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The Future of Behavioral Health: Can Private Equity and Telehealth Improve Access?
Published online by Cambridge University Press: 12 February 2024
Abstract
Treatment of mental illness in the United States is woefully inadequate. One-third of adults report having a mental health condition or substance use disorder, but less than half receive treatment for their condition.
Access is the problem. The U.S. is short on mental health professionals: more psychiatrists are needed and psychologists and social workers are overextended. Proposed solutions are to (1) increase reimbursement rates for psychiatrists and other mental health practitioners, and (2) use a wider range of providers, including nurses and family support specialists—all good ideas. My focus however is on two other forces that are moving into the behavioral health area, offering both financing and technologies to extend the reach of mental health services—private equity and telemental health.
First, private equity firms see high demand in this market. Behavioral health is desperately needed but is highly fragmented and lacking in innovation. Private equity is attracted to outpatient programs that target specific conditions that have evidence-based clinical models—programs aimed at addiction, eating disorders, and autism; these areas require less capital. Federal and state reimbursement is available, some regulations have been relaxed to allow remote prescribing of medicine; and innovative telehealth tools can be used. The problem is that private equity has a poor track record in both nursing home care and behavioral care for teens. The private equity model and its financial incentives are at odds with good care.
Second, telemental health tools, already in use because of the need during the pandemic, appear attractive. These tools require less capital to treat a higher volume of patients and promise much improved access to mental health treatment for populations that could not get such care because of travel distance, costs, and time limitations. The problem is that the telemental health tools have yet to be subjected to evidence-based testing.
My goal in this article is to test whether these two developments – private equity and telemental health —can improve access for patients at an acceptable level of quality. I conclude that both have substantial problems and I offer a range of regulatory approaches to control patient abuses and poor quality.
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References
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3 Id.
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13 This graphic was prepared by Kelly Porter, my able research assistant.
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34 Hollis et al., supra note 1, at 845.
35 See Pim Cuijpers, Targets and Outcomes of Psychotherapies for Mental Disorders: An Overview, 18 World Psychiatry 276, 276 (2019).
36 For full discussion of the field, see generally Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, (Michael Barkham et al. eds, 7th ed. 2021).
37 See What is Cognitive Behavioral Therapy?, Am. Psych. Assoc’n, https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral.pdf [https://perma.cc/7KGQ-4PU9].
38 Stefan G. Hofmann et al., The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses, 36 Cognitive Therapy & Res. 427 (2012) (“…[I]t is clear that the evidence-base of CBT is enormous. Given the high cost-effectiveness of the intervention, it is surprising that many countries, including many developed nations, have not yet adopted CBT as the first-line intervention for mental disorders.”).
39 P. Musiat & N. Tarrier, Collateral Outcomes in E-Mental Health: A Systematic Review of the Evidence for Added Benefits of Computerized Cognitive Behavior Therapy Interventions for Mental Health, 44 Psychol Med. 3137 (2014), https://pubmed.ncbi.nlm.nih.gov/25065947/ [https://perma.cc/BQT5-D78Q].
40 Simon Gilbody et al., , Computerised Cognitive Behaviour Therapy (Ccbt) as Treatment for Depression in Primary Care (REEACT Trial): Large Scale Pragmatic Randomised Controlled Trial, BMJ (Nov. 11, 2015), https://www.bmj.com/content/351/bmj.h5627.long. [https://perma.cc/BVZ4-X5E4].
41 Ellen Driessen et al., Does Publication Bias Inflate the Apparent Efficacy of Psychological Treatment for Major Depressive Disorder? A Systematic Review and Meta-Analysis of US National Institutes of Health-Funded Trials, 10 PLOS One 1371 (2015), https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0137864&type=printable [https://perma.cc/T7R2-89BD].
42 I note that a variety of medical treatments also may have substantial placebo effects.
43 Paul Enck and Stephan Zipfel, Placebo Effects in Psychotherapy: A Framework, 10 FRON PSYCHIATRY 456 (2019), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6606790/
44 Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change: 50 th Anniversary Edition 320 (Eds. Michael Barkham, Wolfgang Lutz, and Louis G Castongua, 2021).
45 Id. at 321.
46 Sarah C. Cook et al., Evidence-Based Psychotherapy: Advantages and Challenges, 14 Neurotherapeutics 537 (Jun. 26, 2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5509639/ [https://perma.cc/J8HQ-HTLA].
