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We sit down with Paula Muto, a vascular surgeon, who discusses the challenges she’s faced in a health care system on the brink of collapse. From hospital closures driven by private equity to network restrictions that limit patient access, Paula shares her candid insights on how we can rebuild a better system. She advocates for banning network restrictions, restoring physician authority, and increasing financial transparency. Drawing on her years of experience, she highlights the urgent need for change and calls on fellow physicians to take the lead in transforming health care.
Paula Muto is a vascular surgeon.
She discusses the KevinMD article, “A physician’s perspective on the crisis in Massachusetts health care.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at kevinmd.com/podcast. Today, we welcome back Paula Muto. She’s a vascular surgeon. Today’s KevinMD article is “A Physician’s Perspective on the Crisis in Massachusetts Health Care.” Paula, welcome back to the show.
Paula Muto: Oh, it’s great to be here, Kevin.
Kevin Pho: So before talking about the article, let’s start with what led you to write this particular one in the first place.
Paula Muto: So, as you know, I’m pretty talkative about what’s happening in health care, but I’m living it firsthand in Massachusetts, and I think that it’s a cautionary tale. You know, somebody had referred to me recently as being a prophet, and I said, no, I’m more like Cassandra telling the Trojans’ story. Bring that horse in. And so now it’s sort of coming to fruition. And I think that people have to spend this time understanding the reasons and how we got here, so we can get ourselves out of this and perhaps prevent other places from following.
Kevin Pho: All right. Coincidentally, my high school daughter is studying ancient Greece. So that metaphor certainly rings true. So talk about that article itself and tell me about the warning signs that you’re seeing.
Paula Muto: You know, again, put it in context—Massachusetts, Steward Health Care. Steward Health Care was one of the larger consolidated groups. It was a for-profit group that came in. It started in Massachusetts out of a group of Catholic hospitals that came together. And then back in 2010, the hospital network partnered with Cerebus, which is a large private equity organization. And interestingly, about three days after the inking of Obamacare—which makes it all sort of, makes us all scratch our heads, right?—because Obamacare followed RomneyCare, which was a Massachusetts-born entity, which was also created by Bain Capital, Mitt Romney, and Bain Capital. Four years before, they had actually invested in HCA, which is now one of the biggest companies on earth right now. I think they just announced. So, if you go back to sort of who thought of all of this, it really did come up from that model. So, Steward Health Care expanded in the state, expanded across the country through a series of deals with leveraged debt, utilizing hospital beds, actually, as currency and then sort of got caught with their pants down in some ways, you know, because that debt didn’t get paid. And it got paid out to investors, and there was actually nothing left behind to pay vendors at the hospitals.
Kevin Pho: Yeah.
Paula Muto: And so now the hospital network in Massachusetts had broken up. Steward went and filed for bankruptcy. And the hospitals went to a variety of different fates, my own hospital included.
Kevin Pho: So tell us how that is directly affecting patients and the clinician staff today.
Paula Muto: When you’re living it right over the years, going down this slope, you kind of, every day, every day you see where you’re going, but you have to do your work, right? You don’t pay attention; you do your work, and you trust. And there’s a lot of trust here that your leadership will draw the line in the sand somewhere, right? At some point, they’re going to draw a line in the sand. Like, you know, when all else fails, we’re all going to show up and do what’s right for the patient. You know, no one’s ever going to put a profit ahead of a patient. No one’s ever going to tell us that the oxygen delivery isn’t happening. But when the oxygen delivery literally didn’t happen to the operating room, you know, how does it affect people? It’s a very scary place for physicians and nurses and patients to be, right? I mean, I think you’ve talked about this endlessly on your podcast when people talk about moral injury.
Kevin Pho: That’s moral injury.
Paula Muto: So, in my article, I kind of referenced back to a different day when I was in training, which is, I imagine, probably the same time you were in training. I don’t know. Did you train in the 90s and, you know, 80s and 90s?
Kevin Pho: I finished training in 2002.
Paula Muto: Oh, so you’re a little younger than me. I finished in ’96, ’97.
Kevin Pho: ’96.
Paula Muto: So when I was at Tufts New England Medical Center, our CEO was actually our chief of surgery and chief of vascular surgery. The person who ran the hospital, the one who literally was in charge, was operating with me as a chief resident. And then he’d go and put out fires. Why was that important? Because when we were at Tufts, something very impressive was that they started these network restrictions, right? Harvard Pilgrim decided that no patient could go anywhere in Boston but a Harvard hospital. And you had people at New England Medical Center on cancer protocols. And Tom O’Donnell, who was my mentor, went to the statehouse and said, “No. Absolutely not. This is not safe. This is inappropriate. It’s bad patient care.” And guess what? They believed him. Why? Because he was a doctor. And it carried a lot of weight with the legislators and politically. And it was simply reversed.
Kevin Pho: Right.
Paula Muto: Right now, our hospitals are run by doctors. Only 10 percent of the boardroom are doctors. Physicians don’t own hospitals. They’re not allowed to. Physicians aren’t even in the boardrooms, so we don’t even have that position anymore. And I think that has had a huge impact on why the Steward saga occurs. Everyone says, “Well, Steward was run by a doctor,” but it was really run by private equity. The hospitals themselves had no physicians really involved. It was quote “physician-led” only in name. The person in charge of the trajectory was really private equity from the moment he stepped out of the operating room. But when we had a surgeon operating every day, running a residency program, and solving problems, communication could be instant, and trust was there. We have lost that in a major way. It’s not just the autonomy of a doctor; we’ve lost leadership, and so we’ve lost a voice.
Kevin Pho: So how did the evolution of that occur over the past few decades? How did physicians lose their voice in the boardroom?
