This is granular. Going over the basics here. Statues and Regulations are what most people have a working knowledge of. It is the guidance -the "sub regulatory" where the trouble lies. Unfixed and can change overnight.

📁MF #115 The Knowledge Is Already Here Organizational capacity begins with what people already know. A CNA may notice a subtle change in a resident because she has seen that person through many ordinary shifts. A nurse brings clinical assessment and knowledge of the resident’s condition. A family member may recognize a familiar expression, routine, or shift in personality that no one else has seen. Environmental and housekeeping staff may notice patterns in the surroundings that affect comfort, movement, or daily life. Each person sees from a different position, and each position reveals something. Together, these perspectives build a fuller understanding of the work and the people it serves. The opportunity for an organization is to recognize this knowledge, understand what each kind contributes, and create reliable ways for it to inform decisions. When observations can travel across roles and reach people who can act on them, experience becomes an organizational resource. The first step toward renewal is learning to see what is already there. @consumervoices @NYNHCare @INOmbudsman Ask Better Questions.

📁WF #17 Capacity for Self-Renewal An organization’s capacity for self-renewal is its ability to learn from its own work, connect what it knows, and develop new ways of meeting its purpose. Every organization has resources. People bring experience, judgment, technical knowledge, relationships, and pattern recognition. Processes and programs supply structure. Leadership sets priorities and allocates resources. The real question is how these elements work together—and what becomes possible as a result. Some resources keep daily operations running. Others enable people to learn, share knowledge across roles, and build capabilities that strengthen the whole organization. Seeing the difference means looking at the organization’s composition: what its parts do, how they relate, and what emerges when they work in concert. Capacity develops through use. Assessment establishes Point A—coordinates clear enough to understand where you stand. Point B remains in view. The work itself builds the road between them. This week we examine how an organization recognizes the capacity it already has, creates the conditions for that capacity to grow, and carries learning into practice. What does an organization need to understand about itself to renew its capacity? @mtaylorstark @ConsumerVoices Ask better questions.

The parenthetical on Great Bend and the “at least 25” figure do broaden the piece beyond the Marshall–Tasset facts. The sharper claim is the one right before it: PE securing doctors as owners “in name only” so the vehicle can still claim the physician-ownership advantages while the equity and extraction sit with the sponsor. @CMAorg That’s the pattern that shows up across the PE footprint—roughly 9–10% of hospitals and 10–12% of nursing homes, with several firms accelerating acquisitions during COVID. Clicking the red underlines in that section pulls up the underlying sources (including the Great Bend docket). The disclosure-compliance suit against Great Bend was dismissed without a finding of liability, so it doesn’t itself prove the model is corrupt. It does illustrate how contested the “physician-owned” label has become once PE is involved. The ACA restrictions on self-referral were aimed at the risk that physicians would steer volume to facilities they own. A PPO network has its own version of that incentive: the plan profits by keeping care inside the contracted network and limiting out-of-network options. Both arrangements create structural pull toward preferred facilities; the difference is who captures the margin and how visible the ownership is.

The piece isn’t treating all physician-owned facilities as the problem. It specifically flags how PE has co-opted the label—“securing doctors who are hospital owners in name only”—so the vehicle can claim the advantages of physician ownership while the equity, control, and extraction sit with the PE sponsor. That’s the pattern Maureen has tracked for years: physicians lend their names and licenses, PE runs the financial engineering. The Marshall–Tasset/Nueterra examples are presented as instances of that, not as an attack on independent physician-led models. @moetkacik

Good one! The interest compounds either way. One path just has a lower rate and a better maturity date.

