Brian Thompson spent more than 20 years climbing through the ranks at UnitedHealthcare, one of the nation’s largest health insurers and a main division of the conglomerate UnitedHealth Group, and there were no signs that his ascent was slowing.He had been chief executive of the insurance division since 2021, overseeing a period of substantial profits. The division reported $281 billion in revenues last year, providing coverage to millions of Americans through the health plans it sold to individuals, employers and people under government programs like Medicare. The division employed roughly 140,000 people.During his tenure, the company’s profits rose, with earnings from operations topping $16 billion in 2023 from $12 billion in 2021. Mr. Thompson received more than $10 million in salary and compensation last year.He was well-respected by Wall Street analysts, where he was known for his reassuring description of the company’s outlook.Those who worked with him during his oversight of the company’s government programs in Medicare and Medicaid said he was responsive to concerns about how to best serve the individuals in those programs. “Every interaction with him felt extremely genuine,” said Antonio Ciaccia, a consultant who discussed using pharmacists to help provide better care for people receiving Medicaid. “He was a very good listener.”On a recent call with Wall Street analysts and investors to discuss the company’s financial results, Mr. Thompson provided a confident voice when questioned. When asked about the employer segment, he told one analyst, “I feel really good about not only our performance, but our cost management inside our commercial business.”We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

The Justice Department and four Democratic state attorneys general argued that United’s takeover would limit competition and harm consumers needing home or hospice care.The Justice Department and four Democratic state attorneys general on Tuesday filed an antitrust lawsuit against the giant UnitedHealth Group in an attempt to block its $3.3 billion deal to take over Amedisys, a large home health company.“Unless this $3.3 billion transaction is stopped, UnitedHealth Group will further extend its grip to home health and hospice care, threatening seniors, their families and nurses,” Jonathan Kanter, the assistant attorney general who heads the department’s antitrust division, said in a statement on Tuesday.Antitrust regulators have been reviewing the proposed acquisition amid a federal inquiry into UnitedHealth’s sprawling dominance across nearly every segment of health care. As one of the biggest U.S. companies overall, with $372 billion in revenue in 2023, UnitedHealth’s operations include the nation’s largest health insurer and its Optum subsidiary, which oversees some 90,000 physicians, clinics and is a large pharmacy benefit manager. Last year, United bought one of the nation’s largest home health outfits, LHC Group.The company had come under broader scrutiny this year when the Justice Department began an antitrust investigation as part of the Biden administration’s crackdown on what it considered to be anti-competitive behavior among corporate behemoths like Apple and Google.Filed in federal court in Maryland just one week after the presidential election, the lawsuit was joined by the Democratic attorneys general from Maryland, Illinois, New Jersey and New York.UnitedHealth Group argued that its merger would give consumers more choices. “The Amedisys combination with Optum would be pro-competitive and further innovation, leading to improved patient outcomes and greater access to quality care,” Optum said in a statement. “We will vigorously defend against the D.O.J.’s overreaching interpretation of the antitrust laws.”We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

For two weeks at the 140-hospital system, doctors and nurses have had little access to digital records for patient histories, resorting to paper and faxes to treat people.In more than a dozen states, doctors and nurses have resorted to paper and handwritten treatment orders to chart patient illnesses and track them, unable to access the detailed medical histories that have long been available only through computerized records.Patients have waited for long stints in emergency rooms, and their treatments have been delayed while lab results and readings from machines like M.R.I.s are ferried through makeshift efforts lacking the speed of electronic uploads.For more than two weeks, thousands of medical personnel have turned to manual methods after a cyberattack on Ascension, one of the nation’s largest health systems with about 140 hospitals in 19 states and the District of Columbia.The large-scale attack on May 8 was eerily reminiscent of the hack of Change Healthcare, a unit of UnitedHealth Group that manages the nation’s largest health care payment system. The assault shut down Change’s digital billing and payment routes, leaving hospitals, doctors and pharmacists without ways to communicate with health insurers for weeks. Patients were unable to fill prescriptions, and providers could not get paid for care.While some earlier cyberattacks affected a single hospital or smaller medical networks, the breakdown at Change, which handles a third of all U.S. patient records, underscored the dangers of consolidation when one entity becomes so essential to the nation’s health system.Ascension systems remain down indefinitely, but doctors and nurses are working to find ways of getting access to some information about patients’ medical histories by looking at health records kept by other providers. Ascension is also telling doctors and nurses that they will soon be able to see existing digital records.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

