Private equity continues to expand its holdings in healthcare, having invested almost $1 trillion in hospitals and specialized practices over the last decade. And patient care and government healthcare plans such as Medicare and Medicaid are feeling the impact as evidence mounts that private equity may be crossing the line between managing the business operations of a healthcare provider and exercising control over patient care decisions.

A 2021 study published by the Becker Friedman Institute for Economics concluded that private equity ownership increases the short-term mortality of nursing home residents by 10%. That represents more than 20,000 lives lost during a 12-year period, likely due to lowered nursing-staff-to-resident ratios and the diversion of patient care funding to private equity owners. An investigation by USA Today and Newsday found that when private equity firms acquire an interest in dental practices treating Medicaid patients, those practices tend to incentivize dentists to increase the volume of procedures, regardless of medical necessity. Surprise billing, where patients receive outsized bills for out of network services provided on an emergency basis, or for supplemental services rendered by an out of network provider working within an in-network facility, are correlated to private equity ownership and outsourcing tactics.

If a private equity firm seeks to, or has acquired, your healthcare organization, there are few things you should know.

1. Purpose: The sole purpose of a private equity firm is to provide its investors with profits. In the healthcare context they do this through the strategic acquisition of various types of health care providers, some of which may be large companies like hospital systems, and others which may be smaller, such as physicians group practices. The acquisition targets are providers from which the firm believes it can generate value for itself and its investors. Typically, a private equity firm acquires a portfolio company for five to seven years, during which it cuts costs, sells off assets, and/or enhances efficiencies (sometimes by “rolling up” individual physician practices providing the same services) to improve financial results. Then it sells off the portfolio company.

2. Organizational Structure: Many private equity firms with portfolio companies in the healthcare sector have adopted the “Friendly PC” organizational model, which when used properly, can help to separate patient care (and the medical judgments which lie at the heart of patient care), from the private equity firm thereby avoiding accusations that it is unlawfully practicing medicine. Under this model, the professional corporation is owned by physicians and employs the physician providers as well. The professional corporation then enters into an agreement with a management services organization (“MSO”) which is controlled by the private equity firm. The MSO manages the day-to-day business operations of the medical practice and employs the non-clinical employees.

3. Operational Anomalies: Private equity firms and/or their MSOs may contract out critical care services, such as emergency, radiology, and anesthesiology, as well as administrative departments, such as accounting. This gives them greater leverage in pushing costs down but can result in the elimination of healthcare provider services and jobs, and the implementation of new billing and/or service tactics. Issues that can arise from private equity ownership are many — from surprise billing, to acquiring excess debt (just weeks ago, private equity-owned Envision Healthcare, discussed below, declared bankruptcy), to making decisions about patient care.

Unfortunately, private equity acquisitions in the healthcare sector may create an inherent conflict of interest between patients and their government healthcare plans on one hand, and private equity firms and their investors on the other.

Medical professionals and administrators are sometimes caught in the middle as patient care suffers.

In these situations, medical staff have legal resources to seek recourse and accountability. Many states have longstanding laws that prohibit non-licensed medical professionals, including private equity limited partnerships, from engaging in the practice of medicine. Additionally, the federal False Claims Act (FCA) and its state law counterparts have long been used to remedy and deter all manner of health care fraud directed at government payers.

The corporate practice of medicine (“CPOM”) doctrine prohibits corporations from practicing medicine or employing a physician to provide professional medical services. The doctrine exists, in part, to ensure that physicians are free to exercise their medical judgment independent of a corporation’s obligations to its shareholders.

More than thirty states have CPOM statutes, and while every state allows for the creation of professional corporations, most restrict shareholders, owners, or board directors to persons licensed to render the same professional service as the professional corporation. Other states allow non-physician owners or shareholders but limit such ownership to a minority percent. The aim of these statutes is to preserve a physician’s independence in exercising his or her medical judgment for the benefit of the patient.

