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Non-profit health systems driving income inequality

If you follow along with my rantings on THCB, Twitter and Linkedin you’ll know that I am unhappy with America’s growing inequality, both in wealth and income. Now, there are a few signs that so long as we have full employment the income picture for the lowest paid is getting a little better. But wealth inequality is clearly not getting better. 

You may remember this video explaining wealth inequality. Worth a watch if you haven’t seen it.

Well that was made in 2011. Back then Elon Musk was barely a billionaire, and more than a decade of massive stock market appreciation later, we know that the rich have gotten a lot richer, and their taxes went down following the Trump tax cuts in 2017.

Meanwhile, something similar has been going on in health care. The health economy has amazingly not taken much more of the overall economy since 2010. It went from 13% to 17% of GDP between 2000 and 2010 but has amazingly stayed around there–only popping up during the Covid recession and then heading down again. But the amount of money flowing into health care has stayed at a constant rate. And the American people continue to hate their experience with the health system.

They’re aren’t many selfless heroes. Payers, providers, doctors, pharma, equipment suppliers are all doing well. Wendell Potter has continued to show how health insurance companies have consolidated and gotten richer over the past decade plus. Big Pharma has managed the translation away from the mass market blockbusters of the 1990s to the high priced niche drugs of today, and now with GLP-1s is managing to keep those high prices. Despite lots of whining by the AHA, hospitals–which got massive handouts from the CARES Act during Covid–are all doing well again. But it’s always good to check in with the big non-profit systems. This isn’t the first time I’ve written about this. Early this year in a larger rant I wrote:

Over the last 30 years America’s venerable community and parochial hospitals merged into large health systems, mostly to be able to stick it to insurers and employers on price. Blake Madden put out a chart of 91 health systems with more than $1bn in revenue this week and there are about 22 with over $10bn in revenue and a bunch more above $5bn. You don’t need me to remind you that many of those systems are guilty with extreme prejudice of monopolistic price gouging, screwing over their clinicians, suing poor people, managing huge hedge funds, and paying dozens of executives like they’re playing for the soon to be ex-Oakland A’s. A few got LA Dodgers’ style money. 

One of the things that the non-profits have to do is file the 990 form with the IRS. Among other things it shows how much money the organization’s executives make. Now it’s not like non-profit health system execs are the only ones coining it. In 2022 the biggest for-profit chain HCA’s CEO made $20m and 4 others there made over $5m. But at least HCA is a nakedly capitalist organization, and it pays taxes.

Recently one of the bigger hospital systems, UPMC put out a new 990. Unlike the previous version they put out, the 990 on their website is a photocopy that can’t be searched. Maybe that’s an accident, although any non-profit can put out an easily searchable document. For instance here’s the one from a teeny non-profit that I control. You can search the words “Reportable Compensation” and find that sadly I got paid zilch for my efforts. Not sure why UPMC can’t do the same.

Luckily for those of us who care, Propublica is a little more aggressive. They reproduced a searchable version. The way ProPublica did it was to download an xls from the IRS. One reason it’s worth looking at was that this year as opposed to 2022, UMPC didn’t post its compensation in $$ order.

I’m not knocking UPMC too much. Very few other big non-profit health systems put anything like as much effort into detailing who makes what amount on their 990s. They usually stop after the first 10-20 employees. UPMC goes down to 220+

So I copied and repasted the compensation information from ProPublica and did the necessary editing of 230 cells to be able to sort by compensation. You can find the spreadsheet here. (Feel free to copy & paste and do your own edits).

So what does it tell you? 

UPMC had a CEO called Jeffrey Romoff who worked there his whole career. Romoff became President in the 1990s and took over as CEO in 2006. Using aggressive M&A, and some very sharp elbows including against the unions, Romoff essentially created the massive local monopoly that is the modern UPMC. His biggest moment in the national spotlight was when he went on 60 Minutes in 2011 and forgot his salary (he said it was $7m but then corrected it to $6m). Ten years later Romoff’s salary was a tad under $13m. If you are wondering, the median annual wage in the US in 2011 was $34,460. By 2022 it was $45,760. So the average salary increased 34% in nominal terms over that time. Romoff’s went up by more than 100%.

But that’s all well and good. Romoff retired at the age of 75 in August 2021 and was replaced by Leslie Davis.

So for the period covering July 2022 to June 2023, who was the highest paid person at UPMC?

