How Centene Corporation’s subsidiary Ribera Salud shaped the NHS Integration and Innovation White Paper

This is a 10K word update on Centene Corporation’s Spanish subsidiary Ribera Salud, and both companies’ establishment in the English NHS through the New Care Models programme – both of whose directors then jumped ship to Centene Corporation’s UK subsidiary Operose Health.

Starting in 2011, private health companies in the NHS Confederation, and the Kings Fund think tank, started promoting Ribera Salud as a model for the NHS. In 2012 the company gained the ear of David Cameron’s government and its model was written into the 2014 Five Year Forward View, with its emphasis on the introduction of “New Care Models.”

While the New Care Models programme was promoting Ribera Salud and Centene Corporation between 2015-2019, in Valencia the Regional Government was fighting numerous, long drawn out court battles to hold Ribera Slaud and its subsidiary B2B Salud to account for corrupt practices regarding cash for contracts for suppliers of prosthetics and drugs, overcharging the government for its Accountable Care contracts and distributing pharmaceuticals without authorisation. At the same time, as the Valencia regional government tried to enforce new legislation to end the company’s Accountable Care contracts, Ribera Salud and Centene Corporation undertook all kinds of obstructive practices.

Apparently no mention of these scandals or the Valencia government’s rejection of the entire Ribera Salud model was allowed to reach the attention of the 50 ‘Vanguard’ schemes in NHS England’s New Care Models Programme, who were on the receiving end of Centene Corporation/ Ribera Salud “advice”. This exposure intensified in 2016 and 2017 as the Valencia Accountable Care gravy train derailed and Centene Corporation used Ribera Salud to expand both companies’ presence and influence in the English NHS. Key enablers included the then Health Secretary Jeremy Hunt, the Kings Fund, the NHS Confederation – and crucially, Samantha Jones and her successor Louise Watson as the New Care Models Directors. All were only too eager to push the Ribera Salud Accountable Care model without any regard to the evidence from Spain that it was deeply flawed, susceptible to fraud and corruption and no longer welcome on its home turf.

Covid-19 was used by the powers that be to accelerate changes introduced by the New Care Models programme.Now the NHS Integration and Innovation White Paper aims to lock in the cost-cutting ‘new care models’ that were funded and promoted in 50 Vanguard schemes by Samantha Jones before she jumped ship to run the UK subsidiary of the USA Centene Corporation (from where she has just flitted to 10 Downing Street to advise Boris Johnson on NHS Transformation and social care.)

Now 90% owned by American health insurer Centene Corporation, Ribera Salud is the Spanish company that pioneered a form of Private Finance Initiative, known as the Alzira model, that covers not just buildings but “integrated” health care delivered by hospitals, GPs and community services for the whole population in designated areas.

The “Alzira” Public Private Partnership model of Accountable Care

Ribera Salud was set up as the holding company for the Special Purpose Vehicle Ribera Salud Unión Temporal de Empresas consortium. The shareholders were initially:

  • The medical insurance company Adeslas S.A. (51%)  as the technical provider of health services, with regional savings bank Agbar S.A as its majority shareholder.
  • Regional savings banks Bancaja, CAM and Caixa-Carlet by means of a jointly-controlled entity – Ribera Salud S.A.- (45%), which was the financial partner for the project.
  • Construction companies Dragados and Lubasa, which each took a 2% holding.

However, in 2010 Bancaja merged with six regional savings banks to form the Bankia group. In 2012 Bankia was bailed out by the Spanish government after declaring a profit of €328m in May and two weeks later adjusting that figure to a loss of €4.3bn. One year on, this was revised to €19bn – the largest corporate loss in Spanish history.

2011 NHS Confederation Alzira Study Visit

While all this was going on, in 2011 Nigel Edwards from the Kings Fund led an NHS Confederation study visit to the Alzira regional Public Private Partnership (also known as an Accountable Care System) for healthcare, in Valencia, Spain.

In the Alzira Public Private Partnership (Accountable Care System), the private contractor receives a fixed annual sum per local inhabitant (capitation) from the regional government for the duration of the contract and in return must offer free, universal access to its range of health services that include both primary/GP care and hospital care. It differs from previous public-private partnerships by providing the whole range of population’s healthcare. The Chairman of a UK private healthcare company who was on the Alzira study visit commented:

‘As a private sector organisation, this is and will continue to be invaluable information for our use in developing an approach to delivering services to NHS commissioners.’

The Report also noted that,

“It was clear that without the inclusion and clinical integration of primary care into the wider system, this model is unlikely to operate successfully. The importance of clinical integration, supported by incentives, information systems, clear goals and effective management, is key.”

Reading the report now that the Integration and Innovation White Paper has been published, it’s startling how congruent with the Alzira model it seems to be.

Ribera Salud’s first Public Private Partnership hospital was the Hospital de La Ribera in Alzira. It differed from UK Private Finance Initiative hospitals in that it provided the healthcare in the hospitals, as well as funding building and managing the building. The second phase of the Public Private Partnership “concession” included Ribera Salud also providing all the non-hospital health care in the local area. Soon over 20 per cent of the Valencia region was covered by similar contracts, with the Public Private Partnership model also used in an area of Madrid. All the hospitals were managed by the Ribera Salud Group.

The NHS Confederation study visit noted a number of changes that would need to take place in the NHS in order for the Alzira Public Private Partnership model to work.

These changes were pretty much all included in Simon Stevens’ Five Year Forward View and the Sustainability and Transformation Plans/Partnerships that were to carry out the Five Year Forward View.

Alzira screwed up badly but the rhetoric declared it a success story

The NHS Confederation report on the 2011 study visit to Alzira didn’t mention what had gone wrong with the Alzira Public Private Partnership/Accountable Care System from 1997-2012 – including the fact that, as with PFI contracts in the UK:

“contracts may have been designed to mitigate risks to the private sector.” (Spanish healthcare Public Private Partnerships: the ‘Alzira model’. Acerete, B., Stafford, A. and Stapleton, P. (2011), Critical Perspectives on Accounting. Vol. 22, 533-549)

The study by Dr Anne Stafford of Manchester Business School, and others, assembled evidence that the financial reality was at odds with:

“the rhetoric, which declares this project to be a success story.”