Two recent court decisions in which state CPOM statutes were applied are particularly noteworthy:

  • In a unanimous 2017 decision in Allstate Ins. Co. v. Northfield Med., the New Jersey Supreme Court reinstated a nearly $4 million dollar verdict that Allstate Insurance received against a chiropractor and his lawyer, based on violations of New Jersey’s CPOM statute. In this case, the chiropractor, rather than the affiliated medical doctor, was extracting the profits from and maintaining control over a multidisciplinary healthcare provider.
  • In 2019, in Andrew Carothers, M.D., P.C. v. Progressive Insurance, the New York Court of Appeals affirmed the jury’s determination that a medical professional corporation had given nonphysicians too much operational and financial control over its activities and thus violated New York’s CPOM statute requiring that medical professional corporations be owned and controlled solely by licensed professionals. 

There are at least two recent examples of healthcare providers holding private equity firms accountable for crossing the line between managing the non-clinical aspects of a health care provider and unlawfully making decisions about patient care. Both involve Kohlberg Kravis Roberts Envision Healthcare:

  • In 2019, the American Academy of Emergency Medicine Physician Group sued Envision, alleging that the private equity firm violated California CPOM statutes when it assumed responsibility for managing the emergency department at Placentia-Linda Hospital in 2018. Specifically, through its own employees, officers and agents, Envision assumed control of the medical professional corporation which was ostensibly created to prevent Envision from making medical treatment decisions. AAEMPG alleges that Envision engaged in this unlawful strategy nationwide.
  • In 2022, an emergency room doctor who had complained about deliberate staffing shortages at a Kansas hospital and was terminated in response, was awarded $26 million by a jury in compensatory and punitive damages. The physician claimed that Emcare, a division of Envision, had staffing policies that caused persistent staffing shortfalls and endangered patient safety.

Could a court find that a violation of CPOM gives rise to parallel violations of the FCA when the private equity firm causes Medicare or Medicaid claims to be submitted for reimbursement?

No court has yet been presented with this question. However, the U.S. Supreme Court has held that the submission of claims for services provided by unlicensed professionals can violate the FCA. This legal backdrop is immensely instructive when considering strategies for policing the activities of private equity firms that exercise control over the operations of healthcare providers and prevent independent medical decision-making — especially when their activities are shortchanging patients and government payers, all in the name of profits.

The potential for private equity to insidiously undermine the doctor-patient relationship and usurp the ability to make treatment decisions from physicians is growing at an alarming rate. Such activity may also lead to the submission of illegal false claims to Medicare and Medicaid.

It is vital that healthcare professionals at health facilities owned and operated by private equity firms have in place effective enforcement strategies to ensure physician autonomy and quality patient care are not sacrificed. Barring that, medical professionals and administrators should be wary of the potential for private equity, in its quest to extract value out of a healthcare provider, to unlawfully exercise control over patient treatment decisions. If private equity is intervening in medical care or patient outcomes are worsening, pursuing legal action can be vital to winning accountability. CPOM statutes, the FCA, and state false claims statutes offer a powerful means of preserving patient care and physician independence to exercise effective patient care.

On May 16, the United States District Court for the Southern District of New York preliminarily approved a $1 billion settlement in In re Wells Fargo Securities Litigation (S.D.N.Y.). If granted approval, following a hearing scheduled for September 8, 2023, it would be among the top securities class action settlements of all time.

A Story of Betrayal and Fraud

Wells Fargo Bank is one the largest banks in the United States.

Between May 30, 2018 and March 12, 2020 (the “Class Period”), Wells Fargo and its top executives allegedly made a series of false and misleading statements to not only investors, but the public and Congress. Specifically, Plaintiffs allege that the Bank, which had been fined $3 billion by the U.S. Department of Justice, SEC, and other federal and state authorities for opening an estimated 3.5 million phony bank accounts, misrepresented its compliance with government mandated consent orders.

These orders, mandated by the Federal Reserve Board (FRB), the Office of the Comptroller of the Currency, and the Consumer Financial Protection Bureau, were created to rectify Wells Fargo’s governance and oversight failures, which allowed such consumer fraud to happen in the first place.