47 Winfried Rief, Moving from Tradition-based to Competence-based Psychotherapy, 24 Evidence Based Mental Health 115 -20 (2021), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311107/pdf/ebmental-2020-300219.pdf [https://perma.cc/ENA5-ZADS].
48 Alexandrine Royer, The wellness industry’s risky embrace of AI-driven mental health care, Brookings (Oct. 14, 2021), https://www.brookings.edu/techstream/the-wellness-industrys-risky-embrace-of-ai-driven-mental-health-care/ [https://perma.cc/SPN2-P6BU].
49 What is telehealth? Health Rescs. & Servs. Admin., https://www.hrsa.gov/rural-health/topics/telehealth/what-is-telehealth [https://perma.cc/T3M5-3NAA] (last reviewed Mar. 2022); Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders, Substance Abuse & Mental Health Servs. Admin. (2021), https://tbhcoe.matrc.org/wp-content/uploads/2021/07/PEP21-06-02-001.pdf [https://perma.cc/5DXE-G5J6].
50 Nat’l Inst. of Mental Health, What is Telemental Health, https://www.nimh.nih.gov/sites/default/files/health/publications/what-is-telemental-health/what-is-telemental-health.pdf [https://perma.cc/ACY9-G98C].
51 Hannah Zeavin, The Distance Cure: A History of Teletherapy 4, 5 (MIT Press 2021).
52 Id. at 4-5.
53 Chris Hollis et al., Identifying Research Priorities for Digital Technology in Mental Health Care: Results of the James Lind Alliance Priority Setting Partnership, 5 Lancet Psychiatry 845 (2018), https://eprints.whiterose.ac.uk/139048/1/Resubmission_DigitalMHQ_v1.4%20FINAL%20CLEAN%20%281%29.pdf [https://perma.cc/T72V-SFRZ].
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55 Bell et al., supra note 54.
56 Ateev Mehrotra et al., Rapid Growth in Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States, 36 Health Affairs 909, 916 (May 2017).
57 Id.
58 For an example of A. Bergin’s early skepticism as to the effectiveness of psychotherapy, see A. Bergin, Evaluation of Therapeutic Outcomes, in Handbook of Psychotherapy and Behavior Change 217, 256-63 (A. Bergin & S. Garfield eds. 1971).
59 Tom Foley & James Woollard, The Digital Future of Mental Healthcare and Its Workforce: A Report on a Mental Health Stakeholder Engagement to Inform the Topol Review, National Health Service 31 (2019).
60 Bell et al., supra note 54.
61 Haley Grieco-Page et al., Beyond the Pandemic: Leveraging Rapid Expansions in U.S. Telemental Health and Digital Platforms to Address Disparities and Resolve the Digital Divide, 12 Frontiers Psychiatry 1, 2 (2021), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8377496/pdf/fpsyt-12-671502.pdf [https://perma.cc/E24U-2FHE].
62 Mostafa Langarizadeh et al., Telemental Health Care, an Effective Alternative to Conventional Mental Care: a Systematic Review, 25 Acta Informatica Medica 240 (2017),
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5723163/pdf/AIM-25-240.pdf [https://perma.cc/F9KB-U3MQ]; Richard O’Reilly et al., Is Telepsychiatry Equivalent to Face-to-Face Psychiatry? Results from a Randomized Controlled Equivalence Trial, 58 Psychiatric Servs. 836 (2007); Donald M. Hilty et al., The Effectiveness of Telemental Health: A 2013 Review, 19 Telemedicine & e-Health 444 (2013).
63 See generally Barry R. Furrow, Mainstreaming Telehealth? Start with the Underserved, 31 Kan. J.L. & PUB.Pub. Pol’y 435 (2022).
64 Grieco-Page, et al., supra note 59.
65 Bell et al., supra note 54.
66 David C. Mohr et al., Three Problems with Current Digital Mental Health Research … and Three Things We Can Do About Them, 68 Psychiatric Servs. 427 (2017).
67 See generally Johanna Boettcher et al, Combining attention training with internet-based cognitive-behavioural self-help for social anxiety: a andomized controlled trial, Cognitive Behaviour Therapy (2014), https://www.tandfonline.com/doi/full/10.1080/16506073.2013.809141 [https://perma.cc/JGJ4-KYWJ].