The capitation payment was set too low (204 Euros), which caused the failure of the Accountable Care System (the Ribera Salud Unión Temporal de Empresas – RSUTE – consortium). The RSUTE consortium consortium shareholders were:

  • The medical insurance company Adeslas S.A. (51%), as the technical provider of health services, with regional savings bank Agbar S.A as its majority shareholder.
  • Regional savings banks Bancaja, CAM and Caixa-Carlet by means of a jointly-controlled entity – Ribera Salud S.A.- (45%), which was the financial partner for the project.
  • Construction companies Dragados and Lubasa, which each took a 2% holding

Compensation paid out by regional government was 69.3 million Euros. The Accountable Care System consortium was re-constituted (RSUTE II) at a higher, and progressively higher, capitation amount (379 Euros in 2004 up to 639 Euros in 2012).

Under the RSUTE II consortium there were doctor shortages, a doctors’ strike and continued staff dissatisfaction. According to a study carried out by the Universities of Zaragoza/Manchester and Manchester Business School, there were allegations that the consortium ‘cherry picked’ the most profitable medical and surgical specialities. At the same time it was referring HIV and other chronic disorders to other non-RSUTE II hospitals. The annual bill for regional government was very high.

None of this bothered the Cameron Government

In 2012, Ribera Salud advised the ConDem coalition government on the preparation of a five-year plan to redisorganise the NHS, according to Valencia Plaza. In the plan – launched in October 2014 as the NHS Five Year Forward View by Cameron’s new appointee as Chief Exec of NHS England, Simon Stevens – the Alzira model was considered as a possible new management model.

Strikes and High Court drive Alzira system from Madrid as Centene Corporation tries and fails to enter the Spanish health service

But in Spain, the Alzira model was put on the back foot in 2013, when mass health workers’ strikes combined with a High Court injunction forced the resignation of Madrid’s health minister and the Madrid government’s abandonment of its plan to impose the Alzira system on six public hospitals.

At the same time, in 2013 the American sub-prime health insurance companyCentene Corporation made an unsuccessful attempt to enter the Spanish health service, through the Puerto Rican company HIMA San Pablo. It planned to build and manage three hospitals (in Parla, San Sebastián de los Reyes and Aranjuez). The project, launched by the then regional president, Ignacio González, was paralyzed by the health and justice strikes. The González government finally abandoned the plan, in which hospitals had also been awarded to Ribera Salud and Capio (today IDC Health).

Massive bank corruption scandals allow Centene Corporation to buy 50% of Ribera Salud shares

Massive corruption scandals emerged, involving 83 executives of one of Bankia’s constituent regional banks embezzling millions of euros on black credit cards. The European Commission ordered Bankia to divest and sell its shares in Ribera Salud.

In 2014 the shares were acquired by Centene Corporation, a massive beneficiary of Obamacare. In 2015 Centene Corporation had made £355m profit on income of £22.8bn.

It later emerged in a January 2016 report in the newspaper El Confidential that Centene Corporation’s purchase of Bankia’s shares was conditional on a secret agreement that the company would buy out the remaining 50% of Ribera Salud’s shares from the Bank of Sabadell in 2019. In fact that year Centene ended up buying 40% of the Bank of Sabadell shares.

Through its 50% acquisition of Ribera Salud in 2014, Centene Corporation placed part of its business in the Valencia Region, where it controlled three Hospitals in the provinces of Valencia and Alicante (Alzira, Torrevieja and Elche).

NHS Confederation promotes Alzira model following publication of the NHS 5 Year Forward View

With the publication of the NHS Forward View, the NHS Confederation’s European Office enthusiastically promoted Ribera Salud’s Alzira model:

“Following our visit in 2011, the Alzira model has attracted considerable interest in England, both politically and from the service. It has been referred to in different policy debates, and more recently featured in the Five Year Forward View as one of the models for the NHS to look at to help inform our thinking around a whole-system integration approach…it is …the right time now to reflect on our report on the Alzira model and to think whether this approach is the right one for your institution and, more importantly, your community.”

Samantha Jones appointed NHS England Director of New Care Models

In January 2015, coming from a variegated NHS executive and private company background, Samantha Jones was appointed Director of New Care Models, with responsibility for funding and directing 50 Vanguard schemes across England to set up different models of integrated care that “dissolve the traditional boundaries between primary, community, and hospital services.”

Working with the NHS Confederation, in 2015 the New care models programme provided vanguards and pioneers (sounds so old-skool soviet) with

“the opportunity to see first-hand how these care models work and learn from our international colleagues in order to assess how we could adapt these models locally and replicate some of their successes here.”

This included an October 2015 Valencia study visit for delegates to study Spain’s Alzira model in depth and consider how various aspects could be implemented in the UK.

In 2015 the Principia Multispecialty Community Provider Vanguard was set up in Rushcliffe, Nottinghamshire . It was invited by the New Care Models Programme to work with Ribera Salud and Centene Corporation to develop a cost-cutting accountable care system with a key role for a “system integrator”.

New Valencia government promises health law to end Alzira model and take the health service back into direct public management and provision, as Ribera Salud comes under police investigation for corruption

In 2015 a new Green/Podemos/Socialist coalition government was elected in Valencia autonomous region, on an electoral commitment to to take back the Alzira- model health “concessions” into direct public management and to pass a new health law to make public provision the preferred model of service delivery and define new (tighter) requirements for any future PPPs aiming to set up in the autonomous region of Valencia.

The “concession” – whereby the Valencia autonomous regional governmnent pays Ribera Salud to build and run the Alzira hospitalas well as the whole range of primary health services in its area – was not to be renewed, when it ended on April 1 2018. The company’s other concessions – which run until 2024 – were also to be taken back by the government when they ran out.

The Valencia regional government also ordered Ribera Salud to come up with audited accounts – which it hadn’t produced since 2008.

Carmen Monton, Minister of Health and Public Health in the Valencia regional coalition government, told the newspaper El Pais that for a long time the management of Ribera Salud had absolutely lacked control. The Alzira hospital had never been audited by the Comptes Sindicatura. There had been no audited accounts since 2008 and she added:

“The opacity was tremendous.”

