The recent buyout of a chain of London GP practices by the giant US insurer, Centene, prompted considerable media coverage last month with many Labour MPs and campaigning groups claiming the deal represented ‘privatization by stealth’. However, while this description may have been apt in 2005 it is now entirely outmoded as there is nothing covert nor slow about the process anymore. Instead, what is taking place – and has been for many years – is a full-blown, US-led takeover, by the same corporate interests, adopting the same instruments and organizational structures and effected by the deployment of key personnel within public office.
In fact, primary care services are only a branch-line within Centene’s English ambitions; as in the US its core business will be managing as many of the regional-scale Integrated Care Systems (ICSs) as it can. And, as in the US, making huge profits from the role.
Anyone doubting the speed and transparency of this takeover need only consider two recent headlines. On the 24th March the Health Service Journal (HSJ) reported that Timothy Ferris, the CEO of a leading US healthcare organization had been hired as NHS England’s new Director of Transformation and even, according to the journals’ editorial, a strong candidate to replace Sir Simon Stevens as head of the NHS in England. While undoubtedly the Director role is extremely important, it was thought that Ferris was unlikely to take such a pay loss unless something even bigger was in the offing. Even more tellingly, it was announced a week later that Boris Johnson’s new health ‘supremo’ was Centene’s UK Chief Executive Officer, Samantha Jones, and that she was entering government as expert adviser for NHS transformation and social care delivery.
Having its UK CEO within the corridors of Number 10 is the culmination of several years of engagement with the NHS transformation agenda, and Centene’s business model also reveals a great deal about the nature of this agenda and its intended outcome.
The corporation is unusual in that, unlike its main US competitors, UnitedHealth, Aetna, Anthem and Cigna, its revenues have been built almost entirely from public health programmes. While Centene’s annual accounts highlight its diversified portfolio of, among others, behavioral health management, correctional healthcare services, home-based primary care services, and telehealth, its core business is that of managing services for the poor and disabled, under what is known as Medicaid Managed Care (MMC).
Collecting money from the state on a per-patient basis, the corporation promises to negotiate with healthcare providers for patient care. As it is allowed to keep any cost difference that may accrue, the incentive is to reduce such care to a minimum. While MMC existed before 2010, it was greatly expanded by the US Affordable Care Act – or Obamacare – in that year, and since then Centene has become the largest Medicaid insurer in the nation. Following its buyout of a major competitor, WellCare, in January 2020, it now commands 21% of this market and is the dominant presence in such key states as California, New York, Florida and Texas. Given the above-mentioned incentive to cut care, the company has inevitably left a trail of scandals, financial penalties and public outcry in almost every state it entered. (See attached examples)
On the back of its rapidly growing wealth, in 2014, the company sought opportunities overseas, and whilst its first entry point was a 50% share in the Spanish Public Private Partnership company Ribera Salud, this was largely a stepping stone to the English NHS, where Managed Care was being pursued at a systemic level. Centene’s entry to the NHS in fact followed an event in October 2015 co-organized by NHS England’s New Care Model programme, led by Samantha Jones, and the NHS Confederation.
At least 20 of these New Care Model vanguards – prototypes of the Integrated Care Systems (ICSs) – were introduced to Centene though it is not known how many engaged its services. They did include Nottingham and West Essex, and in the case of the former, the corporation designed the entire ICS over a two-year period beginning in early 2016. This involved an actuarial analysis – necessary for an insurance system – and 32 workstreams including those on patient pathways, population health management, social care integration, IT services, provider payment models, together with governance and contract design.
Nottingham leaders were happy to boast of their affiliation with Centene and Ribera, saying they were now “standing of the shoulders of giants”. In subsequent events organized by the leading think thanks, the Kings Fund and Nuffield Trust, the corporation was described as a ‘system integrator’ or ‘transformation partner’ but little clarity was offered in terms of its future role.
However, one presentation revealed far more than the policy community intended – and has since been removed – which described the corporation as an “impartial ICS manager, accountable for all services, data reporting, contracts, and other functions to manage the financial risk effectively”. It would also provide investment via capital and loan guarantees and risk-sharing would be involved. In other words, it would act as a middleman between public funding bodies and provider networks, be able to financially profit from the management of risk, and effectively be a Medicaid Managed Care Organization.
It is clear that the US Managed Care model lies at the heart of the ICS Programme and of the entire NHS transformation process and is a model which systematically profits from the denial of care to patients, particularly the most vulnerable sections of the population. This is what the headlines should be saying, and this is the role that Centene is primarily seeking to replicate throughout as many ICSs as it can and why with Jones once again at the centre of government such ambitions will be rapidly realized. GP services, while very useful, will be small change in comparison.
References
- https://leftfootforward.org/2021/04/privatisation-by-stealth-dozens-of-mps-slam-private-takeover-of-49-gp-practices/
- >https://www.hsj.co.uk/policy-and-regulation/the-leading-candidates-for-the-next-ceo-of-nhs-england/7029994.article
- It should also be pointed out that Centene has a large presence in both Medicare Advantage – the over 65’s equivalent of MMC – and in the Obamacare market exchanges.
- The list also includes: Arizona, Alaska, Georgia, Illinois, Kentucky, Michigan, and Mississippi.
- https://www.latimes.com/business/la-fi-medicaid-insurance-profits-20171101-story.html
- https://www.latimes.com/business/la-fi-medicaid-private-insurance-20181018-story.html
- https://eu.desmoinesregister.com/story/news/investigations/2018/07/01/iowa-new-private-medicaid-company-troubled-past-centene-millions-dollars-penalties/637740002/
- https://claudepeppercenter.fsu.edu/side-posts/dallas-morning-news-pain-and-profit-briefing-by-the-claude-pepper-center/
- Nottingham City Clinical Commissioning Group, ‘NHS Clinical Commissioners. Core Cities’, 6 December 2016.
Stewart Player is a political analyst with over 20 years experience of working in the field of healthcare policy. Research areas covered include primary care, ISTCs, US healthcare policy, and long-term strategic developments within the NHS. Most recently working on NHS estates policy, restructuring within the private healthcare sector, and the political theory of transnational class formation.