For nearly a week, people have been waylaid at pharmacies after a unit of the nation’s largest insurer was shut down by a possible ransomware assault.A cyberattack on a unit affiliated with UnitedHealthcare, the nation’s largest insurer, has disrupted drug prescription orders at thousands of pharmacies for nearly a week.The assault on the unit, Change Healthcare, a division of United’s Optum, was discovered last Wednesday. The attack appeared to be by a foreign country, according to two senior federal law enforcement officials, who expressed alarm at the extent of the disruption on Monday.UnitedHealth Group, the conglomerate, said in a federal filing that it had been forced to disconnect some of Change Healthcare’s vast digital network from its clients, and as of Monday, had not been able to restore all of those services.Change handles some 15 billion transactions a year, representing as many as one in three U.S. patient records and involving not just prescriptions but dental, clinical and other medical needs. The company was acquired by UnitedHealth Group for $13 billion in 2022.This latest attack underscores the vulnerability of health care data, especially patients’ personal information, including their private medical records. Hundreds of breaches at hospitals, health plans and doctors’ offices are being investigated, according to federal records.In this case, the disturbance has been widespread, including for U.S. military overseas. Change acts as a digital intermediary to helps pharmacies verify a patient’s insurance coverage for their prescriptions, and some reports indicate that people have been forced to pay in cash.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Finding an aide to help an older person stay at home safely takes work. Here’s a guide.Most older Americans want to live at home as long as they can, but finding and affording the help they need often isn’t easy. There are severe shortages of home health aides in many parts of the country. Hiring them is costly. And most middle-class people will have to pay for home care themselves if they will need it for the long haul. Here’s a guide to locating home care for an older person.What kind of home care do you need?After a fall or surgery, some older people will need short-term care at home from a nurse or therapist to help them recover. Medicare, the federal insurance program for those 65 and over, typically pays for this kind of home health care. A nurse can make sure a wound is healing properly, for example, while a physical therapist can help a person get back on their feet after a knee replacement.But millions of older Americans need assistance over months or years to stay in their homes safely instead of moving to an assisted-living facility or nursing home. They may require help getting out of bed, taking a shower or going to the bathroom; getting to the doctor; shopping for groceries or making meals. They need a home health aide or personal care assistant, who may not have much, if any, medical training.How do I find help?A wide range of services are available, whether it’s light housekeeping or hiring a private-duty nurse. Monica Moreno, senior director of care and support at the Alzheimer’s Association, suggests that you start by making a simple list of the kind of help you or your loved one needs and the number of hours each day or week required.To identify agencies and services available in your area, Ms. Moreno recommends looking through a database of community resources provided jointly by the association and AARP, the nonprofit group representing older Americans, that is searchable by location. A list of agencies and a brief description of what they provide can be found under the category of home care. AARP also has a guide to finding a home health aide.Laurie Gregory, a patient care aide at Interim HealthCare, with a client, Dan Missroon, at his home in Summerville, S.C.Desiree Rios/The New York TimesShould I use an agency?While Medicare certifies and gives star ratings to home health agencies, the businesses that provide home care services are not subject to federal oversight or required to be licensed in every state. But a good agency will run background checks on its workers and give them training and support. If an aide calls in sick or quits, the agency can find a replacement. Some businesses also bond and insure their caregivers.To choose an agency, Jennifer Battista, the chief operating officer for the Home Care Association of America, suggests inviting several of them to your home to conduct an assessment. Ask them how they vet their employees, whether they run criminal background checks, and whether their employees are required to know how to perform CPR or provide first aid. Be sure to ask for references for individual aides and talk to families who have employed them before.Once you pick an agency, you may want to try a few caregivers before finding the right one. The more information you share about your loved ones’ needs, the better the agency will be able to find an aide who’s a good fit. “It’s a lot like matchmaking,” Ms. Battista said.What about finding someone through word of mouth?Many families have success