On May 29, 2015 – five days after the left/green Coalition won the regional elections and formed the Generalitat Valenciana, Ribera Salud announced the purchase of 100% of Torrevieja Salud and Elche-Crevillente Salud and 51% of the company that managed the Alzira hospital and its health area. 

Despite this, on October 5-6 2015 NHS England’s New Care Models Programme, directed by Samantha Jones, held a Valencia study visit for delegates to study Spain’s Alzira model in depth and consider how various aspects could be implemented in the UK.

Putting the private health company genie back in the bottle

The decision by the Valencia regional government to return the Ribera Salud concessions to public hands by passing what could be seen as their version of the NHS Reinstatement Bill is an object lesson in the problems of trying to put a private health company genie back in the bottle. 6 years later, the process is still ongoing and Ribera Salud and its parent company Centene Corporation are throwing everything they’ve got into the fight.

At the same time – and a contributing factor in the coalition government’s decision to legislate to return the region’s health service to public provision – Ribera Salud came UNDER POLICE INVESTIGATION FOR EMBEZZLEMENT AND CORRUPTION.

Massive legal battles then ensued over both the regional government’s decision not to renew Ribera Salud’s “concession” and over the charge that B2B Salud, a purchasing, logistics and shared services platform that services the centres taking part in Ribera Salud Public Private Partnerships, had been making suppliers of ortho-prosthetic materials pay a “commission” to get contracts.

In Feb 2016 the Union of Public Assistance Doctors (SIMAP) received an anonymous envelope by post, with documents about an alleged collection of kickbacks from by Ribera Salud through its B2B Salud purchasing center, that “could suggest criminal activities”. The documents related to B2B Salud’s collection of commissions from suppliers of prosthetic products (namely pacemakers, intraocular lenses, breast and knee, hip and shoulder prostheses), as a condition of getting contracts to supply the Ribera Salud “concessions” of hospitals and health centers in the Alzira, Torrevieja, Dénia and Vinalopó areas.

SIMAP immediately passed the envelope and all its contents to the Economic and Fiscal Crime Unit (UDEF) of the Provincial Brigade of the Judicial Police, “due to responsibility as any citizen and in strict compliance with the law upon knowledge of a possible crime “.

Centene Corporation sets up UK subsidiary

In 2016 Michael Neidorff, CEO of Centene Corporation, told the St Louis Post -Dispatch that he wanted the company to expand into more international markets, having established a presence in Spain as joint owner of Ribera Salud.

In February 2016, Centene UK was set up by a Centene Corporation director with an address at Centene Corporation’s St Louis headquarters, with US $100 shares held by MHS Consulting International, Inc. A confirmation statement indicated that Centene Corporation was the person with significant control and that Centene UK was a business carrying out “Activities of other holding companies not elsewhere classified”.

Ribera Salud bosses present the ‘Alzira model’ to New Care Models Conference in London

At the March 2016 “Adapting international care models” conference, organised by NHS England’s New Care Models programme together with the NHS Confederation, Vanguard and Pioneer scheme delegates followed up on the 2015 study visits to Valencia and elsewhere by:

  • developing their plans for adapting these models with detailed insight and advice directly from the European and international leads
  • learning how colleagues in other vanguards and pioneers intend to implement aspects of these models locally
  • discussing with international and national leaders how we overcome the common challenges facing health and care integration and what elements all successful care models share. 

The models included:

  • Alzira in Spain
  • Jonkoping in Sweden
  • Buurtzorg in The Netherlands
  • Gesundes Kinzigtal in Germany
  • Medicaid in New York State

The session on Ribera Salud/Alzira was presented by Ealing Clinical Commissioning Group (part of the North West London Integrated Care Pioneer) and attended by Alberto de Rosa, CEO Ribera Salud and Santiago Delgado, Deputy CEO Ribera Salud.

The Ealing presentation explained that the success of the Alzira model relies on a highly integrated clinical and business model, stretching between and across primary and secondary care, the innovative use of a unified IT system across all services and a rigorous management culture requiring compliance with a set of procedures and guidelines. 

The Ribera Salud bosses’ session focussed on the Alzira model’s use of a unified IT system across all services, with a shared patient record, that is accessible to the patient, who can use this to interact with their GP. Alberto de Rosa and Santiago Delgado also showed how population level healthcare metrics, based on both patient and national data, enable targeted public health interventions and how data is used to cost and measure the outcome of each intervention, e.g. admission and readmission, in real time.

Ealing Integrated Care workshop “inspired by the success of Ribera Salud”

After the Adapting International Care Models conference Dr Serena Foo, Ealing GP Partner and member of Ealing Clinical Commissioning Group governing body, reflected that

“Ribera Salud and the Alzira model have shown…Ealing’s integrated care model… what is possible and inspired us to face similar challenges…We were inspired by the success of Ribera Salud and, as part of the new care models leadership support programme, have developed a strong relationship with them. ”

“Following their attendance at the conference, we were fortunate enough to host Alberto de Rosa, chief executive, and Santiago Delgado, deputy chief executive from Ribera Salud, who visited Ealing to help us explore these challenges. 

“On 13 May, Ealing CCG held a workshop with our Spanish guests and invited key strategic personnel from local providers. The aim was to use the expertise in the room to see whether we could find a way over the obstacles we saw, in particular those around culture change.“

Six months later Alberto de Rosa would be summoned by the Provincial Prosecutor’s Office of Valencia as ‘vicariously liable’ in its ongoing investigation of the B2B Salud cash for prosthetics supply contracts scam

After investigating the documents, in May 2016 the National Police reported to the Valencia Court of Instruction no. 4 that the matter could be criminal – in particular embezzlement of public funds and prevarication,  since prostheses are paid for by the Valencian Government. Sources familiar with the investigation said the amount of the ‘commissions’ would amount to one million euros and the investigation period extended back to May 2015.

The Police named a dozen people to the Valencia Court, specifying the responsibility they had in Ribera Salud and B2B Salud, but none had the status of accused. The Court promptly opened a preliminary investigation phase and asked for a report from the Valencia regional government Ministry of Health.