68 Samantha Spanos, Blended Care-the Future of Therapy, Black Dog Inst., https://medcast.com.au/blog/blended-care-the-future-of-therapy; see. e.g., Fiona Davies et al., Implementing web-based therapy in routine mental health care: Systematic review of health professionals’ perspectives, J. Med. Internet Rsch., (2020).
69 Telehealth for Corona Virus, AMD Global Telemedicine, https://amdtelemedicine.com/telehealth-solutions-for-covid-19/ [https://perma.cc/ZBJ6-7P67] (last visited Jun. 1, 2023).
70 Rajat Arora, Role of Virtual Humans in Healthcare Simulations, eLearning Industry, https://elearningindustry.com/virtual-humans-in-healthcare-simulations [https://perma.cc/P9PJ-6GHN].
71 Id.
72 Andrew Tieu, We Now Have an AI Therapist, and She’s Doing Her Job Better than Humans Can, Futurism (Jul. 16, 2015), https://futurism.com/uscs-new-ai-ellie-has-more-success-than-actual-therapists [https://perma.cc/U9LS-ZADN]; see Ellie in operation, https://www.youtube.com/watch?v=ejczMs6b1Q4&t=24s [https://perma.cc/Q5EV-RBKS].
73 Gale M. Lucas et al., It’s Only a Computer: Virtual Humans Increase Willingness to Disclose, 37 Computers in Human Behavior 94, 94 (2014), http://multicomp.cs.cmu.edu/wp-content/uploads/2017/09/2014_CHB_Lucas_It.pdf [https://perma.cc/E6AK-E8MB]; Amelia Fiske et al., Your Robot Therapist Will See You Now: Ethical Implications of Embodied Artifical Intelligence in Psychiatry, Psychology, and Psychotherapy, 21 J. Med. Internet Res. 1 (2019).
74 Fiske et al., supra note 73, at 3.
75 Barry R. Furrow, Mainstreaming Telehealth? Start With the Underserved, 31 Kan. J.L. & Pub. Pol’y 435, 459 (2022).
76 Fiske et al., supra note 73, at 4.
77 John Pestian et al., Suicide Note Classification Using Natural Language Processing: A Content Analysis, 3 Biomedical Informatics Insights 19, 26 (2010), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107011/pdf/10.4137_BII.S4706.pdf [https://perma.cc/UAC7-LUD6].
78 Gillinder Bedi et al., Automated Analysis of Free Speech Predicts Psychosis Onset in High-Risk Youths, 1 NPJ Schizophrenia 15030, 6 (2015), https://www.nature.com/articles/npjschz201530 [https://perma.cc/356N-4753].
79 Donald M. Hilty et al., The Effectiveness of Telemental Health: A 2013 Review, 19 Telemedicine & e-Health 444 (Jun. 2013), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662387/pdf/tmj.2013.0075.pdf [https://perma.cc/X3PB-K27C].
80 Chris Hollis et al., Technological Innovations in Mental Healthcare: Harnessing the Digital Revolution, 206 Brit. J. Psychiatry 263, 265 (2015).
81 Jonah Bossewitch et al., Digital Futures in Mind: Reflecting on Technological Experiments in Mental Health & Crisis Support 5 (Univ. Melbourne, 2022), https://automatingmentalhealth.cc/ [https://perma.cc/L7NK-GB22].
82 Id.
83 Id.
84 Royer, supra note 48.
85 Catalight, Top Trends in Behavioral Health for Payers, https://choose.catalight.org/assets/catalight-payer-trends-whitepaper.pdf [https://perma.cc/3GBH-CURZ].
86 What’s the Point?, The Scorpion and the Fox (Oct. 26, 2011), https://whatsthepont.blog/2011/10/26/the-scorpion-and-the-fox/ [https://perma.cc/8Q95-J5WY].
87 Fred Schulte, Patients for Profit: How Private Equity Hijacked Health Care, Kaiser Health News (Nov. 14, 2022).
88 Eileen Appelbaum & Rosemary Batt, Financialization in Health Care: The Transformation of US Hospital Systems 58 (Ctr. for Econ. Pol’y. and Rsch., Sept. 2021).
89 Troy Segal, Understanding Private Equity, Investopedia (Mar. 17, 2022), https://www.investopedia.com/articles/financial-careers/09/private-equity.asp#:~:text [https://perma.cc/NZE9-SBTJ].