finding a caregiver by asking people they trust for recommendations, said Nicole Jorwic, a lawyer who is the chief of advocacy and campaigns for Caring Across Generations, an advocacy organization. “Cast a wide net, post on private social media and ask family and friends,” she said, noting that she found caregivers for her grandparents by asking people in her community.Churches and other religious institutions, local charities and community organizations may also have suggestions. A primary care doctor or local medical practice may have experience with specific home care agencies or know of individual caregivers. If you decide to hire someone privately, you should be sure to do a thorough background check and talk to families who have employed that person before. Family Caregiver Alliance, a California nonprofit group, provides a guide.Will Medicare cover the cost of an aide?Many home agencies erroneously say they can’t send a home aide and will tell a doctor’s office or patient that Medicare won’t pay for one. “This is a longstanding problem,” said Judith A. Stein, the executive director for the Center for Medicare Advocacy, a nonprofit legal group.While it’s true that Medicare doesn’t pay for long-term care, it may pay for an aide as part of a patient’s care plan if that person also qualifies for a home nurse or therapist for a time. Agencies often refuse to provide someone because Medicare pays a lump sum per patient, meaning the agency isn’t paid more for sending an aide in addition to the nurse or therapist. Talk to the doctor about whether an aide is necessary so one can be specified in the care plan presented to the agency.Medicare patients are getting fewer visits from an aide now than they did some 25 years ago, and the center is now appealing a judge’s dismissal of a lawsuit claiming that Medicare, under the U.S. Department of Health & Human Services, discouraged the use of aides for thousands of people. The judge did acknowledge that many people were not getting care.Robin Lee, center, who has had dementia for about a decade, took a walk through her yard with the help of her son, left, and a dementia care specialist, Ronnie Smalls, right.Desiree Rios/The New York TimesWill other insurance pay for an aide?Under Medicaid, the state-federal program for the poor that provides long-term care, the cost of an aide is often covered as an alternative to a nursing home. But the shortage of workers can make it difficult to find one even if you qualify. Families complain of frequent no-shows, and the low wages paid under the program mean that agencies often have high turnover among workers.Some private Medicare Advantage plans offer home care as a supplemental benefit, and it’s possible that some help will be covered under a long-term care insurance policy. If you or your loved one is a veteran, it’s worth checking with Veterans Affairs to see if it will pay for home care.How much will an aide cost?If you decide to pay privately, the hourly rates charged by agencies vary widely, and some agencies may not be able to fill a position for just a few hours a week. In San Jose, Calif., half of the agencies charged more than $37 an hour for a home health aide in 2021, according to Genworth, the long-term care insurer. Across the country, agencies are charging roughly $27 an hour with a little more than half of that going to pay their workers.There are no good estimates for how much people working for themselves may charge. You could save some money because there is no middleman taking a cut, but some independent caregivers charge roughly the same as an agency.How do I report a problem?If the agency you’re using is licensed by your state, you can check with the government office overseeing it if you run into a problem. You can also file a complaint with various state agencies, including the state health department.Where else can I get help?State or local government agencies that focus on aging or nonprofit groups can provide information. You can also try the eldercare locator. The Alzheimer’s Association also has some advice for finding caregivers, and it offers a 24-hour help line, 1-800-272-3900.What about respite care?Family caregivers should also think about taking advantage of respite care to give themselves a break from time to time. Depending on the circumstances, insurance may cover the cost, and there are local government and community groups that will also pay for an aide for a brief period. Churches and other organizations may also provide respite care.

Especially in California, people could experience delays in appointments or test results and even have medical procedures postponed after thousands of health care workers walked out.More than 75,000 Kaiser Permanente health care workers began a three-day strike after contract negotiations failed over wages and staffing shortages.Damian Dovarganes/Associated PressTens of thousands of Kaiser Permanente workers, including pharmacists, lab technicians, therapists and housekeepers, went on strike Wednesday morning. Kaiser patients in California, Colorado, Oregon, Virginia and Washington State, where Kaiser health care workers are walking out, will be affected.Kaiser, whose health plans cover nearly 13 million people through a network of hospitals and clinics, says its hospitals and emergency departments remain open. But patients should expect delays in scheduling appointments, and procedures that are not considered urgent could be postponed. Doctors and many nurses