Six months later on November 4 2016, the complexity of the case was declared, which allowed the maximum period of instruction to be extended to 18 months, since the initial six months was about to run out. This gave the court more time to decide whether to turn the investigation into an accusation.

The Ministry of Health had not supplied the report, although the Minister of Health, Carmen Montón, said the Ministry was preparing to take part in the investigation. The Court had taken statements from several witnesses and more were pending. Ribera Salud declined to comment, although the Provincial Prosecutor’s Office of Valencia announced it would summon the president of Ribera Salud (who was also the CEO of B2B), Alberto de Rosa, and Pablo Gallart, executive manager of the purchasing center, to make a statement as vicariously liable in the alleged scam. Both Alberto de Rosa and Pablo Gallart were named as administrators of B2B Salud

(Alberto de Rosa is a bit of a darling of Jeremy Hunt, the Kings Fund and NHS England.

And here is Hunt’s call to denationalise the NHS and

“break down the barriers between private and public provision”.)

Valencia MPs in the coalition government also said there may be reasons to open a sanctioning file or even terminate the contract for the concessions with Ribera Salud. This followed El Espanol’s publication of an internal document from Ribera Salud’s purchasing centre B2B Salud that showed it was secretly ripping off the the Valencia regional government by billing pharmaceutical companies 10.6 million euros over six years. This rip off was based on a confidential agreement with B2B Salud that requires pharmaceutical companies to pay in cash part of the money they collect from hospitals as a percentage of sales. A commission that in the case of specific drugs exceeds 25%. In 2015, B2B Salud declared a gross turnover of 4.5 million euros.

As far as the Valencia regional government knew, the Ribera Salud concession hospitals such as Alzira, Elche or Torrevieja – which cover 636,440 potential patients – were buying drugs at an ‘official’ price set by the laboratories and approved by the regional government.

El Espanol published an infographic showing how Ribera Salud moved the public’s money out of public control into B2B Salud, by means of the secret contract with pharmaceutical companies that supply the Ribera Salud Hospitals

At the same time, SIMAP told the Ministry of Health to step up to its “responsibility to act in the face of the facts that are being verified [which] lies with the Council of the Valencia regional government, which must act in defense of the general interest…”

In 2016, the Northumbria Foundation Group hospital started its “Strategic Partnership” with Ribera Salud.

Seemingly oblivious to the company’s corruption scandals and its takeover by Centene Corporation, David Evans, chief executive of Northumbria Healthcare NHS Foundation Trust, wrote:

“To me, the real deal is about moving to the Riberia Salud-type ACO model…If many people in the NHS look up what an ACO is in the USA context, they will probably find it scary. Some American ACOs are, frankly, aggressive money-making institutions. We have aligned ourselves with Ribera Salud Grupo in Valencia. We like their concept of a truly integrated service out of hospital, run by a joined-up delivery system: that is where we want to be… We have dipped into a range of ACO-type systems around the world: the Riberia Salud model looks like it could work in the NHS.”

New commodification of health

In June 2016 Luisa Lores, a radiologist at the Pontevedra Hospital Complex and a member of the Federation of Associations for the Defense of Public Health, pointed out that health management companies like Ribera Salud are now looking at a new commodification of health. They are moving from the management of hospitals and community and GP services, to sectors such as transplants, research or big data.

Pitchbook describes Ribera Salud as a healthcare company that specializes in the areas of outpatient surgery, haematology, primary care, pharmaceuticals and biological diagnosis among others. The company was founded in 1997 and is headquartered in Valencia, Spain. It focuses on acquiring other companies that provide general healthcare services, hospital services and other medical services.

Valencia Ministry of Health takes legal action against B2B Salud’s cash for pharmaceutical supply contracts

While the Valencia anti-corruption prosecutor’s office were still investigating B2B Salud’s demands for kickbacks from suppliers of prosthetic products, in March 2017 the Ministry of Health of the Valencia regional government did open a sanctioning file against the company in relation to its secret contract for commisions from pharmaceutical companies. The Ministry of Health alleged that B2B was carrying out drug distribution activities without having the mandatory authorization.

El Confidencial reported it had seen invoices showing that B2B Salud had billed pharmaceutical companies including Merck, Janssen-Cilag and Shire Pharmaceutical, which supply drugs to public hospitals in the Ribera Salud concession, for thousands of euros for items such as “provision of advertising services”, payments for “corporate advertising” on the company website, “training sponsorships” or “administrative burdens”.

El Confidencial pointed out such kickbacks are likely to breach the Law of Guarantees and Rational Use of Medicines and Health Products and the Pharmaceutical Industry Code of Practice.

B2B Salud appealed against the Valencia regional government’s sanctioning file, despite the fact that B2B Salud’s quality committee minutes showed that their managers set goals of penetration into the pharmacy in the group’s hospitals.

Despite this, B2B Salud defended itself by saying that it did not buy or sell drugs, but was a service provider whose activity is not subject to administrative authorization. Therefore, an activity for which they were not authorized was not being carried out. B2B Salud claimed that medicines are prescribed, bought and sold directly between Ribera Salud hospitals and providers.

Samantha Jones updates on new care models progamme at Kings Fund event

Also in March 2017, The Kings Fund held an event about learning from the new care model vanguards . NHS England’s New Care Model’s Director Samantha Jones gave an update on the new care models programme. She said 2016 had been about developing and delivering new care models.

The Principia Vanguard scheme in Rushcliffe – one of many that Samantha Jones was responsible for funding and overseeing as NHS England Director of new care models – reported the New Care Models Programme

“was invited to collaborate with international experts Ribera Salud…and Centene Corporation to ‘develop an Accountable Care System’.”

A key slide in the Principia presentation shows how the Principia Vanguard model had been used as the basis for the Greater Nottingham Accountable Care System model – the successor to the Sustainability and Transformation Partnership.

Sabadell Bank and Centene Corporation take over dialogue with Valencia Regional Government, sideline RIbera Salud CEO and bring out top lawyers and Deloitte

At this point, Ribera Salud’s shareholders Sabadell Bank and Centene Corporation stepped forward to control the dialogue between the Valencia Regional Government and the Ribera Salud CEO, Alberto de Rosa.