90 Appelbaum & Batt, supra note 88, at 58.
91 Id.
92 Id.
93 Id.
94 Id.
95 Umar Ikramet al., Private Equity and Primary Care: Lessons from the Field, NEW ENG. J. MED. (Nov. 9, 2021).
96 Id.
97 Id.
98 Jane M. Zhu et al., Private Equity Acquisitions of Physician Medical Groups Across Specialties, 2013-2016, JAMA (Feb. 18, 2020).
99 Jane M. Zhu, Private Equity Investment in Physician Practices, UNIV. PENN. LEONARD DAVIS INST. HEALTH ECONS. (Feb. 15, 2020), https://ldi.upenn.edu/our-work/research-updates/private-equity-investment-in-physician-practices/ [https://perma.cc/C2W3-J4LX].
100 Christina Severin & Michael Curry, Telehealth Funding: Transforming Primary Care and Achieving Digital Health Equity for Underresourced Populations, HEALTH AFFAIRS (Sep. 9, 2021), https://www.healthaffairs.org/do/10.1377/forefront.20210908.121951/ [https://perma.cc/SFV6-CYNP].
101 KENAN INST. OF PRIV. ENTER., Private Equity in Healthcare: What the Experts Want You to Know (Feb. 10, 2022), https://kenaninstitute.unc.edu/kenan-insight/private-equity-in-healthcare-what-the-experts-want-you-to-know/ [https://perma.cc/38MP-VDDK].
102 Benjamin Brown et al., Private Equity Investment in Behavioral Health Treatment Centers, 77(3) JAMA Psychiatry 229-30 (2020).
103 Joyce Famakinwa, Private Equity Backing Becoming ‘Qualifying Criteria’ for Home Care Franchise Companies, HOME HEALTH CARE NEWS (Nov. 14, 2021), https://homehealthcarenews.com/2021/11/private-equity-backing-becoming-qualifying-criteria-for-home-care-franchise-companies/ [https://perma.cc/ZL8T-L7YQ].
104 Rebecca Hinds & Caroline Schwanzer, 3 Ways Private Equity Firms Use Technology as a Competitive Advantage, AFFINITY, https://www.affinity.co/blog/private-equity-firms-use-technology.
105 Richard M. Scheffler et al., Soaring Private Equity Investment in the Healthcare Sector: Consolidation Accelerated, Competition Undermined, and Patients at Risks, Antitrust Inst. (May 18, 2021), https://www.antitrustinstitute.org/wp-content/uploads/2021/05/Private-Equity-I-Healthcare-Report-FINAL.pdf [https://perma.cc/VSG3-6NFZ]; Andrew B. Ellis, Private equity’s role in the future of healthcare, 41 NEW HAMPSHIRE BUS. REV. 17 (Aug. 2019); Angela Humphreys, What will private equity investment in healthcare look like in 2020?, MED CITY NEWS (Feb. 20, 2020), https://medcitynews.com/2020/02/what-will-private-equity-investment-in-healthcare-look-like-in-2020/ [https://perma.cc/Q7ZG-WQCK]; David Champagne et al., Private equity opportunities in healthcare tech, MCKINSEY (May 23, 2019), https://www.mckinsey.com/industries/private-equity-and-principal-investors/our-insights/private-equity-opportunities-in-healthcare-tech [https://perma.cc/692S-ETNY]
106 How Cardinal helped the country’s largest mental health care provider scale digital marketing to 500+ locations, CARDINAL DIGIT. MKTG., https://www.cardinaldigitalmarketing.com/healthcare-case-study/behavioral-health-digital-marketing-ppc-seo/ [https://perma.cc/J2HM-XP2J] (last visited Apr. 20, 2023).
107 See, e.g., Nicole LaMarco, LifeStance Health Online Therapy Review, https://www.verywellmind.com/lifestance-health-online-therapy-review-6826811 [https://perma.cc/W2PS-L4DN] (review by one user who found that the use of telehealth to find a therapist worked well for her).
108 Ravi N. Shah & Obianuju O. Berry, The Rise of Venture Capital Investing in Mental Health, 78 JAMA Psychiatry 351 (2021), https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2770792 [https://perma.cc/G7CQ-CSNK].
109 Atul Gupta et al., Does Private Equity Investment in Healthcare Benefit Patients? Evidence from Nursing Homes 2-3 (Nat’l Bureau of Econ. Rsch., Working Paper No. 28474, 2021), http://www.nber.org/papers/w28474 [https://perma.cc/GZ69-X7WB].