are not on strike.What services are affected?In an earlier statement, Kaiser emphasized that “a strike should not dissuade anyone from seeking necessary care.” But an array of services, such as lab tests, imaging and the filling of prescriptions, could be delayed because of the walkouts. Some clinics and pharmacies could be closed, and Kaiser said it would contact patients with any cancellations.Kaiser’s hospitals are open. But some people seeking care could be directed to a hospital outside of Kaiser’s usual network if their doctors thought it was necessary. Kaiser’s hospital-based pharmacies also remain open, though the health system is urging people to use its mail order pharmacy if they can wait. Some patients may also be able to go to an outside retail pharmacy to fill a prescription.Patients may feel the effects of the strike in other ways: Hospital rooms may be cleaned less frequently, and the outside workers that Kaiser has brought in to help may not be as familiar with the way a facility operates.Where did Kaiser workers walk out?Kaiser Permanente operates in eight states and the District of Columbia, with 39 hospitals and more than 600 medical offices. Most of the striking workers are in California, where the health system is based. The system operates nearly all of the hospitals in the state, as well as more than 500 medical buildings there.There are no strikes in Georgia, Maryland and Hawaii, according to Kaiser officials, and few walkouts occurred in Washington State. In Virginia and the District of Columbia, only pharmacists and optometrists took part on Wednesday, and they were expected to return to work after a day.What are the main labor issues?The coronavirus pandemic exacerbated staffing shortages that even Kaiser officials acknowledge still plague hospitals and other medical centers around the country. Patients and workers have had to deal with fewer nurses, aides and support staff members, according to many accounts.Kaiser’s union representatives said a lack of adequate staffing created unsafe conditions for patients, and argued that better wages would lure workers to close the gaps created by burnout and the exodus of employees in the last few years.Under a proposed four-year contract, the union had sought a $25 hourly minimum wage and additional increases over the next few years.Kaiser had countered with minimum hourly wages of between $21 and $23 next year, increasing by a dollar a year. Raises would vary, it proposed, depending on locations.How long will the strike last?The strike started on Wednesday morning and could last through Saturday morning, with the exception of Virginia and the District of Columbia. The two sides were still in talks on Wednesday, so it’s possible that a settlement could be reached before then.

A new study finds that people have a very difficult time finding doctors in their networks under the private-sector policies.People with private Medicare coverage may not be getting the mental health services they need because they cannot find a psychiatrist within their plan’s network, according to a new study. More than half of the counties the researchers studied did not have a single psychiatrist participating in a Medicare Advantage plan, the private-sector counterpart to traditional Medicare. Some 30 million people, just over half of all participants in the federal program, are enrolled in these private plans.The researchers, in an article published on Wednesday in the journal Health Affairs, found that of the plans reviewed, nearly two-thirds were narrow, with fewer than a quarter of available psychiatrists in a plan’s network. The networks offered under either an Obamacare plan or Medicaid managed care were not as restrictive and included about 40 percent of the available psychiatrists, according to the study.The more limited “networks present a frustrating additional barrier in mental health services even when, on paper, there are a sufficient number of providers in a geographic region,” the researchers wrote.The pandemic helped expose a widespread need for mental health services among older Americans, many of whom are struggling with loneliness, the loss of a loved one or their own deteriorating health. While roughly one in four people enrolled in Medicare has a mental illness like depression, anxiety or schizophrenia, an estimated half or fewer receive treatment, according to a recent analysis of mental health coverage by the Commonwealth Fund, a nonprofit group.“We need systems in place so people can easily find and afford the care they need,” said Gretchen Jacobson, vice president of Medicare at Commonwealth. “It’s not clear people are able to do so.”The difficulty in finding a psychiatrist is not unique to Medicare Advantage policyholders, in part because of increased demand. The scarcity of psychiatrists, particularly those willing to accept insurance, makes it difficult for plans to find providers. Many psychiatrists have also opted out of seeing patients under traditional Medicare, according to a recent report.“Part of what is going on is we have this big problem of a shortage of psychiatrists and mental health providers writ large,” said Beth McGinty, the chief of the division of health policy and economics at Weill Cornell Medicine and the author of the Commonwealth report. “It is exacerbated here.”Because going out of network is costly, many people will delay or skip treatment, said Dr. Jane M. Zhu, one of the study’s authors and a primary care physician at Oregon Health and Science University. She said her own patients often had difficulty finding help.