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Want to get rich in health care? Ditch the startup and run a hospital

By MATTHEW HOLT

Given that I ran a health technology conference for many years, I tend to run in a circle of people who have some ambition to get rich in health care. After all, billions of dollars of VC money have been dropped in lots of startups over the last decade, and a few prime examples have done very well. For example Jeff Tangey of Doximity, Glen Tullman of Livongo,  Chaim Indig of Phressia and many others did fine when their companies IPOed in the late 2010s. But the truth is that many, many more have either started a health tech business that didn’t make it, or were foot soldiers in others that died along the way (Olive, Babylon, Pear, etc, etc). Which has been leading me lately to thinking about whether that’s the right approach to take if you want to make money in health care. Hint: it’s not.

There’s still tremendously little transparency about which health care organizations have what amount of money and what people earn. There is though one sector that by law has to publish information about revenue, profits, investments and executive compensation. That is the non-profit hospital/health system sector. Nonprofits are required to file Form 990 with the IRS that has that information and more on it. Having said that, most hospitals are frequently late in filing them, and file them in a very confusing way. The wonderful journalism organization ProPublica maintains a database of all 990 filings and it’s instructive to look around in it.

Some health systems make it relatively easy. UPMC, the huge western PA conglomerate files one 990 for the whole group. Others, not so much. I know that Providence, the huge west coast system, has overall revenue of $28bn but only because Fierce Healthcare told me. Had I tried to piece that together from its 990s, I’d have started with its Washington filing ($6bn), moved on to its Oregon filing (~$5bn) and then started getting confused..

Let’s say you wanted to easily figure out Advocate, the system that was the merger of the huge midwestern system with Atrium, the North Carolina-based one. Good luck. You can find Advocate but Atrium’s seems to be missing. Ditto for Carolinas Health, its previous name. There is a page calling itself Financial Information on the Atrium website, but it doesn’t have any, and tells you to go to a website set up for municipal bondholders. In fact I couldn’t find any evidence of the IRS auditing any large system, or fining them for non-compliance in filing.

The good news is that last year the North Carolina State Employees plan, i.e. a pissed off purchaser, dug into all the N. Carolina hospital systems and found out that Atrium’s CEO pay went up nearly five-fold over six years. But even the state had real trouble finding out the truth:

“It is important to understand that these figures are significant underestimates for three reasons. First, a legal loophole denies the public the right to see how much publicly owned hospitals reported paying their top executives on their tax filings. This failure of oversight hides the tax filings of more than three in 10 nonprofit hospitals in North Carolina, including Atrium and UNC Health. UNC Health did not answer a public records request for executive compensation data until February 13, 2023, two days before this report’s publication and almost three months after its receipt of the request. UNC Health’s system wide data is therefore not included in this report.” 

So the very top dogs are doing well. At UPMC it turns out that seven made more than $3m including the CEO Jeff Romoff –the same one who forgot on 60 Minutes whether he made $6m or $7m. Turns out he didn’t have to remember that number for long as by 2021 he was making $12m.

But the munificence is spreading down the executive ladder. To demonstrate, let me introduce you to Tracey Beiriger Esq. There’s almost no information about Tracey on Linkedin or anywhere else on Google other than it appears he or she is an IP lawyer at UPMC. So why do I bring them up?

Because in 2021–the last year for which UPMC filed a 990 –Tracey was the 118th highest paid executive at UPMC and had the misfortune to only make $499,446.

Which means that 117 executives working at UPMC made more than $500,000. It’s a little tricky figuring out the similar numbers at Providence because of the multiple 990s in 2021 but there are 38 in Washington (not including CEO Rod Hochman who made $9m in 2020 and then vanished from the 2021 990!), 18 in Oregon and another 21 in Southern California. So call it 80+.

I bring this up because $500,000 is a pretty decent individual income. When I asked ChatGPT it estimated about 1.2 million Americans earned that much or more. Given the workforce is 167m, that puts those several hundred hospital execs way into the top 1%.

Now I have no objection to people earning good money. I’m sure they have all worked very hard for it. But if you look at these organizations, they do not seem to be spreading the wealth very far. 

Last year UPMC was accused by unions of suppressing staff wages. There is yet to be an outcome from that complaint to the DOJ, but last week there was one from a formal class action complaint about Providence shortchanging employees by rounding down their pay to the nearest half-hour, even though they were clocking on and off by the minute. Providence was fined $200m which probably isn’t much split between 33,000 employees but at least indicates that their senior management acts just like any other aggressive business in terms of cutting costs on the backs of their employees. And it’s not just their employees. They also just got fined $137m for aggressively suing patients.

Which leads me to two final points.