110 Id.
111 Id.
112 Epstein Becker Green, Private Equity’s Push into the Mental Health Space, 2021, Vector Med. Group, https://vectormedicalgroup.com/app/uploads/Q4-2021-Industry-Brief_Final.pdf [https://perma.cc/L9JC-Y2DR].
113 Sajith Matthews & Renato Roxas, Private equity and its effect on patients: a window into the future, Int. J. Health Econ. Manag. (May 23, 2022).
114 Eileen O’Grady, Private Equity Stakeholder Project, Understaffed, Unlicensed, and Untrained: Behavioral Health Under Private Equity 2 (Sept. 2020), https://pestakeholder.org/wp-content/uploads/2020/09/PESP-behavioral-health-9-2020.pdf [https://perma.cc/LH7E-LDDP].
115 Matthews & Roxas, supra note 113.
116 Eileen Appelbaum & Rosemary Batt, Financialization in Health Care: The Transformation of US Hospital Systems 23 (2021).
117 In this survey study of 4129 adults in the US, survey data from 1996 to 2006 showed improvements in public beliefs about the causes of schizophrenia and alcohol dependence, and data from a 2018 survey noted decreased rejection for depression. Changes in mental illness stigma appeared to be largely associated with age and generational shifts. Bernice A. Pescosolido et al., Trends in Public Stigma of Mental Illness in the US, 1996-2018, JAMA Network Open (2021).
118 This useful chart was prepared by Kelly Porter, my research assistant.
119 Ctr. on Budget & Pol’y Priorities, Chart Book: Accomplishments of Affordable Care Act (Mar. 19, 2019),https://www.cbpp.org/research/health/chart-book-accomplishments-of-affordable-care-act [https://perma.cc/BKJ8-ECK6].
120 This settlement is described “…as the largest publicly disclosed government health care fraud settlement in the nation involving private equity oversight of health care providers, as well as the largest amount a private equity company itself has agreed to pay to resolve fraud allegations involving health care portfolio companies.” See Alexis Finkelberg Bortniker et al., PE Firm Pays Record Settlement for Allegedly Deficient Health Services: Identifying Traps for the Unwary, Health Care Law Today, Foley & Lardner LLP, https://1npdf11.onenorth.com/pdfrenderer.svc/v1/abcpdf11/GetRenderedPdfByUrl/PE%20Firm%20Pays%20Record%20Settlement%20Health%20Services.pdf/?url=https%3a%2f%2fwww.foley.com%2fen%2finsights%2fpublications%2f2021%2f10%2fpe-firm-pays-record-settlement-health-services?format=pdf&attachment=false (2021).
121 Eileen O’Grady, UNDERSTAFFED, UNLICENSED, AND UNTRAINED: BEHAVIORAL HEALTH UNDER PRIVATE EQUITY, Private Equity Stakeholder Project (Sept. 2020).
122 Gabriel Perna, How Autism Became the Latest Target for Disruption, Digital Health (Dec. 06, 2022), https://digitalhealth.modernhealthcare.com/digital-health/autism-digital-health-startups-aim-disrupt-amid-aba-challenges [https://perma.cc/7P3Z-KR3D].
123 Id.
124 Bain & Company, Global Healthcare Private Equity and Corporate M&A Report 36 (2020), https://www.bain.com/globalassets/noindex/2020/bain_report_global_healthcare_private_equity_and_corporate_ma_report_2020.pdf [https://perma.cc/2YYL-YXAE].
125 One meta study however concluded: “Those results suggested outcomes of socialization, communication and expressive language may be promising targets for ABA-based interventions involving children with ASD. However, significant effects for the outcomes of autism general symptoms, receptive language, adaptive behavior, daily living skills, IQ, verbal IQ, nonverbal IQ, restricted and repetitive behavior, motor and cognition were not observed.” Qian Yu et al., Efficacy of Interventions Based on Applied Behavior Analysis for Autism Spectrum Disorder: A Meta-Analysis, 17 Psychiatry Investigation 432-40 (2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265021/pdf/pi-2019-0229.pdf [https://perma.cc/3M9Y-UV4H].
126 Tara Bannow, Parents and clinicians say private equity’s profit fixation is short-changing kids with autism, Stat (Aug. 15, 2022), https://www.statnews.com/2022/08/15/private-equity-autism-aba-therapy/ [https://perma.cc/HK72-SCQM].