“I was referring them out, but they could just not get access to any mental health providers,” Dr. Zhu said. One of her patients called more than a dozen providers before getting an appointment, she said.Insurers say their goal is to provide a wide array of mental health services. “Everyone deserves access to effective, affordable and equitable mental health support,” Kristine Grow, a spokeswoman for AHIP, a trade group representing the insurers, said in an email.But Ms. Grow criticized the Health Affairs study for not comparing the plans with traditional Medicare and for not examining other types of mental health services available to patients that would be provided by other clinicians or via telehealth. “In essence, this study uses a very narrow definition of mental health clinician to prove a pre-existing thesis about Medicare Advantage,” she said.More broadly, regulators and lawmakers have voiced concerns that people in the private Medicare plans may not be getting the services they are entitled to under the federal program. Critics have long complained about inadequate access to mental health services.Senator Ron Wyden, the Oregon Democrat who leads the Senate Finance Committee, held a hearing in May about so-called “ghost networks” of mental health providers, in which many of the clinicians listed in the Medicare Advantage plans’ directories are not, in fact, accepting patients. His staff conducted a secret shopper survey and could only obtain an appointment 18 percent of the time.The Health Affairs study may have overstated the availability of psychiatrists because it only looked at which providers were listed in the plan’s directory, Dr. Zhu said. “It likely paints a rosier picture,” she said.Doctors may be unwilling to participate in Medicare Advantage plans because of the low payments paid by the insurers, coupled with all of the required paperwork, said Dr. Robert Trestman, who is the chairman of the council on health care systems and financing for the American Psychiatric Association and testified at the Senate hearing. “Many of the challenges and frustrations are emphasized in the Medicare Advantage plans,” he said.Some insurers pay psychiatrists less under their Medicare Advantage plans than traditional Medicare pays for the same services, the researchers said. The plans may also have an incentive to contract with a smaller group of doctors to have more control over the cost and care being delivered, the researchers said.

The NewsA majority of Americans with health insurance said they had encountered obstacles to coverage, including denied medical care, higher bills and a dearth of doctors in their plans, according to a new survey from KFF, a nonprofit health research group. As a result, some people delayed or skipped treatment.Those who were most likely to need medical care — people who described themselves as in fair or poor health — reported more trouble; three-fourths of those receiving mental health treatment experienced problems.“The consequences of care delayed and missed altogether because of the sheer complexity of the system are significant, especially for people who are sick,” said Drew Altman, the chief executive of KFF, formerly known as the Kaiser Family Foundation.The survey also underscored the persistent problem of affordability as people struggled to pay their share of health care costs. About 40 percent of those surveyed said they had delayed or gone without care in the last year because of the expense. People in fair or poor health were more than twice as likely to report problems with paying medical bills than those in better health, and Black adults were more likely than white adults to indicate they had trouble.Why It Matters: Delayed care can endanger health.Nearly half of those who encountered a problem with their insurance said they could not satisfactorily resolve it. Some could not obtain the care they had sought, while others said they paid more than expected. Among the nearly 60 percent who reported difficulty with their insurance coverage, 15 percent said their health had declined.“This survey shows it’s not enough to just get a card in your pocket — the insurance has to work or it’s not exactly coverage,” said Karen Pollitz, the co-director for KFF’s patient and consumer protections program.People have a hard time understanding their coverage and benefits, with 30 percent or more reporting difficulty figuring out what they will be required to pay for care or what exactly their insurance will cover.“Insurances are way more complicated than they should be,” said Amanda Parente, a 19-year-old college student in Nashville who is covered under her mother’s employer plan. She was surprised to find that her out-of-pocket costs spiked recently when she sought treatment for strep throat. While she realized her co-payments would be higher, “I guess we didn’t know how drastic it was going to be,” she said.Background: Insurance coverage is confusing to everyone.Navigating the intricacies of coverage and benefits were similar regardless of what kind of insurance people had. At least half of those surveyed with private coverage, through an employer, those with an Obamacare plan, or a government program like Medicare or Medicaid, said they experienced difficulties.Survey ResultsNearly 60 percent of Americans with health insurance had a problem with their coverage over the past year.

