When Corporations Take Over Health Care

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• A New Generation of Philanthropists
• Child of an Older Mother

To the Editor:

Re “Insurers Add Primary Care to Portfolios” (front page, May 9):

It seems to me that the fact that “multibillion-dollar corporations, particularly giant health insurers,” are gobbling up primary care practices to make more money and increase their control of health care delivery is old news to most American physicians. As the power of the corporations in our health care system increases, the power of our physicians decreases.

Back in the day when physicians, and not corporations, ran the whole show, it used to be a beautiful thing to be a primary care physician in America.

Calvin Shapses
Los Angeles
The writer is an internist.

To the Editor:

In 1980 the editor of The New England Journal of Medicine, Dr. Arnold Relman, saw the rise of a “new medical-industrial complex” as “the most important health care development of the day.”

Having built a vast empire, corporate America is now solidifying it by adding primary care, squelching any remaining autonomy in the medical profession. Profit-seeking organizations should not be given this overwhelming authority to administer health care, precisely because it is a conflict of interest: profit motive over equitable patient care.

In addition, costs continue to soar and quality suffers as the private sector acquires health care facilities, such as nursing homes.

We need to promote health equity, not private equity. When the American people realize that their tax dollars are subsidizing corporate America, maybe they will see the light. As history demonstrates, empires rise and fall. We need to rescue American health care before it falls any further.

Cheryl L. Kunis
New York
The writer, a nephrologist and bioethicist, is professor emerita of clinical medicine at Columbia University and the director of national issues for the New York chapter of Physicians for a National Health Program.

To the Editor:

“Insurers Add Primary Care to Portfolios”outlines many of the risks posed by a rapidly progressing trend: physicians becoming employees in large for-profit organizations.

Serious ethical dilemmas, unnecessary care and safety complications can arise when physicians make medical decisions based on meeting profit expectations. Employment in not-for-profit settings may feel safer for some physicians.

However, in both settings, strong physician leadership is an important solution that experts agree plays a critical role in creating a mission-driven culture, mitigating patient-care risk. Hospitals and private equity firms that own physician practices should find a way to give physicians a say in determining the way practices operate.

Doing so can offset the negatives of consolidation by strengthening the patient-physician compact, and can protect physician well-being from the moral tension that can occur when financial and patient care considerations are out of balance. Training physicians to take on oversight roles while remaining in touch with patients is also critical to uphold health care’s most important goal: keeping people healthy.

Alexa B. Kimball
Boston
The writer is the president and chief executive of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center and a professor of dermatology at Harvard Medical School.

To the Editor:

Why are corporate giants buying up primary care practices? And why will investors buy their shares? Because they expect to make lots of money. The question is, How will they make enough money for these to be good enough investments?

If they are paid a fixed fee to take care of patients — that’s the H.M.O. idea from the 1970s — the only way to make money is to spend less providing care. These are the ways to do that: Enroll healthy people who do not need care, provide less care to those who do need it, or pay providers less.

The alternative is a fee-for-service plan. In that system, they earn more fees by providing more services. If the primary care providers are integrated with other levels of care, the organizations have not only the incentive but also the means to make that happen.

The talk about providing better care more efficiently is nothing more than public relations to lull the public — and regulators? — into approving these purchases.

As students of the health care system have pointed out for many years, we spend astronomically more in the market-oriented U.S. system than other developed countries, and our outcomes are worse. Markets may be great in other sectors, but when will we stop believing that they are the best way to deliver these essential services?

Stephen M. Davidson
Philadelphia
The writer is emeritus professor of health sector management and policy at Boston University.

A New Generation of Philanthropists

To the Editor:

Re “Baby Boomers Leaving Behind Riches, Still Mostly for the Rich” (front page, May 15):

I read with interest this article about the greatest wealth transfer in history, with trillions of dollars reinforcing inequality. While I don’t disagree that there will be extraordinary, unprecedented wealth in new hands, my experience working with millennial and Gen Z inheritors gives me hope.

Their mind-set, values and sense of responsibility include broad, inclusive criteria for how they will use their resources to advance social change.

The young philanthropists I work with are unwilling to accept the status quo. They feel it’s their responsibility to be deeply informed about the systems they are trying to change, including those that made them rich and others poor. They lead with curiosity and humility, rather than ego and greed.

Solving big global challenges like gender inequality, climate change and food insecurity demands a paradigm shift and a new type of philanthropist. I’m hopeful that this next generation of wealth holders leads to the greatest generation of philanthropy the world has ever seen.

Rena Greifinger
Washington
The writer is managing director of Maverick Collective, a community of female philanthropists.

Child of an Older Mother

To the Editor:

Re “Joy, Loneliness, ‘Rejuvenation’: Becoming a Mother After 40” (Family, nytimes.com, May 14):

As a child of parents in their 40s, I read your article with interest. I was the last of six children, a “late-life surprise,” born when some of my siblings were old enough to be my parents.

My mother, like most married women at the time, was a homemaker and did not work outside the home. I grew up surrounded by adults, and became an aunt at 5. I remember always being aware of my status as a child of older parents. Of course there were reminders, such as when, as a small child, I would answer the door and the person would ask to speak to my “grandparents.”

I was aware that my fellow students mostly had different family structures, with brothers and sisters close to their own age. In some ways, it was like being an only child, but with summer trips to visit my brother and a sister who lived a state or so away.

My father retired while I was still in high school. As a teenager, I got a front-row seat at what retirement meant.

Late-life children with older siblings can also be on the receiving end of a special type of jealousy and resentment. The last child born long after the others is often seen as being “spoiled,” receiving more leniency, attention and material things than the older children. The child born later is also around to comfort the later years of aging parents.

One downside, of course, is that inevitably, the late-life child may be the only one left.

Rebecca S. Fahrlander
Bellevue, Neb.
The writer is a retired adjunct professor of psychology and sociology.