The first is, is it more likely you’ll make that $500K+ in a hospital system or in a tech startup? Blake Madden at Hospitology has been tracking systems that have more than $1bn in revenue. He’s found 113 so far. Second bottom of the list is Atlanticare in NJ, which has 16 execs making more than $500K.  Which by my wild guess means that the average system has about 50 employees making $500k+  which rounds up to something like 5,000 hospital execs making at least $500K and many of them are making a whole lot more. 

Compare that to a successful health tech startup that actually makes it. Take Phreesia, a VC-backed start-up that went public in 2019 having started way back in 2007. (I know the year because CEO Chaim Indig launched at Health 2.0 in 2008. He was nice enough to let me buy some stock at the IPO and I made a few bucks). Chaim made $300K the year it went public and as CEO of a public company that’s bounced around at being worth between $1Bn and $4Bn, he made $750K last year. No one else made more than $500K. Now yes, he owned 4% of the company at the IPO and got awarded more stock. He is doing very well, but the point is that there were dozens of companies launching at Health 2.0 in 2008 and the vast majority don’t get close to an IPO or making any money for the founders, let alone the staff. 

My conclusion is, it’s not a rational bet to go the health tech route if instead you can find a regional hospital chain and brown-nose your way up into the exec ranks!

The second point is more fundamental. Remember UPMC and its 117 execs making $500K+? What would a comparable government agency be paying out? I looked at the state of California salaries.There look to be about 50 state employees making more than $500k a year, almost all working for the state investment fund CALPERS. But the top paying one only makes $1.6m a year. I’m not saying that CALPERS should be paying out that much even if it is competing with Wall Street, after all members of the Senate only make $205,000 a year and the state could just put the whole pension into an S&P index fund. But what I am saying is that we should be thinking about paying our big non-profit systems similarly to government employees because they essentially are government employees.

Beckers posted UPMC’s payor mix last year. I highly suspect you’ll find something similar at almost every big system. 

  • Medicare 48%
  • Medicaid 17%
  • UPMC as Insurer 11%–(60% of whom are Medicaid/Medicare patients)
  • Commercial, Self Pay, Other 24%

More than 70% of the money comes from the government, and the rest from the suckers who have to buy their insurance on the “open market”–which includes those buying via the ACA exchange, receiving government subsidies, and government employees.

So while these huge systems act like Fortune 100 companies and reward their executives accordingly, almost all the money comes from the taxpayer.

I wish I could say we are getting good value for it.

And yes, I didn’t even mention the for-profits and the big insurers, but that will have to wait for another day….

Matthew Holt is the founder & publisher of THCB

GoodWill’s Lessons for Health Care

By KIM BELLARD

The New York Times had an interesting profile this weekend about how Goodwill Industries is trying to revamp its online presence – transitioning from its legacy ShopGoodwill.com to a new platform GoodwillFinds — in the amidst of numerous other online resellers.  It zeroed in on the key distinction Goodwill has:

But Goodwill isn’t doing this just because it wants to move into the 21st century. More than 130,000 people work across the organization, while two million people received assistance last year through its programs, which include career navigation and skills training. Those opportunities are funded through the sales of donated items.

Moreover, the article continued: “Last year, Goodwill helped nearly 180,000 people through its job services.” 

In case you weren’t aware, Goodwill has long had a mission of hiring people who otherwise face barriers to employment, such as veterans, those who lack job experience or educational qualifications, or have handicaps.  As it says in its mission statement, it “works to enhance the dignity and quality of life of individuals and families by strengthening communities, eliminating barriers to opportunity, and helping people in need reach their full potential through learning and the power of work.”

As PYMNTS wrote earlier this month: “Every purchase made through GoodwillFinds initiates a chain reaction, providing job training, resume assistance, financial education, and essential services to individuals in need within the community where the item was contributed.” 

I want healthcare to have that kind of commitment to patients.

Healthcare claims to be all about patients. You won’t find many that openly talk about profits or return on equity. Reading mission statements of healthcare organizations yield the kinds of pronouncements one might expect.  A not-entirely random sample:

Cleveland Clinic: “to be the best place for care anywhere and the best place to work in healthcare.”

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Matthew’s health care tidbits: Hedge Funds that Do Health Care on the Side

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Lots of news about bad behavior in health care this week, with real shots about patient & staff safety at home care company Papa, and Grail misinforming 400 people that they had cancer. But the prize for tone deafness this week comes from another very well funded health care provider system being heartless to its poorest patients. 