A coalition of unions has filed an antitrust complaint with the Justice Department, accusing the Pennsylvania hospital system of suppressing wages and worsening working conditions.A coalition of labor groups on Thursday filed an antitrust complaint with the Justice Department against UPMC, the giant Pittsburgh-based hospital employer, accusing the system of using its enormous clout to depress wages and harm workers.In its complaint, the group, which includes S.E.I.U. Healthcare Pennsylvania, claims UPMC workers are subject to a “wage penalty” because of the health system’s dominance in local markets. The complaint describes nurses who are given heavier workloads than nurses at other hospitals, creating concerns over patient safety, and catalogs what the coalition considers to be labor law violations that it says illustrate the powerlessness of employees to improve working conditions.“We have watched UPMC grow and amass power,” said Matthew Yarnell, the president of the S.E.I.U. group there, which has long sought to organize workers at the health system, which is largely not unionized. After a series of acquisitions, it is Pennsylvania’s largest private employer with more than 40 hospitals, 800 doctors’ offices and clinics, and a health plan. With operating revenue of $26 billion last year, it employs about 95,000 people.While antitrust cases frequently address how powerful organizations can operate as monopolies and unfairly raise prices, a company can also be accused of operating as a monopsony in which it exerts unfair leverage over suppliers, including employees.Health care and legal experts say this is a novel legal approach to consider the effects on workers of widespread consolidation in the health industry.In the complaint, the unions claim that UPMC’s monopsony power has also prevented workers “from exiting or improving these working conditions through a draconian system of mobility restrictions and widespread labor law violations that lock in sub-competitive pay and working conditions.”Reached for comment, a spokesman for UPMC did not directly address the unions’ claim that it violated antitrust law, but defended its treatment of employees. The system “is among the best places to work in all the regions we served,” Paul Wood, UPMC’s chief communications officer, said in an email. He said the system’s average wage was more than $78,000 annually.“There are no other employers of size and scope in the regions UPMC serves that provide good paying jobs at every level and an average wage of this magnitude,” he added.He also said that the health system assigned nurses based on patient need and that there was no policy that would prohibit an employee who left one facility from being rehired at another one.But federal regulators have signaled an increased willingness to look at the effects of an employer’s market power on workers, and concern about how consolidation affects labor markets “is gaining a lot of momentum and attention,” said Jaime King, a law professor at the University of Auckland and an antitrust expert.“The problem is much bigger than a single merger in a single market,” said Marka Peterson, legal director for Strategic Organizing Center, a labor coalition formerly known as the Change to Win Federation.The Justice Department could decide whether to undertake its own investigation and whether any charges would be warranted.The Biden administration highlighted its concerns about the impact of concentration on labor markets in a 2021 executive order, and the Federal Trade Commission recently issued a proposed rule that would ban the use of noncompete agreements.Increasing consolidation in the health care industry has also focused some attention on fallout among the work force. Some research into hospital mergers has shown a reduction in nurses’ wages. “Health care stands out as being concentrated on both sides,” said Kate Bahn, an economist and research director at the Urban Institute.And health care workers, many of whom suffered severe burnout during the pandemic, are in short supply across the industry. The high workloads led to numerous strikes by nurses, including recent walkouts at New York City hospitals.UPMC has often been criticized for what some describe as anticompetitive conduct, and a report released earlier this year echoed some of the issues raised in the complaint.But whether the Justice Department will pursue action against the health system remains to be seen. While federal regulators may appear sympathetic to the theory underlying the unions’ complaint, these cases are challenging. “Monopsony cases are not new, but they are very hard to prove,” said Matthew L. Cantor, an antitrust lawyer and partner at Constantine Cannon.This would be the first case to rely primarily on the argument that a powerful health care employer is using its clout in ways that harm workers, and prosecutors must decide whether they have strong enough evidence to take action. “They’re not going to want to fight a case they don’t think they can win,” said Elena Prager, an economist at the Simon Business School at the University of Rochester who has served as a visiting scholar with the Justice Department.