To make matters worse for the Bank, the FRB issued an unprecedented asset cap, restricting any future growth until the bank was in compliance with the consent orders.

As senior bank executives continued to allegedly mislead investors that regulators were satisfied with the Bank’s progress on fulfilling the consent orders and that the asset cap would be timely removed, Wells Fargo’s common stock traded at artificially inflated prices.

The Truth Revealed

The truth regarding Wells Fargo’s fraud was revealed over a number of corrective disclosures. Ultimately, in March 2020, a House Committee on Financial Services report revealed that, after a yearlong investigation, Wells Fargo’s remediation plans were “materially incomplete” and fell “woefully short” of regulators’ expectations.

Congressional hearings revealed even more. Wells Fargo CEO Charles Scharf testified that “the company’s leadership failed its stakeholders” and “we did not have the appropriate controls in place across the company.”  As a result of these revelations, Wells Fargo’s stock plummeted.

The Role of Investors

Given the significant losses to their public pension funds, the Public Employees’ Retirement System of Mississippi (Mississippi) and the State of Rhode Island, Office of the General Treasurer (ERSI), stepped in and addressed Wells Fargo’s fraud head on. In November 2020, shortly after the initial investor suit was filed, both ERSI and Mississippi were appointed co-Lead Plaintiffs, Cohen Milstein was appointed Lead Counsel with co-counsel.

If the court grants final approval, this $1 billion settlement will help compensate the public pension funds and other investors impacted by Wells Fargo’s fraud.

Significance of Investor Involvement

Research confirms that when large, sophisticated institutional investors, such as ERSI and Mississippi, serve as lead plaintiffs in securities class actions, the case is more likely to survive defendants’ motions to dismiss, settlements are higher in value and are from a higher percentage of recoverable damages. Their involvement in securities class action helps to deter companies from engaging in fraud in the future.

Indeed, a $1 billion settlement is also an effective warning to other banks and companies: investors are not only watching, but they are also ready to act.

Investor Impact on Industry

In re Wells Fargo Securities Litigation also highlights the enforcement role private litigation can play when banks fall short of their obligations to ensure proper compliance with regulators and other government entities.

This is important to note as banks get bigger through market consolidation. The effect will likely mean less executive and board oversight and less market choice for customers, creating ripe opportunities for customer harm and fraud.

Investor confidence and our economy are dependent upon the integrity of the banking industry, and institutional investors are critical to helping keep banks accountable.


Shareholder Advocate Summer 2023

On June 9, 2023, Chancellor Kathaleen St. J. McCormick of the Court of Chancery of the State of Delaware issued a telephonic ruling which largely denied Defendants’ motions to dismiss the complaint in the In re XL Fleet (Pivotal) Stockholder Litigation, C.A. No. 2021-0808-KSJM, allowing a class of investors to pursue claims related to the fairness of a de-SPAC transaction.

This class action arises from the merger between Legacy XL, a provider of electrification solutions for commercial vehicles in North America, and Pivotal II (“Pivotal”), a Delaware corporation formed as a special purpose acquisition company (SPAC).

Plaintiffs alleged that Defendants, including Pivotal’s board of directors, Pivotal Investment Holdings II LLC, and Pivotal’s sponsor, used Pivotal to enrich themselves by using funds held in trust for the benefit of the public stockholders to consummate a value-destroying merger with Legacy XL without disclosing information that was material to the stockholders’ decision to allow their funds to be invested in the merger. As a result of Defendants’ actions in pursuing the merger without disclosing material facts to stockholders, the stockholders sustained substantial financial losses.

The merger closed on December 21, 2020. Just ten weeks later, Muddy Waters Research issued a report revealing that the proxy statement, which Pivotal investors relied on when determining how to vote on the merger, contained false and misleading information, while also omitting material information about Legacy XL’s value. That news caused the company’s stock’s price to begin a steep downward decline from trading at nearly $17 per share to less than $2 per share a year later, when the company disclosed that it was under investigation by the Securities and Exchange Commission.