This week it’s Allina, a Minnesota “nice” system which actually amended its Epic system so that clinicians could literally not book appointments or provide care to patients who owed Allina money. Clinicians on the sharp end of this were so appalled that they went on the record about their own employer to NY Times’ reporter Sarah Kliff. The most egregious example was a doctor unable to write a prescription for a kid that had scabies–an infectious parasitic disease–who was sharing one bed with two other kids!

Of course Allina also is on the low end of charity care provision (below 1% of revenues). In contrast ten employees make more than $1m a year and another 10 make more than $500,000. 

We all know about egregious private equity funds investing in payday loans and other scummy outfits that prey on the poor. Turns out that if you let a non-profit hospital become beholden to its financial, rather than moral, north star, it starts to behave in a similar manner. Allina, of course, had a smidge under $4bn in its “investment reserve” at the end of 2021. It’s by no means special. UPMC has over $7bn in its reserves (unclear if this includes the investments it has made in startups), while Ascension has a formal private equity fund that controversially paid its former CEOs over $10m as part of its $18bn reserves.

Somehow having hedge funds that provide a little health care service on the side doesn’t leave the best taste in the mouth for how we should be organizing this health care system.

UPMC’s Rasu Shrestha on Consumer Health in ‘Big’ Healthcare

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By JESSICA DA MASSA, WTF Health

The phrase ‘consumer health’ doesn’t mean what it used to. And, when you really think about it, neither does the word ‘consumer.’ We’ve changed. Wielding the power of our smart phones, wearable devices, and proximity to CVS Minute Clinics – and armed with expectations of near-instant gratification thanks to the Amazons and Ubers of the world – we’re more demanding, exacting and impatient of the health system than ever before.

As all of this starts to change demand, supply, and (fingers crossed) our entire industry, it’s tempting to focus on what the new guys are doing. I’m as guilty as any for being fixated on the doings of the big tech companies and sexy little startups that are coming into our space. But, the reality is that the greatest amount of change will have to come from those stalwarts of the ‘healthcare establishment’ – the health systems and the payers that ARE the system in and of itself.

So, how are they thinking about the consumerization of healthcare? What does it mean to ‘empower consumers’ when your organization is bearing the risk associated with caring for their lives? Lucky for us, Dr. Rasu Shrestha, Chief Innovation Officer of health-system/payer-system giant UPMC can break it down.

Warning: This interview is long and heady, but, man, is it ever worth it. Rasu talks about the macroeconomics of shifting risk from insurers to providers and consumers, business model implications for all players involved, and how the ‘free the data’ movement feeds into all this. Last but not least, he talks about the kinds of startups he’s hoping will help payers and providers usher in this new consumer-driven era.

If you’re doing any kind of business in healthcare today, you’ll want to give this a listen. And, if Rasu wants to add another doctorate to his name, this interview analyzing ‘the macroeconomics and shifting risk environment of the consumerization of healthcare’ might be the start of his dissertation. We’ll look for our @wtf_health footnote.

Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health. Filmed at the Bayer G4A Accelerator Launch in NYC, May 2018.

The UPMC-Highmark Brawl Spills Into Philadelphia’s Backyard

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By TORY WOLFF

The UPMC/Highmark rivalry continues to open new fronts in Pennsylvania. Highmark’s response to UPMC is differentiated in two ways: first, Highmark is using a coalition-building strategy and, second, it is controlling its exposure to big in-patient assets; in contrast, UPMC is building an integrated, single-brand system and happily taking over hospitals (and building more) along the way. When UPMC and Highmark make major investments in a region, local systems will be caught in the capex arms and feel the pressure to affiliate. Credibly threatening to respond in kind may defuse the arms race. But unaffiliated systems may struggle to find partners willing to bankroll a battle with both Highmark and UPMC, leaving no option for unaligned systems than to pick sides. Philadelphia systems – so far largely neutral to Highmark vs. UPMC – should be able to stay neutral as the fight develops in their western backyard. If the battle moves into northeastern Pennsylvania or jumps into south Jersey, however, the Philadelphia systems will have to develop a response.

The competitive rivalry between Highmark and UPMC is truly epic. Long ago – when Highmark largely focused on insurance and UPMC largely focused on care delivery — they were good partners in the Pittsburgh market. But as each has become more vertically integrated – with Highmark acquiring the West Penn Allegheny system and UPMC’s health plan buisness growing – they have since become bitter rivals. The competition has expanded out of Western Pennsylvania and into the rest of the state. 

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Big Data in Healthcare: Good or Evil? Depends on the Dollars

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By JOE FLOWER

flying cadeuciiAn organization’s “business model” means: How does it make a living? What revenue streams sustain it? How it does that makes all the difference in the world.