By April 2017, El Confidencial was reporting that Ribera Salud had marshalled the legal elite and global consultancy elite against the Valencia Generalitet in its ‘Waterloo’ and

“an army of lawyers and consultants defends the concessionaire against the determination of the Valencian Government to rescue public hospitals”

This army of lawyers and consultants were hired mainly from Broseta and Cuatrecasas, two of the best law firms in Spain and Deloitte, to represent Ribera Salud’s shareholders Sabadell and Centene Corporation in all interactions with the Ministry of Health.

Sabadell also rolled out its representative Ramón Mas Sumalla, President of Ribera Salud, to negotiate with the Valencia regional government. This was agreed in a meeting around January 2017 between Sabadell and Health Minister Carmen Monton, which was also attended by Centene’s representative and vice president of Ribera Salud, Cynthia Brinkley.

Ribera Salud was trying to prevent the Valencia Regional Government from appearing in the open court case, and to backtrack on the plan to not extend the Alzira concession.

However, Montón was unmoved and announced that the administrative machinery would be set in motion to assimilate Ribera Salud’s assets and personnel in the Alzira concession, and the contract would not be renewed in April 2018. The Health Ministry also stopped B2B Salud from distributing medical supplies and opened a court file for distributing medicines without authorization (which Ribera challenged).

Another of Ramón Mas’s hot potatoes was the Dénia hospital concession, Marina Salud. Ribera Salud owned 35% of the concession, 65% was owned by the German insurance company DKV. In 2015, DKV lost 3.5m euros on the concession, which is in a poor area with big health problems, Even so, the insurer closed the year with benefits of 25.4 million, 14.4% less than the previous year. But DKV also owed Ribera Salud 16 million euros of a 28 million loan made in 2008 to undertake the construction of the Dénia hospital. This loan expiry date was December 31, 2019.

By November 2016 DKV had been trying for months to get rid of its shares and end its involvement in the concession, although the contract runs until 2024. The Valencia government was fine with this as it was a chance for them to take back the concession ahead of schedule. However they hadn’t reckoned with Ribera Salud’s right of first refusal and preferential acquisition. The right of first refusal of one and the veto capacity of the other have blocked the exit of DKV, as reported by El Confidencial.

Ribera Salud Vice President becomes Centene UK Director

In April 2017, Ribera Salud Vice President and Centene Corporation Director Cynthia Brinkley, along with fellow Centene Corporation Director Arvan Chan, became directors of Centene UK. The company’s  registered office address changed first to a cheap serviced office building in Croydon, then in October 2017 to 11-13 Cavendish Square, W1G 0AN   – same as the Kings Fund. In fact, according to a reliable source of information, their registered office was a rented room (with no phone) at the Kings Fund (according to the KF receptionist).

At their conference on Sustainability and transformation plans: moving towards implementation in May 2017, the Kings Fund hosted Ribera Salud CEO Alberto de Rosa who presented a session on ‘From hospital to population health management’.

In the summer of 2017 Samantha Jones left her job as NHS England new care models director and was replaced by Louise Watson, now Operose Health Chief Integration Officer

Greater Nottingham Sustainability and Transformation Partnership pays Centene Corporation £2.7m to turn it into an Accountable Care System based on the Ribera Salud/Alzira system

In August 2017 Centene Corporation was hired by Greater Nottingham Accountable Care System via a £2.7m contract brokered by the notoriously useless company, Capita. The subcontract was to pay Centene Corporation as “system integrator” to set up Greater Nottingham Accountable Care System along the same lines as Ribera Salud’s discredited Alzira model of public/private partnership.

Greater Nottingham Accountable Care System – and the other handful of Sustainability Partnerships that were to become Accountable Care Systems in April 2018 – were under instructions from NHS England to partner with organisations across the world with experience of Accountable Care Systems.

Earlier in the summer at an NHS Confederation event in Liverpool, NHS England boss Simon Stevens said that a number of areas of the country, covering seven million people, would be designated as “accountable care systems” (ACS) in April 2018, which would allow commissioners and providers to bypass tendering and competition rules.

In a Nottingham West Clinical Commissioning Group meeting in December 2017, Toby Douglas, Centene’s then-Senior Vice President for Medicaid Solutions, said the Accountable Care System,

“would agree from looking at projections what they would expect from savings in the system overall, and pay the integrator accordingly”.

Given these Greater Nottingham Accountable Care System “savings” should be in excess of £700m over 5 years, the system integrator could siphone off a lot of the NHS’s money. At that meeting – having left her NHS England job as New Care Models Director – Samantha Jones acted in an advisory role for Centene and recommended a 25-30% cut in secondary care activity to bolster savings.

Ribera Salud creates a joint venture diagnostic company in Slovakia

Centene apparently bought into Ribera Salud as a way into the EU (and Latin America).

On 2nd August 2017,  Ribera Salud/Centene  created a joint venture SP PDG: Pro Diagnostic Group, in Bratislava, Slovakia.

Its partners are investment holding company Pro Partners Holding of Bratislava, and Nephros S.R.O. which describes itself as a large organization in the health practioners industry that generates $5 million in annual revenue.

A Slovakian website described Pro Diagnostic Group as a target company that provides healthcare in the field of radiology and nuclear medicine (magnetic resonance, PET/CT, X-ray, ultrasonography) in non-state medical facilities, through 6 Slovakian companies that between them operate 8 MRI facilities, one PET/CT centre and one radiology centre providing CT, USG and X-ray examinations.

Valencia court brings criminal charge against B2B Salud and the Ministry of Health fines the company for distributing medicnes without authorisation

In September 2017, following the Valencia anti-corruption prosecution office’s investigation, a criminal charge was brought against B2B Salud for charging illegal commissions to suppliers of the health departments its parent RIbera Salud manages.

The same month The Ministry of Health fined B2B Salud 30,001 euros, for lacking authorization for the distribution of medicines. This followed a decision by the Spanish Agency for Medicines and Health Products (AENPS), which considers that the activities carried out by the B2B Salud purchasing center “are typical of a distribution entity” so the company should have requested an authorization.