127 Audit of Medicaid Applied Behavior Analysis for Children Diagnosed With Autism, Office of the Inspector Gen., https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000601.asp [https://perma.cc/XHA8-K6QZ] (last visited Apr. 15, 2023).
128 See Elizabeth Devita-Raeburn, The Controversy Over Autism’s Most Common Therapy, Spectrum (Aug. 10, 2016),
https://www.spectrumnews.org/features/deep-dive/controversy-autisms-common-therapy/ [https://perma.cc/5R66-ZHGR].
129 For a critical look at ABA for autistic children, see a personal account: Ariana Cernius, The Autistic Community is Having a Reckoning with ABA Therapy. We Should Listen, Fortune (May 13, 2022, 6:00 AM), https://fortune.com/2022/05/13/autistic-community-reckoning-aba-therapy-rights-autism-insurance-private-equity-ariana-cernius/ [https://perma.cc/S5M4-T8J9].
130 Amy S. Weitlauf et al., Therapies for Children with Autism Spectrum Disorder: Behavioral Interventions Update 103-04 (2014).
131 Perna, supra note 122.
132 Laura Lovett, Why 2023 Could Be the Year of Behavioral Health Tuck-In Acquisitions, Behav. Health Bus. (Jan. 19, 2023), https://bhbusiness.com/2023/01/19/why-2023-could-be-the-year-of-behavioral-health-tuck-in-acquisitions/ [https://perma.cc/2G8J-3966].
133 Linda Rose, What is the Difference Between an Add-on, Bolt-on, and Tuck-in? Types of Acquisitions Part II, Rosebiz (Apr. 15, 2021), https://rosebiz.com/what-is-the-difference-between-an-add-on-bolt-on-and-tuck-in/ [https://perma.cc/X7ZL-7ZF4].
134 Inbar Fischer et al., Hyperbaric Oxygen Therapy Alleviates Social Behavior Dysfunction and Neuroinflammation in a Mouse Model for Autism Spectrum Disorders, 23 Int’l J. Molecular Scis. 11077 (2022), https://scitechdaily.com/autism-breakthrough-new-treatment-significantly-improves-social-skills-and-brain-function/ [https://perma.cc/2THF-J4U3].
135 Daniel M. Bagner et al., Telehealth Treatment of Behavior Problems in Young Children with Developmental Delay, 177 JAMA Pediatrics 231 (2023).
136 Eileen O’Grady, Private Equity Firms Reaped Billions of Dollars in Debt-Funded Dividends from Healthcare Companies in 2021, Private Equity Stakeholder Project (Jan. 5, 2022), https://pestakeholder.org/news/private-equity-firms-reaped-billions-of-dollars-in-debt-funded-dividends-from-healthcare-companies-in-2021/ [https://perma.cc/7LDD-UALU].
137 Mary Bugbee & Eileen O’Grady, Two PE-owned behavioral health companies initiate closures, layoffs in Florida and Ohio, Private Equity Stakeholder Project (2023), https://pestakeholder.org/news/two-pe-owned-behavioral-health-companies-initiate-closures-layoffs-in-florida-and-ohio/ [https://perma.cc/4JT9-6TDL].
138 Gabriel Perna, How Autism Became the Latest Target for Disruption, Modern Healthcare (Dec. 6, 2022), https://digitalhealth.modernhealthcare.com/digital-health/autism-digital-health-startups-aim-disrupt-amid-aba-challenges [https://perma.cc/R2HF-SWCT].
139 David Dayen, Rollups: Private Equity Eyes Youth Treatment Centers as a Takeover Target, Am. Prospect, (Feb. 17, 2022), https://prospect.org/power/rollups-private-equity-eyes-youth-treatment-centers-as-takeover-target/ [https://perma.cc/YU44-U5U7]
140 Eileen O’Grady, Private Equity Stakeholder Project, The Kids Are Not Alright: How Private Equity Profits Off of Behavioral Health Services for Vulnerable and At-Risk Youth (2022), https://pestakeholder.org/wp-content/uploads/2022/02/PESP_Youth_BH_Report_2022.pdf.
141 Daniel M. Bagner et al., supra note 135.
142 Id.
143 Id.
144 O’Grady notes that “[p]private equity firms love to roll up industries, create a platform company and buy others.” She notes for example that in 2021, for example, Sevita acquired at least five other companies that operate homes for children with intellectual and developmental disabilities. Dayen, supra note 139.