Significantly, the Court found that the de-SPAC transaction was subject to “Delaware’s most onerous standard of review”—entire fairness—because “the complaint sufficiently pleads it’s a conflicted controller transaction.” The Court rejected Defendants’ argument that the sponsor of the SPAC, which only held 20% of the company’s equity, was not a controlling stockholder. The Court highlighted that the sponsor was conflicted because of its interest in consummating “a bad deal over no deal at all,” which would cause the sponsor to lose its entire investment in Pivotal. In contrast, Pivotal investors would receive their $10 per share investment back if they had decided to vote against the merger.

Next, the Court found that Plaintiffs sufficiently pled breach of fiduciary duty claims against the Pivotal board by alleging that the proxy statement omitted material information, which fell into two categories: (1) the cash-per-share investment that Pivotal would make into the newly merged companies; and (2) the valuation of Legacy XL that stockholders would receive in exchange.

Finally, the Court upheld Plaintiffs’ claim that Pivotal breached the 80% requirement in its charter because Legacy XL was not worth at least $178.4 million at the time of the merger. As a result, the Court allowed claims to proceed against the Pivotal board for breaching the charter’s terms.

By Chris Lometti and Richard E. Lorant
Securities Litigation 101
Shareholder Advocate Summer 2023

In prior articles, we have mentioned the importance of enacting a policy to govern a pension fund’s approach to tracking and managing its securities litigation assets. Today we will focus on a key section of that policy: the criteria for active involvement in a securities lawsuit.

How Private Enforcement by Institutional Investors Promotes Fair and Free Markets

First, some background on what makes the federal securities class action mechanism such a vital tool to enforce transparency and accountability for publicly traded companies in U.S. markets and why active involvement by institutional investors is important to making class actions effective.

Private enforcement of U.S. securities laws through civil litigation provides an important complement to government prosecution by  the Securities and Exchange Commission through its civil enforcement and administrative actions, and the Department of Justice, which is responsible for criminal enforcement. Chronically underfunded and understaffed, federal enforcement agencies necessarily focus on the largest, most egregious cases. Moreover, the SEC typically retains money it collects through civil penalties rather than returning money to shareholders. When the SEC does reimburse defrauded investors directly through its Fair Fund, its disgorgements are dwarfed by the amounts recovered through private securities class action settlements; the top 50 Fair Fund disgorgements totaled $11.5 billion, about a fifth of the $56.8 billion recovered by the 50 largest securities class action settlements.

Likewise, a class action mechanism that allows parties with similar claims to pursue damages collectively is essential because the vast bulk of individual securities losses are “negative claims” too small to pursue alone: the cost of hiring an attorney exceeds the value of the potential award or settlement. This is true even for most institutional investors, which explains why only a small number of frauds generate the kind of massive losses required for big pension funds to opt out of class actions to seek their own settlements. Without class actions—and the contingency fees that make them economically feasible for plaintiffs’ lawyers—most frauds would simply go unpunished; all but the very largest shareholders damaged by the very largest frauds would absorb their losses as part of the cost of investing in public markets. It’s noteworthy that, while most countries outside the U.S. have prioritizedsending corporate fraudsters to prison above compensating investors, that is changing. The European Union, for example, is instituting rules to facilitate collective actions in all member nations.

As further context when considering involvement, it is also important to remember that the emergence of institutional investors as lead plaintiffs following passage of the Private Securities Litigation Reform Act of 1995 (PSLRA) has benefited all shareholders. Numerous academic studies show that cases led by sophisticated institutional investors have better outcomes, bigger recoveries, and lower attorneys’ fees than those led by individual investors on average, even when controlling for case size. In fact, at least one study found that the involvement of institutional lead plaintiffs has lowered attorney fees for all shareholder lawsuits, since judges often look at similar-sized cases when deciding on fee awards. These improved results argue for pension funds to continue to selectively pursue meritorious litigation for their own benefit—and for the greater good.