Paula Muto: I think it’s economics. We go into practice, and you always want to be your own boss. There’s not a doctor out there who didn’t dream about just scheduling themselves, right? Except for academics, which is a totally different world. The number of academic surgeons and doctors has remained constant for a century. Let’s put them over here. The rest of us, who have always been running small businesses, essentially became employees, not for academic reasons but because it became harder and harder to run a practice. We had more restrictions, regulations. If you weren’t part of a network, it became really difficult. And the state of Massachusetts should 100 percent put a bill that bans network restrictions because access is at a crisis level. Patients simply can’t get in. Massachusetts has the longest wait times to see a doctor in the country. And that’s a disgrace because we train so many doctors.
Kevin Pho: Right.
Paula Muto: These network restrictions made it hard to make a living. You had to be part of a group. If you weren’t with them, you were against them.
Kevin Pho: How is your hospital, caught up in the Steward saga, affecting you professionally?
Paula Muto: We’ve lost a lot of good nurses and doctors. During the transition, salaries were protected, but they forgot people on medical leave. Those on maternity leave or recovering from surgery lost health insurance overnight. People panicked and left, uncertain about job security. The uncertainty continues, affecting everyone.
Kevin Pho: Network restrictions are foundational in our health care system’s issues. What first steps should be taken to reverse this?
Paula Muto: A state-level moratorium on network restrictions is crucial. If a patient and doctor are in the same network, nothing should prevent them from connecting. Legislative action could relieve systems’ pressure. We also need to understand why young doctors can’t start practices. Massachusetts provides tax breaks for movies; why not for doctors serving Medicaid patients?
Paula Muto: And it’s not just about relief for tuition or loan forgiveness; it’s about providing real, tangible tax breaks that enable young doctors to stay in practice and serve their communities. This support would help them set up independent practices and encourage more of them to stay in the field, which is ultimately beneficial for patient care and access. The more young doctors we can keep in practice, the more we can distribute the patient load and reduce the burnout that’s so prevalent now.
We need to look at the economic factors that push doctors out of private practice and into hospital employment or even out of medicine entirely. Consolidation and the power of large health care systems play a huge role in this. When individual doctors can’t make a living on their own and have to rely on big networks, we end up in a situation like the one with Steward. It’s a vicious cycle of consolidation that leads to less competition and fewer options for both patients and doctors.
Kevin Pho: Right. And as we touched on earlier, private equity is a significant part of this problem. It has seeped into so many areas of health care. You mentioned that private equity is likely here to stay. What strategies can we adopt to put guardrails around it and protect our health care system?
Paula Muto: It’s going to be tough to untangle private equity from health care because it’s already deeply embedded in the system. From hospitals to outpatient facilities, to the very medications we prescribe—private equity has a stake in all of it. But I think there are a few measures we can take to mitigate its negative impact.
First, we need clear regulations that ensure the profits made in health care stay within the community it serves. When tax dollars come into a system for patient care, those dollars should be reinvested locally, not siphoned off to fund investments overseas or in unrelated industries. This idea of reinvesting in the community could be a fundamental step in controlling how private equity operates in health care. Guardrails can be set up that specify how profits are spent and reinvested, ensuring that the quality of care and resources for patients are maintained.
Kevin Pho: That’s an important point. It’s about keeping the focus on the community and reinvesting locally. What about the political aspect of this? How do we encourage our lawmakers to take this seriously?
Paula Muto: It comes down to advocacy and awareness. Physicians need to be more involved in policy discussions. We need to band together and present a unified front. There’s power in numbers, and if doctors can agree on certain key issues—like price transparency, access to care, and responsible management of health care funds—we can make a difference.
We also need to work on educating the public. Patients often feel powerless, as if they have no say in the health care they receive. While it’s true that the system is complex, patient awareness and grassroots movements can influence change. Patients need to be informed about the importance of choosing health care providers who prioritize patient care over profit and understand what private equity involvement means for their care.
Kevin Pho: So, it’s not just about physicians making noise; it’s about empowering patients to understand what’s at stake and pushing for change alongside the medical community.
Paula Muto: Exactly. Patients need to realize that these aren’t abstract policy issues; they have real impacts on wait times, access to specialists, and the quality of care they receive. And as physicians, we need to guide them. We should be proactive about discussing options with our patients, whether that’s recommending a cost-effective imaging center or explaining how network restrictions limit their choices. By educating patients, we build a collective voice that can push for better health care policies.
Kevin Pho: We’re talking to Paula Muto, a vascular surgeon. Today’s KevinMD article is “A Physician’s Perspective on a Crisis in Massachusetts Health Care.” Paula, as always, let’s end with some of your take-home messages for the KevinMD audience.
Paula Muto: My main message is that we need to take ownership of the state of health care. We can’t sit back and think that these problems are too big or too complicated to address. They’re not. The crisis in Massachusetts should be a wake-up call for all of us. If it can happen here, it can happen anywhere. It disrupts patient care, undermines trust, and leads to burnout for medical professionals. We need to reclaim our leadership roles, push for regulations that benefit both doctors and patients, and maintain a focus on the good stuff—training residents, practicing medicine with passion, and making sure patients are well taken care of.
And we have to be louder. Join organizations, get involved in advocacy efforts, and make your voices heard. There are opportunities, like Call on the Mall in Washington, D.C., where physicians can gather, talk to lawmakers, and push for the changes we need. We need to stay engaged and united, for ourselves and for the next generation of doctors and patients.
Kevin Pho: Paula, thank you so much for sharing your perspective and insight. And thanks again for coming back on the show.
Paula Muto: Thank you, Kevin.