145 O’Grady, supra note 114.
146 Kenan Insight, Private Equity in Healthcare: What the Experts Want You to Know (Feb 10, 2022), https://kenaninstitute.unc.edu/kenan-insight/private-equity-in-healthcare-what-the-experts-want-you-to-know/ [https://perma.cc/T5UY-NDDX] (response from a market-oriented think tank).
147 These recommendations include my own analysis of possible modes of improved regulation, plus those of the Private Equity Stakeholder Project’s latest report (which I identify as PESP). See Mary Bugbee et al., Recent Trends in Private Equity Healthcare Acquisitions 15-16 (Feb. 2023) [hereinafter PESP].
148 Maude Barrows Dutton, The Tortoise and the Geese and other Fables of Bidpai 12-13 (1908).
149 I note that in a recent article my coauthors and I consider the merits of banning private equity firms from owning nursing homes, given the vulnerability of residents and the evidence of bad actors in PE. See Robert Field et al., Private Equity in Healthcare: Barbarians at the Gate? 15 Drexel L. Rev. 821 ( 2023).
150 See, e.g., Margaret E Kruk et al., High-quality health systems in the Sustainable Development Goals era: time for a revolution, Lancet Global Health Comm’n (Nov. 2018), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734391/pdf/LGHC-06-11-1196.pdf [https://perma.cc/WV4R-938G].
151 These recommendations include my own analysis of possible modes of improved regulation, plus those of the Private Equity Stakeholder Project’s latest report (which I identify as PESP). See Mary Bugbee et al., Recent Trends in Private Equity Healthcare Acquisition s 15-16 (Feb. 2023) (hereafter PESP), https://pestakeholder.org/wp-content/uploads/2023/02/PESP_Report_HC_Acquisitions_Feb2023_FINAL.pdf.
152 Id. at 15-16.
153 Id.
154 Id.
155 Alexandra D. Montague et al., State Action to Oversee Consolidation of Health Care Providers (Aug. 2021), https://www.milbank.org/wp-content/uploads/2021/08/State-Action-to-Oversee-Consolidation_ib_V3.pdf [https://perma.cc/UB95-KUFC].
156 See, e.g., U.S. Food & Drug Admin., Clinical Decision Support Software: Guidance for Industry and Food and Drug Administration Staff, (2022); see also Device Software Functions Including Mobile Medical Applications, U.S. Food & Drug Admin. (Sept. 29, 2022), https://www.fda.gov/medical-devices/digital-health-center-excellence/device-software-functions-including-mobile-medical-applications [https://perma.cc/MLF5-XEP5] (The FDA’s website states: “The FDA encourages the development of mobile medical apps (MMAs) that improve health care and provide consumers and health care professionals with valuable health information. The FDA also has a public health responsibility to oversee the safety and effectiveness of medical devices—including mobile medical apps.”).
157 See, e.g., Fact Sheet: Private Fund Proposed Reforms, Secs. & Exch. Comm’n, https://www.sec.gov/files/ia-5955-fact-sheet.pdf [https://perma.cc/2759-3Z7F] (last visited Apr. 15, 2023).
158 Since 2013, at least 25 private equity-backed health care companies have paid settlements in excess of $570 million for allegedly violations of the FCA. Behavioral health companies may be at greater risk for enforcement (compared to other health care services companies) given the availability of legislative tools specific to behavioral health, such as EKRA, the Eliminating Kickbacks in Recovery Act of 2018. See generally Robert Field et al., Private Equity in Healthcare: Barbarians at the Gate? 15 Drexel L. Rev. 821 ( 2023).
159 See, e.g., Barry R. Furrow, Defective Mental Treatment: A Proposal for the Application of Strict Liability to Psychiatric Services, 58 B.U. Law Rev. 391 (1978).
160 See, e.g., Cuijpers, supra note 35.
161 Managed Behavioral Healthcare Organization Accreditation, Nat’l Committee for Quality Assurance, https://www.ncqa.org/wp-content/uploads/2019/05/20190425_Employer_Engagement_MBHO.pdf [https://perma.cc/X72H-J3UD] (last visited Jun. 7, 2023); An Overview of the Accredidation Process, Joint Comm’n, https://www.jointcommission.org/-/media/tjc/documents/accred-and-cert/bhc/bhc-guide-to-accreditation.pdf [https://perma.cc/L25F-APAK] (last visited Jun. 7, 2023).