Case-by-Case Factors to Consider for Active Participation as  Lead Plaintiff

So, what factors do funds consider when deciding whether to file a lead plaintiff motion? As in all fiduciary and policy-related practices, one size doesn’t fit all. But what follows are some general concepts.

An analysis of whether to actively pursue a case begins with the size of a fund’s initial loss and potential damages, both as an absolute number and relative to other potential lead plaintiff movants.

Funds who have a securities litigation policy often identify a minimum dollar loss (i.e., “loss threshold”) to consider active involvement in meritorious litigation. This loss threshold, whether firm or flexible, will help fund staff determine if its loss is large enough to warrant spending time on the litigation, since class actions allow absent class members to wait until there is a recovery to file a settlement claim. Consulting with monitoring counsel will also give the fund an idea whether its loss is outsized compared to other funds that are likely movants.

The PSLRA directs judges to select the movant with the largest loss as lead plaintiff, so long as it is a typical and adequate class representative, so calculating the initial loss amount is relatively straightforward. The initial complaint will identify a purported class period based on corrective disclosures—moments the stock price was materially affected because defendants allegedly misled investors or failed to publicly disclose information they should have under the law. Movants then sum up their losses during the class period, typically using the last-in-last-out (LIFO) or first-in-first-out (FIFO) method relied on by most courts.

It’s impossible to determine, at the outset, how much the involvement of any one fund as lead plaintiff will increase the recovery. Finally, while many judges reimburse lead plaintiffs for time spent on their litigation duties, such awards are not guaranteed. Unfortunately, it’s also impossible to predict the final recovery amount, or even the recoverable damages, at this stage of the litigation; those issues are subject to judicial rulings, expert testimony, and the evidence produced in discovery. But the initial case analysis may provide an inkling of potential settlement size based on the overall damages, the legal strength of each corrective disclosure, and the timing of the investor’s class period purchases and sales. It also may identify a legal claim that wasn’t included in the initial complaint, such as a purchase in a particular stock offering, or an additional alleged corrective disclosure. If appointed Lead Plaintiff, the fund could assert these additional claims in an amended complaint, thus increasing the value of the case.

Securities litigation policies also identify non-financial factors to consider when deciding whether to act as lead plaintiff. Those factors include: 

  • The value of ensuring that the litigation is well managed and efficiently handled, especially if the fund has large potential damages.
  • The ability to negotiate the settlement amount.
  • The opportunity to incorporate governance improvements at the settlement stage.
  • The desire to police egregiously unlawful behavior, deter future fraud, and protect market transparency.
  • The ability to negotiate attorneys’ fees.
  • The chance to serve as a positive example of shareholder involvement for institutional investors, which the PSLRA has charged with leading such actions.
  • The interest in sharing the responsibility of serving as lead plaintiff among like-minded institutional investors to ensure that the U.S. class action system continues to function efficiently as an enforcement mechanism.

In addition, it is important to remember that certain lawsuits, such as shareholder derivative class actions, do not directly return money to investors. These lawsuits primarily address breaches of fiduciary duty by corporate leaders who have exposed systemic, harmful governance and cultural practices that harm long-term shareholder value. As fiduciaries, pension fund trustees should consider some or all these policy issues when deciding whether active participation in litigation is warranted.

There is no doubt that boards of trustees perform an essential and critically important function in the oversight of pension plans in the  United States. There is also no doubt that the quality of governance matters, as research has shown that a high-functioning board leads to better outcomes. So, how should a board react when a single trustee seems to be operating at cross-purposes to the rest of the board and behaving inappropriately?

