respondent’s property, including the sidewalks. The Symphony employees were forced to relocate across the street off the Tobin Center grounds onto a public sidewalk where there were fewer patrons.

This reaction lead to litigation before the NLRB, and two decisions, Bexar I – and after remand from an appellate court –  Bexar II.

Congress passed the National Labor Relations Act in 1935, during the New Deal era. Under section 7 of the NLRA employees’ rights include more than just the right to form a union. The NLRA protects any concerted employee activity undertaken for mutual aid. Employee actions have to meet several standards to deserve protection.

At issue in both Bexar I and II is the application of section 7. An underlying problem central to these two cases is that Section 7 only confers rights directly to employees, not to unions or their nonemployee organizers. The off-duty employees who work for a contractor of a property owner do not fit neatly into these categories.They are neither employees of the property owner nor are they nonemployees with no relationship to the property owner’s property where they work.

Precedent for the problem in the Bexar cases dates back to 2011, when the Board in New York New York considered whether off-duty food service employees had the right to engage in organizational leafleting of customers outside their employer’s place of business – not on their employer’s property, but in the public areas of a hotel-casino for which they and their employer provided services integral to the property owner’s business. (New York New York Hotel & Casino, 356 NLRB 907 (2011)).

In Bexar County I, the Board acknowledged that the New York New York test – which had been approved by the D.C. Circuit – controlled this case. Nonetheless, the Board overruled New York New York and announced a new standard to govern off-duty contractor employees’ access to the property where they regularly work (but that is not owned by their employer) to engage in Section 7 activity.

On appeal of Bexar I, the D.C. Circuit held that the Board’s new access standard was arbitrary. The court permitted the Board on remand to “decide whether to proceed with a version of the test it announced and sought to apply in this case or to develop a new test altogether.

On remand the NLRB noted its “agreement with the D.C. Circuit’s conclusion that the Bexar County I standard it established “is arbitrary in the way that it implements its new standard.” Part of the Board’s task in devising an access standard for off-duty contractor employees is to ensure that it only reaches those contractor employees with a sufficient connection to the property to merit Section 7 access rights.

The NLRB concluded in Bexar County II, that it would return to the New York New York Hotel & Casino, 356 NLRB 907 standard, which held that a “property owner may lawfully exclude [off duty contractor] employees only where the owner is able to demonstrate that their activity significantly interferes with his use of the property or where exclusion is justified by another legitimate business reason, including, but not limited to, the need to maintain production and discipline (as those terms have come to be defined in the Board’s case law).”

Applying the New York New York test here, the NRLB affirmed the judge’s finding that Bexar County violated Section 8(a)(1) by excluding the Symphony employees from the Respondent’s property to distribute union leaflets to the Respondent’s patrons about an issue affecting the Symphony employees’ terms and conditions of employment, specifically their number of hours of work. “They had a Section 7 right to inform the public about Ballet San Antonio’s use of recorded instead of live music, which directly affected the Symphony employees’ working conditions.”

“In order to protect contractor employees’ Section 7 rights, we believe that it is appropriate for us to apply the New York New York test to this case and to all pending cases.”