📁MFR*V #114 — The Power of Unity: What Becomes Possible Together? This week began with a deceptively simple proposition: the power of unity lies in the value of people. Each person brings knowledge, experience, judgment, ability, and potential. That capacity exists before people assemble. The organizational question is how to recognize its value and create conditions in which it can contribute to a shared purpose while allowing individuals to retain their distinct perspectives and strengths. A shared point of orientation brings those distinctions into relationship. Relationships allow knowledge to travel, perspectives to inform one another, and contributions to build on what others have already accomplished. In this way, a collection of capable people can develop shared capacity that no individual possesses alone. Shared capacity changes what a group can sustain. Unity can become load-bearing: people together can carry weight that would otherwise overwhelm individuals. Participation can expand individual capacity while strengthening the group's ability to meet demands, solve problems, and support its members. The process can become self-generating. The work changes the people doing it; those people change what the group can do; and the group's growing capacity changes what becomes possible next. New knowledge, stronger relationships, and new resources can expand the field of possibility still further. Yet these outcomes depend on the conditions in which people work. People can influence some of those conditions, and institutions have considerable power to shape them. Institutional decisions can cultivate the capacity on which an organization depends, or erode the resources and relationships that sustain it. When those supports are diminished, the burden shifts to individuals and residents. Calling for unity cannot excuse that transfer of burden. The question, then, is whether an organization enables people to develop their capabilities, support one another, and build a capable whole—and whether it takes responsibility for sustaining the conditions that make this possible. The week's progression MF #107 — The Value of People: Recognizing the capacity people bring and the potential that remains undeveloped. MF #108 — A Shared Point of Orientation: Bringing different perspectives into relationship with a common purpose without requiring uniformity. MF #109 — The Work Between Us: Understanding how relationships transform individual capability into shared capacity. MF #110 — The Weight We Carry: Recognizing unity as load-bearing capacity, not merely the redistribution of tasks. MF #111 — A Whole That Generates More: Exploring how collaboration can renew and expand the capacities of both individuals and the group. MF #112 — Changing the Conditions: Recognizing people's ability to create new relationships, resources, and fields of possibility. MF #113 — The Institution We Make Possible: Examining whether organizational decisions cultivate human capacity or consume it. Reflection Unity is not sameness. It allows people to bring distinct capacities into relationship with a shared purpose, even when their perspectives differ. Its strength lies in the relationships that enable people to contribute, learn, and build on one another's work. When those relationships are supported, the group can carry more while individuals gain capacity of their own. At its most generative, unity creates conditions for further growth. Shared purpose provides orientation. Relationships make cooperation productive. Stewardship determines whether the resulting capacity is cultivated and sustained. The power of unity lies in the value of people—not only in what they bring, but in what they can develop, sustain, and create together. Looking forward Unity opens the possibility of shared capacity. The next question is how that capacity develops within the systems where people work. How does shared knowledge become collective intelligence? How does collective intelligence inform decisions? And what organizational structures allow human capacity to travel through a system and become reliable institutional capability? These questions lead toward the next focus: Capacity for Self-Renewal. We will examine how organizations recognize the capacity they already possess, develop it through the work itself, and create the conditions to move toward what becomes possible next. Unity establishes what people can begin to accomplish together. Self-renewal asks how that capacity can continue to develop. @NYNHCARE @mtaylorstark @INOmbudsman Ask Better Questions. #TheMossFiles #AskBetterQuestions

Living on their own terms When asked how easily they can live life on their own terms, 20% of residents said very easily. Forty-three percent said it is somewhat or very difficult, and 18% said very difficult. The comments explain why. Residents described being woken at 4 or 5 a.m. for medications, showers given when it suits the schedule, and no one asking what time they would like to get up. The report’s conclusion is worth sitting with: even the residents with the better experiences were mostly adjusting to the building’s schedule, not the other way around. When the schedule belongs to the building and not the person, what exactly is the resident adapting to? @mtaylorstark @ConsumerVoices Ask Better Questions theconsumervoice.org/wp-cont…

Capacity for Self-Renewal What makes an organization capable of improving itself? W. Edwards Deming directs our attention to the system: how work is designed, how people are supported, and how management shapes the conditions for results. Peter Senge takes us into the learning organization, where people develop the ability to examine assumptions, recognize patterns, and learn together. Put these ideas alongside each other and an important question emerges: Does the organization have the capacity to learn from its own work—and use what it learns to improve what becomes possible next? That is the deeper promise of continuous improvement. Each cycle of learning can strengthen the organization's capacity for the next. Where does that capacity for learning actually live in an organization? @INOmbudsman @ConsumerVoices Ask Better Questions.