A bedrock of an effectively functioning board is for all trustees to demonstrate respect for the board’s collective decision-making process. To be effective, the board must speak with one voice. This does not mean that there isn’t a full and frank airing of views and that there aren’t disagreements—indeed, there can, should, and inevitably will be disagreements at some point in the operation of a board. Trustees need to encourage and engage in open discussions and respect differences of opinion while weighing decisions. But once the board has voted in favor of a decision, the board should speak with a single voice and give direction as a whole—no matter whether that direction is to staff, members and beneficiaries, legislators, the public, or other stakeholders.

This leads to the question of how to rein in a rogue board member. One potential action is for the board to censure the offending trustee. The U.S. Supreme Court considered this topic in 2022 in a case, Houston Community College System v. Wilson, that did not involve a pension board but is nonetheless illustrative. After years of acrimony, the Board of Trustees of the Houston Community College System (“HCC”) censured one of its members, Mr. Wilson, who responded by filing a lawsuit challenging the Board’s action. The issue before the Supreme Court was: Did the Board’s censure offend Mr. Wilson’s First Amendment right to free speech?

Mr. Wilson’s tenure was marked by controversy from the start. He often disagreed with the Board about the best interests of HCC, brought multiple lawsuits challenging the Board’s actions, and assisted others in filing lawsuits. Four years into his tenure, he had filed four lawsuits costing HCC more than $300,000 in legal fees. He also was accused of leaking confidential information, publicly denigrating parts of the College’s anti-discrimination policy, and drawing media attention in a variety of ways. For example, after the Board voted to fund an overseas campus over Mr. Wilson’s opposition, Mr. Wilson orchestrated a wave of negative robocalls targeting other board members’ constituents. He gave local radio interviews accusing Board members of illegal and unethical conduct and stated that they were not representing the public. He also hired private agents to investigate a fellow Board member and HCC itself, and maintained a private website that used HCC’s name in violation of Board policy.

These escalating disagreements led the Board to reprimand Mr. Wilson publicly. After Mr. Wilson continued to charge the Board—in media outlets as well as in state court actions—with violating its ethical rules and bylaws, the Board adopted another public resolution, this one censuring Mr. Wilson and stating that Mr. Wilson’s conduct was “not consistent with the best interests of the College” and “not only inappropriate, but reprehensible.”

The Supreme Court, in a unanimous decision, held that Mr. Wilson did not possess an actionable First Amendment claim arising from the Board’s purely verbal censure. The Court noted that bodies in this country have long exercised the power to censure their members, as far back as colonial times. The Court stated, “[t]he censure at issue before us was a form of speech by elected representatives concerning the public conduct of another elected representative. Everyone involved was an equal member of the same deliberative body.”

Importantly, the issue before the Court was a narrow one that did not, for example, involve expulsion or exclusion. The censure neither prevented Mr. Wilson from doing his job nor denied him any privilege of office, and Mr. Wilson did not allege it was defamatory. As such, the Court found that the censure was not a “materially adverse action” capable of deterring Mr. Wilson from exercising his own right to speak. Left for another day was the question of how the Court would treat the board’s imposition of other punishment—such as limiting his eligibility for officer positions— that might be a “materially adverse action” deterring the trustee from exercising his own right to speak.

This case involves many of the very same issues that are regularly discussed in this column. Short of formal censure, what other tools in the pension board tool kit can be used to address the rogue trustee situation?

  • Education: A regular and ongoing program of fiduciary education can help trustees understand the fiduciary principles that govern the exercise of their duties and how to apply those principles in real world situations.
  • Board governance manual: A roadmap to guide board operations, the governance manual may include charters for the board and the committees of the board. It should be a living document. Rather than “set it and forget it,” you should regularly review and revisit the board governance manual to determine if it reflects the system’s values, is a tool for board accountability, and is meeting your needs—especially as times change and the operating environment evolves.
  • Policies and procedures: These may be free-standing or contained in the board governance manual. As an example, the Supreme Court case cited above highlights the importance of having a solid Communications Policy that addresses when trustees may speak to the media on behalf of the board. Another important policy that could address the situation of a rogue trustee is a code of ethics for the board. Other policies may address such topics as board delegation; board training, reimbursement for travel and other expenses; service provider selection; succession planning; and periodic reviews of the executive director and any other direct reports to the board. Just as pension systems are not all alike, policies and procedures should be customized and tailored to fit the particular needs of a pension system.
  • Consulting services: An independent outside source can prove invaluable in reviewing governance structure and suggesting ways to enable boards and executives to become more effective. Other ways in which boards may benefit from the use of a consultant includes strategic planning, messaging, and stakeholder relations.
  • Self-evaluation: Does your board conduct annual board selfevaluations? These can confirm strengths and reveal areas for improvement to help the board fulfill its responsibilities and fiduciary duties.