Large health insurers and other companies are especially keen on doctors’ groups that care for patients in private Medicare plans.It’s no surprise that the shortage of primary care doctors — who are critically important to the health of Americans — is getting worse.They practice in one of medicine’s lowest paid, least glamorous fields. Most are overworked, seeing as many as 30 people a day; figuring out when a sore throat is a strep infection, or managing a patient’s chronic diabetes.So why are multibillion-dollar corporations, particularly giant health insurers, gobbling up primary care practices? CVS Health, with its sprawling pharmacy business and ownership of the major insurer Aetna, paid roughly $11 billion to buy Oak Street Health, a fast-growing chain of primary care centers that employs doctors in 21 states. And Amazon’s bold purchase of One Medical, another large doctors’ group, for nearly $4 billion, is another such move.The appeal is simple: Despite their lowly status, primary care doctors oversee vast numbers of patients, who bring business and profits to a hospital system, a health insurer or a pharmacy outfit eyeing expansion.And there’s an added lure: The growing privatization of Medicare, the federal health insurance program for older Americans, means that more than half its 60 million beneficiaries have signed up for policies with private insurers under the Medicare Advantage program. The federal government is now paying those insurers $400 billion a year.“That’s the big pot of money everyone is aiming at,” said Erin C. Fuse Brown, director of the Center for Law, Health & Society at Georgia State University, and an author of a New England Journal of Medicine article about corporate investment in primary care. “It’s a one-stop shop for all your health care dollars,” she said.Many doctors say they are becoming mere employees. “We’ve seen this loss of autonomy,” said Dr. Dan Moore, who recently decided to start his own practice in Henrico, Va., to have more say in caring for his patients. “You don’t become a physician to spend an average of seven minutes with a patient,” he said.The absorption of doctor practices is part of a vast, accelerating consolidation of medical care, leaving patients in the hands of a shrinking number of giant companies or hospital groups. Many already were the patients’ insurers and controlled the distribution of medicines through ownership of drugstore chains or pharmacy benefit managers. But now, nearly seven of 10 of all doctors are either employed by a hospital or a corporation, according to a recent analysis from the Physicians Advocacy Institute.The companies say these new arrangements will bring better, more coordinated care for patients, but some experts warn the consolidation will lead to higher prices and systems driven by the quest for profits, not patients’ welfare.Sara Beth Campos, left, a clinic educator, trained Katie Robertson, a new nurse assistant, at Neighborhood Health Center in Oregon City, Ore.Mason Trinca for The New York TimesInsurers say their purchase of medical practices is a step toward what is called value-based care, with the insurer and doctor paid a flat fee to care for an individual patient. The fixed payment acts as a financial incentive to keep patients healthy, provide more access to early care and reduce hospital admissions and expensive visits to specialists.The companies say they favor the fixed fees over the existing system that pays doctors and hospitals for every test and treatment, encouraging doctors to order too many procedures.Under Medicare Advantage, doctors often share profits with insurers if the doctors take on the financial risk of a patient’s care, earning more if they can save on treatment. Instead of receiving a few hundred dollars for an office visit, primary care doctors can be paid as much as $14,000 a year to manage a single patient.But experts warn these major acquisitions threaten the personal nature of the doctor-patient relationship, especially if the parent company has the authority to dictate limits on services from the first office visit to extended hospital stays. Once enrolled, these new customers can be steered toward chains of related businesses, like a CVS drugstore or Amazon’s online pharmacy.UnitedHealth Group is a sprawling example of consolidated services. It owns the major insurer that has nearly 50 million customers in the United States and oversees its ever-expanding subsidiary, Optum, which has bought up networks of doctors and medical sites. Optum can send patients from one of its roughly 70,000 doctors to one of its urgent care or surgery centers.Senator Elizabeth Warren, Democrat of Massachusetts, is urging the Federal Trade Commission to take a closer look at some of these large deals, which regulators have so far not blocked on antitrust grounds. “I fear that the acquisition of thousands of independent providers by a few massive health care mega-conglomerates could reduce competition on a local or national basis, hurting patients and increasing health care costs,” she wrote to regulators in March.This consolidation of medical care may also run afoul of state laws that prohibit what is called corporate medicine. Such statutes prevent a company that employs doctors from interfering with patient treatment.And experts warn of the potential harm to patients, when corporate management seeks to control costs through byzantine systems requiring prior authorization to receive care.Karen S. Lynch, chief executive of CVS Health, said primary care doctors lower medical costs. “Primary care drives patient engagement and positive clinical outcomes,” she said.Charles Krupa/Associated PressFor example, Kaiser Permanente, the giant nonprofit health plan that also owns physician groups, settled a malpractice case for nearly $2.9 million last year with the family of Ken Flach, a former tennis player who contracted pneumonia and died from sepsis after a Kaiser nurse and doctor would not send him for an in-person visit or to the emergency room, despite the urgent pleading of his wife. Kaiser said medical decisions are made by its providers in consultation with their patients and said its “deepest sympathy remains with