Ribera Salud/Centene Corporation look to the UK

In February 2018, Valencia Plaza reported that Ribera Salud and its parent Centene Corporation were looking more closely at the United Kingdom every day. Ribera Salud had recently appointed Alan Milburn , former British Minister of Health in the Blair government, as independent director of the Valencian company in order to “continue with the company’s expansion plans.” And during the recent visit to Valencia by Simon Manley, United Kingdom ambassador to Spain, Ribera Salud was very interested in contacting him and explaining the company’s plans. This was done by an executive of Centene UK.

Ribera Salud had begun to seek its survival outside of Spain, given that its concession for La Ribera/Alzira health area would end on March 31 2018, and it was in permanent conflict with the Ministry of Health over the immediate reversion of the Denia Hospital/ La Marina concession. As well as closing the purchase of 34% of the Slovak firm Pro Diagnostic Group (PDG) in 2017, in South America, it had a presence in Peru, where it has a minority stake in two hospitals in Lima, and in Colombia. Will the UK be the next stop? Valencia Plaza asked.

Ongoing court case about 103m euros Ribera Salud owed the Valencia Government from 2013-2015

On 1 April 2018 the Ribera Salud Alzira concession reverted to the Valencia regional government, amid an ongoing court case about 103m euros that the government claimed the company must repay in respect of the settlements in 2013, 2014 and 2015. This was because Ribera Salud had added too many health records, and because of the fact that public health had taken over the more expensive health treatments, for example, cancer treatments.

Ribera Salud had consistently denied it owed the government money – but 3 days later in , the manager of the health department of La Ribera, Javier Palau, created a public relations disaster when he publicly acknowledged to journalists that Ribera Salud could have about a 50 million euro debt for the settlements with the Generalitat. Half of the 103 claimed by Health.

Ribera Salud desperately tried to correct Palau. They said the numbers were not final and the situation in the courts would be clarified.

Podemos criticises Health Minister’s decision to drop private prosecution of B2B for prosthetic suppliers’ kickbacks

Also in April 2018, the magistrate provisionally dismissed the case against B2B Salud for allegedly making suppliers of ortho-prosthetic materials pay a “commission” to get contracts. The Valencia regional government Health Minister, Carmen Montón, announced that on the recommendation of the Legal Services of the Generalitat (regional government), they were not going to continue with their private prosecution against B2B.

The Podemos Health spokesperson Daniel Geffner criticised the decision. He said,

“the Alzira model has generated business niches by creating front companies such as B2B Salud, which serve to hide profits and charge scandalous commissions of up to 40 percent…for the sake of transparency and the defense of the interests of the Valencian men and women, it would be best to continue with the case until there were no margins of doubt.”

He wondered if there had been

“an agreement between Ribera Salud and the Generalitat to let the judicial procedure die through pressure from the American embassy or Centene advisers, or to use it as a bargaining chip to reach agreements to negotiate Denia shares.”

This suspicion seemed reasonable – according to an April 2019 report by El Mundo, in November 2018

“The proof of the new spirit shown by the Ministry of Health with Ribera Salud was already appreciated …when senior executives of Centene Corporation, the 50% shareholder of the company present in the Torrevieja, Dénia and Vinalopó hospitals, were received by the Minister of Health, Ana Barceló,”

El Mundo also reported that the Valencia regional government President was making a final attempt to reach an agreement to start the process of reverting the Denia hospital to public ownership and management. DKV was reportedly holding out for more money but Ribera Salud – with American capital – was ok with the offer.

Centene Corporation buys Madrid hospital from insurer Sanitas

In December 2018, apparently anxious not to lose Ribera Salud’s “market share” after the Valencia Government took back the Alzira concession in April 2018, Centene Corporation bought the Torrojon Hospital in Madrid from the insurer Sanitas. With this transaction, Centene owns 89% of the University Hospital of Torrejón, and Ribera Salud would take over management of the center.

Immediately afterwards, Centene Corporation and Ribera Salud began negotiations to buy Sanitas’s Manises Hospital in Valencia. 

Centene Corporation hands control of Centene UK to another of its UK subsidiaries

In February 2018 Centene Corporation ceased to be a person with significant control of Centene UK and handed significant control to another of its UK subsidiaries, MH Services International (UK) Limited.

Centene UK is an approved supplier on the new NHS England Health Systems Support Framework

In 2018 NHS England set up the Health Systems Support Framework. The quango estimated that £300m of business would be done through the Framework over four years.

Following its 2017 Capita subcontract as System Integrator for the Greater Nottingham Accountable Care System, Centene UK was listed on 9 of the 10 lots on the new Health Systems Support Framework.

The new Framework has the explicit function of providing the “support services” needed to get Integrated Care Systems up and running. Specifically:

“digitisation of services and the use of data to drive proactive population health management approaches across Primary Care Networks (PCNs) and integrated provider teams.”

This means companies on the Framework are authorised to sell NHS commissioners/ Integrated Care Systems the skills and software required to analyse patients’ confidential GP records and identify those deemed to be at risk of costing the NHS a lot of money.

The accreditation of companies through the Health Systems Support Framework amounts to the privatisation and Americanisation of NHS Commissioning: Commissioners are required to pay private companies to do the work for them of setting up and using a commercial insurance-based model within the NHS shell of Integrated Care Systems.

Samantha Jones becomes Centene UK CEO

In January 2019 the former NHS England Director of New Care Models Samantha Jones became CEO of Centene UK, along with 3 Centene Corporation Directors including Cynthis Brinkley, Vice President of Ribera Salud. Samantha Jones also became Director of 9 other Centene Corporation UK subsidiaries. She said

“Centene has significant experience that we can learn from, as 95 per cent of the revenue is Government-funded…[Centene UK] are effectively a start-up in a large global company, with the aim of supporting and enabling integration in the health and care sector in this country. What I do know is that the capabilities and work in integrated population health systems in Ribera Salud in Spain and from the US, which are supported and backed by Centene are those which we could capture and use in the UK…Our role at Centene… is to enable the Foundation Trusts, Community Trusts and local authorities to do the work that needs to be done to support system integration.”

The Valencia regional government’s battle to recover the Ribera Salud concessions was not over

In January 2019 the Valencia regional government told the Marina Salud concessionaires Ribera Salud and DKV that it would acquire their shares and Marina Salud would then become a public company. After a subsequent meeting of senior officials of the Health Ministry with the Denia Hospital workers, Workers’ Commissions said that the senior officials had told them that negotiations were continuing with good will by the three parties (Ministry of Health, DKV and Ribera Salud) and that the intention was to close an agreement soon, before elections.