Implementing some of all of these strategies may help a pension system board avoid and address a fellow trustee’s inappropriate behavior.

The Summer 2023 issue of the Shareholder Advocate includes:

Download the Summer 2023 issue (PDF).

Gary L. Azorsky and Raymond M. Sarola attorneys within Cohen Milstein’s Whistleblower/False Claims Act practice, submitted a comment letter to the National Highway Traffic Safety Administration (NHTSA) in response to its proposed rules for implementing its whistleblower program.

We represent individuals who submit claims under federal and state whistleblower programs, including NHTSA’s whistleblower program which is designed to incentivize individuals who work in the automobile industry to report safety violations that pose risks to human lives.

As counsel for whistleblowers, we appreciate NHTSA’s acknowledgement of the critical role of whistleblowers and its efforts to establish an effective and transparent whistleblower program. The opportunity to receive an award is a significant incentive to whistleblowing. The incidence of whistleblowing will increase when rules are adopted that reassure individuals they will be entitled to an award if they satisfy the eligibility criteria, and the government obtains a successful enforcement outcome based on their information.

Cohen Milstein provided comments on four aspects of the proposed rules. We:

  1. Expressed our view that whistleblowers should receive awards based not only on amounts that the government receives from a company in an enforcement action, but also based on amounts that the government requires companies to pay to third parties, such as the victims of automobile defects.
  2. Advocated for a definition of “related action” that includes all government enforcement activity that is substantially related to “covered actions,” so that whistleblowers are not penalized if the government takes enforcement action through multiple agencies in civil and criminal contexts.
  3. Objected to the proposed rule that would grant the Administrator of NHTSA the discretion to deny an award to a whistleblower who otherwise meets all eligibility criteria.
  4. Argued that NHTSA should make payments to whistleblowers of the uncontested portions of their awards even if a portion is subject to judicial appeal.

We believe the views expressed in our letter will assist NHTSA in implementing a world-class whistleblower program – one that enhances public safety by encouraging automobile industry workers with information about safety violations to report that information to NHTSA, thereby assisting the government in protecting drivers, passengers, and pedestrians.

Read our Comment Letter to NHTSA

Who makes the decisions regarding your health care? Your doctor? Maybe not. And that is a growing problem. Today, though patients may not realize it, private equity’s footprint can be found most everywhere health care is provided: emergency rooms, hospital chains, general practitioners’ offices, cardiologists’ offices, home health agencies, nursing homes and more recently, even in behavioral health. Private equity firms have invested almost $1 trillion in hospitals and specialized practices over the last decade and there is no end to this surge in sight. The consequences of this seismic shift upon patient care and costs to the government payers are increasingly drawing scrutiny from industry observers.

The potential for private equity to insidiously undermine the doctor-patient relationship and usurp the ability to make treatment decisions from physicians is growing exponentially. It is vitally important to have in place effective enforcement strategies to ensure that physician autonomy and quality patient care are not sacrificed in a private equity firm’s desire to generate maximum investment returns.

In this article, Jeanne Markey and Gary Azorsky look at how the long under-utilized “corporate practice of medicine” or “CPOM” statutes, combined with false claims statutes, themselves a fixture of our nation’s jurisprudence, can offer a powerful means of preserving a fundamental component of appropriate patient care, the duty and the power of physicians to exercise their independent judgment when caring for their patients.