Saturday, Natasha Singer wrote in the New York Times about health plans and healthcare providers using “big data,” including your shopping patterns, car ownership and Internet usage, to segment their markets.

The beginning of the article featured the University of Pittsburgh Medical Center (UPMC) using “predictive health analytics” to target people who would benefit the most from intervention so that they would not need expensive emergency services and surgery. The later part of the article mentioned organizations that used big data to find their best customers among the worried well and get them in for more tests and procedures. The article quoted experts fretting that this would just lead to more unnecessary and unhelpful care just to fatten the providers’ bottom lines.

The article missed the real news here: Why is one organization (UPMC) using big data so that people end up using fewer expensive healthcare resources, while others use it to get people to use more healthcare, even if they don’t really need it?

Because they are paid differently. They have different business models.

UPMC is an integrated system with its own insurance arm covering 2.4 million people. As a system it has largely found a way out of the fee-for-service model. It has a healthier bottom line if its customers are healthier and so need fewer acute and emergency services. The other organizations are fee-for-service. Getting people in for more tests and biopsies is a revenue stream. For UPMC it would just be a cost.

The evil here is not using predictive modeling to segment the market. The evil here is the fee-for-service system that rewards waste and profiteering in medicine.

Health Care Innovations Hiding in Plain Sight

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By Maureen Bisognano and Charles Kenney

While the nation has been focused on the recent Supreme Court ruling on the Affordable Care Act, innovations in hospitals and physician practices far from Capitol Hill have been triggering an historic transformation of our health care system. Propelled by a mix of urgency and vision, innovators at hospitals, physician groups and companies are remaking American health care by demonstrating that more effective and affordable care is achievable quite apart from statutory changes in Washington.

These organizations are working to achieve the Triple Aim: improve the health of the population; enhance the patient experience of care (including quality, access, and reliability); and reduce, or at least control, the per capita cost of care. This approach, developed by the Institute for Healthcare Improvement, is a sharp break with the traditional focus on single encounters with patients within the strict walls of health care delivery, typically addressing only the most immediate problems.
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Friday Funny: Health care meets Jerry Springer – (in Pittsburgh!)

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I know that secretly you’re all bored of this Supreme Court nonsense, and want to get back to the real business of health care, which is often the ongoing war between regional insurers and regional health systems. And the war in Pittsburgh between Highmark and UPMC has been as fierce as anywhere. But it’s been lacking in the kind of juice that makes for a good Friday afternoon scandal. Until now.

Last Sunday Highmark CEO Ken Melani got arrested. (This is a real arrest not one of the fake kind featured in last Friday’s funny). Melani’s mistress  was some 25 years younger than him and had been working for him at Highmark. That then progressed to her moving in with him. But after an argument with Melani last Sunday she went back to her husband’s place. Melani went around there and apparently accused her of only wanting him for his money –he was on about $4.5m a year–and ended up in a fist fight with her husband. Apparently his mistress wasn’t leaving him for good and wasn’t intending to get back with her husband, but one policeman apparently heard Melani say that he’d have killed both of them if the police hadn’t stopped him.  Either way it’s juicy stuff for health care.

Highmark  is in the process of buying  the only non-UPMC chain in Pittsburgh, West Penn Allegheny, and is still trying to get to a contract with UPMC that keeps it playing in the town–which UPMC of course dominates. Melani is now on unpaid leave and presumably not coming back any time soon, while as of today Highmark Chairman Robert Baum has taken the reins.

This may end up meaning nothing in the ongoing UPMC/Highmark battle, but I do sit here musing that the only way this would have been better for the Friday Funny is if the mistress in question had been UPMC’s CEO Jeffrey Romoff’s wife–who herself is some 30 years younger than Romoff and happens to be wife number 4. But as the Rolling Stones say, you can’t get everything you want!

When Will UPMC Explain the Whole Story?

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By PAUL LEVY

The UPMC kidney transplant story continues to develop.  This was the one where a doctor and nurse were disciplined in a matter that clearly reflected some systemic problems, more than personnel problems regarding those two people.

Now UPI reports:

A report by a federal agency on a kidney transplant at the University of Pittsburgh Medical Center suggests more problems than the hospital has acknowledged.

The Centers for Medicare and Medicaid Services said its investigation found the nephrologist should have been aware the kidney donor was infected with hepatitis C, the Pittsburgh Post-Gazette reported Tuesday. The hospital has suspended the lead surgeon and the transplant coordinator.

The CMS report said the test results were available for two months in the donor’s medical record. But none of the doctors and nurses apparently reviewed the record, and the kidney was transplanted into a man who was not infected with the virus.

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