In early April 2019 the president of the Valencia regional government, Ximo Puig, said the start of the reversal process of the Dénia health concession will be signed with or without an agreement with the concessionaire, Marina Salud. This was made up of the insurer DKV (65% of the shareholders) and Ribera Salud (35%) The Ministry of Health confirmed that it had ordered the start of the necessary actions to allow, through the most appropriate legal instrument, the rescue for the direct public management of the Department of Health of Dénia-La Marina

13m euros repaid by Ribera Salud for overcharging Valencia government

On 23 June 2019 agreement was reached on the 2013, 2014 and 2015 settlements – that Ribera Salud should repay the government 13m euros as the difference between what was paid by the government and what was actually spent by Ribera Salud.

The 13 million sum is very similar to a payment of 12.6 million made by the Generalitat (Valencia regional government) to Ribera Salud in November 2018 for an alleged unfair enrichment for services provided in 2014 and 2015.

The agreement was made official in the Official Gazette of the Generalitat Valenciana (DOGV) in March 2020, that the concessionaire of the Ribera Salud privatized hospitals must return to the Valencian Generalitat 13 million euros of the settlements for the years 2013, 2014 and 2015. This was approved in the plenary session of the Council on 13 March 13.

Centene Corporation increases its share of Ribera Salud to 90%

In July 2019 Centene Corporation’s share of Ribera Salud increased to 90% when it bought an additional stake in the company from Banco Sabadell. (This bore out the January 2016 report in the newspaper El Confidential that Centene Corporation’s purchase of Bankia’s shares in 2014 was conditional on a secret agreement that the company would buy out the remaining 50% of Ribera Salud’s shares from the Bank of Sabadell in 2019.)

Ribera Salud acquires first hospital in Central and Eastern Europe

Spanish hospital PPP operator Ribera Salud acquired its first hospital in Central and Eastern Europe in late 2019, when it bought the bariatric-focused OB Klinika in Prague through its Slovakian subsidiary Pro Diagnostic Group (PDG), acquired in 2017.

OB KLINIKA’s website claims proof of its leadership in the local healthcare market is that the multinational healthcare company Johnson & Johnson has chosen it to be their training center for the Central and Eastern Europe region,  and that it “cooperates in important investigations with Imperial College, London, and Sahlgrenska University Hospital in Sweden.” 

OB Klinika is a Mediczech company and Mediczech is a brand of Progress Medical, Inc – a specialized investment company owning a portfolio of healthcare investments in the Czech Republic. MediCzech says it is a leading medical tourism facilitator providing high quality inbound medical tourism services in the Czech Republic.

MediCzech arranges for medical treatments primarily in clinics directly owned by Progress Medical.

Centene UK changes its name to Operose Health

According to documents filed with Companies House, Centene UK changed its name to Operose Health in November 2019.

The company’s links with NHS England’s New Care Models Programme extend beyond the Operose Health Director and CEO Samantha Jones (the former New Care Models Programme Director from 2015-2017). Operose Health’s Chief Integration Officer Louise Watson succeeded Samantha Jones as New Care Models Director 2017 – 2019) and Operose Health’s Chief Medical Officer Dr Nick Harding formerly worked at NHS England on secondment as Senior Clinical Advisor for the NHS England Accountable Care Systems’ Primary Care Development Programme and for Right Care. (Right Care is a set of spending benchmarks authorised by NHS England that’s widely used in various Integrated Care Systems to “standardise” commissioning of elective/planned operations – which ends up meaning “cuts”).

Operose Health, which advertises itself as a health system support company, took over Centene UK’s position as an approved supplier for 9 of the 10 lots on NHS England’s Health Systems Support Framework although the name has not changed on the Framework.

Valencia Ministry of Health refuses to extend Torreveija concession

In January 2020 Ribera Salud launched a counteroffensive over the October 2021 reversion of the Torrevieja concession/Department of Health, which covers 10 municipalities including Orihuela. It promised that that it would build a 2nd Orihuela Costa Health Centre in the Orihuela municipality – but only if its management concession was extended beyond 2021.

The Ministry of Health asked for an urgent meeting with the mayor of Orihuela, Emilio Bascuñana, to discuss the construction of the new health centre in Orihuela Costa that would meet the needs of the population. The Orihuela council insisted that the Health Ministry should authorise construction. The only health centre that is dedicated to the Orihuela Costa, and which serves more than 30,000 residents, is far too small.

The next day the Valencian Minister for Public Health, Ana Barceló confirmed there would be no five-year extension for Ribera Salud, and she will bring the region’s medical facilities back into the public domain when the Ribera Salud management contract expires in October 2021.

Ribera Salud and Centene Corporation agree a deal to buy Manises Hospital in Valencia without Ministry of Health approval

In March 2020 Ribera Salud and its US parent company Centene Corporation agreed a deal with Sanitas to buy Manises Hospital in Valencia – without the approval of the Ministry of Health. This defied the Valencia regional government’s change to the Valencian health law in 2018, that prevents the same company from controlling more than 40% of the shareholding if it has another concession. If Ribera Salud bought the Hospital de Manises, it would control all the Valencia privatized hospitals, including those in Dénia, Elx-Vinalopó and Torrevieja. 

Ribera Salud said that the Generalitat could not stop its purchase of Manises Hospital if the National Markets and Competition Commission authorized it, since the Generalitat is not the only one authorized to put limits on free competition. If the Department tried to stop the operation, the case would probably end in court. Industry sources explained that Ribera Salud understood that the Health Law would not prevent them from buying the shares that Sanitas has in the Manises hospital because their “only” obligation is to inform the Ministry of Health of the share movements. A priori consent would not be necessary, the sources explained. 

The date for the sale of Manises Hospital was expected to be April 1 2020, pending due diligence. But then Ribera Salud postponed the purchase because the health and economic uncertainty caused by the epidemic had paralyzed the negotiations.