Read Overlooked Law States Can Use to Get Private Equity Out of Health Care Decisions.

By Daniel McCuaig

The Federal Trade Commission recently failed to stop Meta’s acquisition of virtual reality company Within, while the Department of Justice is now attempting to mitigate Google’s monopolization of the online “ad tech stack” by unwinding its 2008 purchase of DoubleClick. Daniel McCuaig outlines the parallels between the two cases and argues that consumers are threatened with anticompetitive harm if the courts continue to side with tech monopolist defendants when faced with uncertainty.

A technology behemoth shells out hundreds of millions of dollars to purchase the most successful innovator in a nascent market adjacent to one dominated by the behemoth. The direct competition between the two is insignificant and the government agency evaluating the merger lacks a sufficiently clear crystal ball to state with grounded confidence that the combination will lead to anticompetitive effects down the line.

That was the fundamental story in 2008 when Google acquired DoubleClick and it is the fundamental story today as Meta acquires Within.

The Agency’s Options

The agency can either (1) attempt to block the acquisition notwithstanding its imperfect information or (2) allow the deal to close and, if anticompetitive effects manifest, sue to unwind the merger years later.

Neither option is ideal, as evidenced by the FTC’s recent failure to block Meta’s acquisition of Within (option 1) and by the headwinds the DOJ faces in its ongoing case against Google for illegal monopolization of the “ad tech stack” in which the key remedy sought is the unwinding of Google’s 2008 acquisition of DoubleClick (option 2). The Google/DoubleClick story has had fifteen years to develop since the FTC decided not to challenge that merger and it’s the clarity that has come with the passage of time that has convinced the DOJ now to seek a do-over.

“Impermissibly Speculative”

The Northern District of California’s decision to deny the FTC’s motion to preliminarily enjoin Meta’s acquisition of Within throws into starker relief the need for the government realistically to be able to unwind mergers. Application of an unrealistically high standard to enjoin mergers, such as in FTC v. Meta, otherwise will leave consumers to suffer anticompetitive effects in a world where vertical tech mergers are nigh impossible to block prospectively because the harms they threaten are “impermissibly speculative,” but then, when those “impermissibly speculative” harms in fact materialize, courts are unwilling to “unscramble the omelet” of a long-consummated merger.

In FTC v. Meta, the FTC sought “to block the merger between a virtual reality (“VR”) device provider [Meta] and a VR software developer [Within].” Within’s Supernatural is indisputably the leading VR dedicated fitness app in the United States, with “an 82.4% share of market revenue.” Meta also is a VR software provider—one that spends “several billion dollars each year on its VR Reality Labs division” —but it has not yet been able to develop its own successful VR dedicated fitness app in a market that “both parties seem to agree . . . is [] nascent and emerging.” Because the FTC challenged this acquisition on horizontal theories of harm rather than vertical ones, the central question for the court to address was whether Meta would have enhanced competition in the VR dedicated fitness app market absent its merger with Within.

Meta could have induced greater competition, either by developing its own successful entrant(s) or by spurring greater efforts from the players in that market just by the threat of doing so. At the same time, the court expressly recognized: (1) the inherently vertical “‘flywheel’ effect”—a phrase the DOJ uses four times in its ad tech stack complaint—that develops when widespread adoption of a platform incentivizes the creation of content for that platform which, in turn, drives even broader adoption of the platform, and so on; and (2) that “Meta repeatedly stated that VR dedicated fitness apps constituted a distinct market opportunity within the VR ecosystem due to their unique uses, distinct customers, and distinct prices.” That is, the court acknowledged the possibility of the vertical aspects of this merger ultimately leading to the kinds of anticompetitive harm we see in the DOJ’s Google case, but it did not translate that recognition into any kind of weighting in the government’s favor as it evaluated the FTC’s case against Meta.

Read Dan’s complete op-ed on ProMarket.

The Spring 2023 issue of the Shareholder Advocate includes:

Download the Spring 2023 issue (PDF).