The Obamacare Boiler Room Perhaps no Florida health care scam has so concisely illustrated the burning need to rethink our broken health care system. Just miles from Mar-a-Lago, two men are on trial for allegedly defrauding Obamacare of $161 million through the Fiorella Insurance Agency. Their scheme? Classic Florida style: recruit homeless and vulnerable people at bus stops, shelters, and clinics with cash, gift cards, food, and alcohol. Coach them to lie about income, get kicked off Medicaid, use fake SSNs and addresses, then enroll them in subsidized ACA plans—often high-deductible bronze plans from Centene’s Ambetter that leave patients with massive bills and denied claims. Prosecutors say this one operation generated $162 million in fraudulent subsidies over four years. Broader complaints to CMS hit 208,000 in just eight months of people fraudulently switched onto ACA plans. Between 2020 and 2025, the annual cost of ACA marketplace subsidies nearly tripled—from $53 billion to over $143 billion. Florida alone went from ~1.4 million enrollees to nearly 5 million. Much of the growth was driven by these boiler-room tactics in non-expansion states, cheered on by private equity (Fiorella was bought by GTCR-backed AssuredPartners, later sold for $13.45 billion). Enhanced subsidies made the system explode—and made the fraud more lucrative. Now the enhanced credits are expiring, premiums are set to skyrocket, and millions face the cliff. This isn’t a glitch. It’s the predictable result of a system built on private brokers, private insurers, and incentives that reward enrollment over care. Full investigation: prospect.org/2025/11/18/obam… @CMAorg @jordanrau @DutchRojas @mtaylorstark @JaniceDean #ACA #Obamaca #HealthCare #PrivateEquity Ask Better Questions

📁MF #113 — The Institution We Make Possible There is a caution we must carry into any discussion of unity: we cannot build shared capacity by systematically diminishing the capacity of the people and organizations expected to provide care. The corporatization of healthcare, including the role of private equity in nursing homes, raises serious questions about the relationship between financial priorities and operational capability. The concern is not simply who owns an organization. It is what its operating decisions do to the conditions that make reliable care possible. When staffing, continuity, institutional knowledge, and the resources required for daily operations are eroded, the consequences extend beyond a list of missing positions or reduced expenditures. Relationships fracture. Knowledge is lost. People have fewer opportunities to learn from one another and less capacity to respond to what they know. The burden migrates to those who remain: frontline workers, nurses, administrators, families, and ultimately residents. Financial performance is not the same as operational capacity. An organization may become more effective at meeting financial targets while becoming less capable of delivering consistent, responsive care. The ability to produce a favorable financial result does not, by itself, demonstrate the ability to sustain the work on which that result depends. Nor should the language of teamwork be used to make depleted people responsible for compensating for a depleted institution. A capable workforce cannot indefinitely substitute for the staffing, continuity, authority, resources, and relationships required to support it. This brings us back to the value of people. People are not merely the means through which an institution accomplishes its purpose. They are the source of its capacity to accomplish that purpose. In long-term care, the resident is not an exception to organizational operations or a burden to be managed. The resident's personhood, preferences, knowledge, and agency are central to the purpose the organization exists to serve. Unity is not a demand that people endure more. It is the development of a whole capable of supporting its members, using their knowledge, sharing responsibility, and generating further capacity. That requires stewardship of human capacity—not its extraction. Does this institution cultivate the capacity of its people, or depend on them to compensate for what it has depleted? @mtaylorstark @LTCconsumer #TheMossFiles #AskBetterQuestions