the Flach family.”Doctors also chafe at oversight that does not benefit patients. “They are trying to run it like a business, but it’s not a business,” said Dr. Beth Kozak, an internal medicine doctor in Grand Rapids, Mich.Her doctors’ group has teamed up with Agilon Health, an investor-owned company, to work with Medicare Advantage plans. Dr. Kozak said she has to work longer hours, not to provide better care, but to supply additional diagnoses for patients, which increases federal reimbursements under the Medicare Advantage program. “It’s not because I’m giving better patient care,” she said. “It’s all tied to the billing.”The corporate consumption of medical care keeps growing. Walgreens Boots Alliance, one of the largest U.S. pharmacy operations, spent $5 billion for a majority stake in VillageMD, a primary care group, and teamed with Cigna to buy another medical group for nearly $9 billion. And short of an outright purchase, UnitedHealth is partnering with Walmart to offer care to older patients.In promoting the benefits of buying Oak Street clinics to investors, Karen S. Lynch, the chief executive of CVS Health, said primary care doctors lower medical costs. “Primary care drives patient engagement and positive clinical outcomes,” she said.Many of these companies are building chains of clinics. On a recent tour of an Oak Street clinic in Bushwick, one of 16 centers opened since October 2020 in New York City, patients were typically seen from 8 a.m. to 5 p.m., with a nurse available after hours to field questions.Ann Greiner, the chief executive of the Primary Care Collaborative, a nonprofit group, defended the recent forays by private companies into this field of health care, saying they are infusing practices with sorely needed funds and may improve access to care for people in underserved areas.Discussing a patient’s file at Oak Street Health in Bushwick, one of 16 centers opened since October 2020 in New York City.James Estrin/The New York Times“The salaries of the folks in those arrangements are higher,” she said. “They are providing more comprehensive care in many of those arrangements. They are providing more tech and more team-based care. That’s all investment.”But these deals also risk shifting the balance from quality treatment to profits, she said.In recent years, some have invoked the laws banning corporate medicine to challenge these large-scale private operations. Envision Healthcare, a private equity-backed company that employs emergency room doctors, is being sued in California by a unit of the American Academy of Emergency Medicine, a professional group that supports independent practices, accusing it of violating that state’s provisions.“Envision exercises profound and pervasive direct and indirect control and/or influence over physicians practice of medicine, ” according to the lawsuit. The suit maintains that Envision controls the doctors’ billing and establishes medical protocols.While Envision would not comment on the litigation, it said it “follows an operating structure that is common across the health care sector and widely used by nonprofit, privately held and public groups as well as hospitals and insurers.”The big insurers find doctors’ groups particularly attractive, although many have reported sizable losses. The acquisition of Oak Street, which has lost more than $1 billion over the last three years, could help CVS’s Medicare Advantage plans improve their quality or “star” ratings and increase payments for one of its plans.Even small numbers of patients can translate into significant revenue. One Medical, the company Amazon owns, is best known for sleek clinics. The company scooped up a practice specializing in Medicare Advantage. Only about 5 percent of One Medical’s 836,000 members are enrolled in that federal program, but roughly half of its revenue comes from that tiny slice of patients, according to its 2022 financial statements.Regulators are already flagging questionable methods employed by some practices. In November 2021, Oak Street disclosed that the Justice Department was investigating sales ploys like free trips to its clinics and payment of insurance agents for referrals. One doctor at a center described recruiting patients with “gift cards, swag and goody bags,” according to a shareholder lawsuit against Oak Street.“We’re dealing with incredible levels of burnout within the profession,” said Dr. Maxwell Cohen, a doctor at Neighborhood Health Center in Portland, Ore.Mason Trinca for The New York TimesThe lawsuit detailed concerns that doctors were inflating the payments from the federal government by overstating how sick their patients were.Oak Street says it has not been accused of any wrongdoing by the Justice Department and says the lawsuit is “without merit.”These private Medicare Advantage plans have been heavily criticized for racking up enormous profits by inflating costs and exaggerating patients’ illnesses to charge the government more than they should.Under new rules, the Biden administration would eliminate some of the most problematic, overused diagnoses, and doctors and insurers could earn less.But other pathways to profit also explain why corporations covet these deals. Unlike the caps on insurers’ moneymaking, where a Medicare Advantage insurer has to spend at least 85 cents of every dollar on patient care, there are no limits to how much profit these doctor practices and pharmacy chains can make.It may be too soon to determine whether consolidated care will improve patients’ health. “So far, when you look across the industry, the record of these acquisitions has been mixed,” said Dr. Sachin H. Jain, the chief executive of SCAN Group, a nonprofit based in Long Beach, Calif., that offers Medicare Advantage plans.And the investments may not halt the rapid disappearance of the doctor still sought by so many people for ordinary care, including a recent report showingfewer medical school graduates going into the field.“We’re dealing with incredible levels of burnout within the profession,” said Dr. Max Cohen, who practices near Portland, Ore. Since the pandemic, his low-income patients have become much sicker, he said, with the level of illness “through the roof.”