Ribera Salud and Sanitas had built the Hospital de Manises through a joint venture formed 60% by Sanitas and 40% by Ribera Salud, which managed the center and the entire health area through concession until the end of 2012. Then Ribera Health, at the request of its then 50% shareholder Bankia – affected by the rescue approved by the EU – was forced to sell the Manises and Torrejón hospitals . They were bought by Sanitas, which paid 77.6 million euros for 50% of the Madrid Torrejon hospital – the other half belonged to Asisa – and 40% of the Valencian Manises hospitals.

Valencia Ministry of Health starts process of taking back Ribera Salud’s Torrevieja concession

In October 2020, the Valencian Ministry of Health again gave notice that it would not extend Ribera Salud’s management contract for the Torrevieja Department of Health, and was initiating an end to the current agreements in October 2021.

The Valencian Government Minister, Ana Barceló, said

“The Generalitat [autonomous regional government of Valencia] thus complies with its election manifesto which specifies: “We will continue working for the recovery of privatised public services once current concessions are ended with a common policy that guarantees a better, more equitable, efficient and quality service and that does not entail economic damage for the Generalitat.
“The importance of strengthening the public health system has also been reinforced at this very important time where the pandemic has required an unprecedented mobilisation of human and economic resources,” the minister added.

Barceló said that the decision has been made exclusively on the basis of efficiency:

“Investment in improving the health of Valencian people cannot be conditioned on cost reductions aimed at obtaining benefits. The only criterion must be that of health efficiency from the optimisation of the necessary resources to adequately cover the demands of the population.“

Ribera Salud fails to comply with the Torrevieja reversion procedure

Under the procedure set out by the Ministry for Health, Ribera Salud had a deadline of December 1, 2020 to comply with the reversion procedure for the Torrevieja concession. But in November 2020 the company filed an appeal to the Valencia Superior Court of Justice (TSJCV) asking for suspension of the reversion procedure because the pandemic made it impossible for them to follow the rules. The Valencia Superior Court of Justice denied Ribera Salud’s request for suspension of the reversion procedure but granted an extension until 31 March 2021. Ribera Salud did not present the required documents by then and has filed a new appeal. Meanwhile the uncertainty is causing front line staff to leave and stopping new staff from replacing them.

Ribera Salud CFO becomes Vice President of Finance, Europe, of the Centene Corporation Group.

In February 2021 Pablo Gallart became Vice President of Finance, Europe, of the Centene Corporation Group. (In 2016 he had been summoned by the Valencia Court to make a statement in his role of executive manager of the B2B Salud purchasing center, as vicariously liable in the company’s alleged kickbacks from prosthetics suppliers scam.)

Operose Health buys 375K London patients in acquisition of 34 Alternative Provider GP contracts from London Doctorpreneurs

In February 2021 the Centene Corporation’s UK Subsidiary Operose Health bought London’s biggest GP provider, AT Medics Ltd, in a secretive process that began on 15 November 2020 with the submssion of a change of control request from AT Medics to SW London Clinical Commissioning Group

The process involved 13 Clinical Commissioning Groups. It only came to light after Operose Health acquired AT Medics’ 5 companies on 10th February 2021, bringing the number of Samantha Jones’ Centene subsidiary directorships to 16.

Samantha Jones leaves Operose Health to become Prime Minister’s adviser on NHS Transformation and social care

On 30th March 2021 Ms Jones, who had just been appointed to a civil service post as Boris Johnson’s health adviser on NHS Transformation and social care, resigned all her directorships of Centene Corporation’s UK subsidiaries except Operose Health Corporate Management Ltd. Shortly after, she also resigned that directorship.

Elizabeth Perry, the Operose Health Chief People Officer, replaced Samantha Jones as Director of 16 Centene Corporation UK subsidiaries. Elizabeth Perry has no NHS experience. She previously worked at IBM, Arthur Andersen Business Consulting and RSM and her industry background includes technology, retail and pharma.

According to the Health Service Journal, at 10 Downing Street Samantha Jones will be working with Boris Johnson’s special political adviser on health, Will Warr – a former lobbyist at the firm of Lynton Crosby, who masterminded numerous Conservative Party election campaigns and Johnson’s successful 2008 London mayoral bid:

Open Democracy reported that,

“Warr described the NHS as ‘outdated’ in a Telegraph article penned shortly before he and Johnson entered Downing Street last year, suggesting that the incoming prime minister should ask himself: ‘If I created the NHS today from scratch, what would it look like?’ Warr answered: ‘Nothing like the monolith we have today.’”

As Johnsons’ adviser on NHS Transformation and social care, Samantha Jones will also be working with management consultancy McKinsey alumnus Adrian Masters – another key Johnson health adviser. Adrian Masters played a key role in shaping the last major piece of NHS legislation, the 2012 Health and Social Care Act. McKinsey was reported to have drafted large parts of that bill.

According to Open Democracy, Adrian Masters re-joined Number 10 in 2020 as civil service policy lead on a secretive “No.10 Health and Social Care Taskforce”, where he advised on elective care recovery. The Taskforce reported to a Steering Group chaired by Munira Mirza, the influential head of Boris Johnson’s policy unit, that met weekly from July to September with a further meeting in October. Open Democracy added,

“Mirza’s leading role and the lack of leaders from the Department of Health suggest that [the taskforce’s] work is politically focused…
Both the Department of Health and the NHS now appear to be taking a back seat in policymaking. Stevens is not on the task force, and none of the four top senior servants in charge comes from the department.”

The NHS Integration and Innovation White Paper that Matt Hancock laid before Parliament on February 11th 2021 proposes that private companies’

“ongoing role in complementing NHS provision would continue; through national and regional procurement exercises as are currently underway to boost NHS capacity to provide elective services; and through simplified AQP arrangements.”

(7.4 NHS Provider Selection Regime Consultation document February 2021)

The “elective recovery” policy is to create a bonanza for private companies, through yet another NHS England framework agreement, and a “simplified” Any Qualified Provider list for GP referrals to elective care that would allow the statutory Integrated Care System NHS Boards envisaged in the White Paper to pre-select companies without any procurement process. All the Integrated Care System NHS Boards would have to do is “demonstrate the providers meet the stated service conditions”.

In December 2020 NHS England published the £10bn Increasing Capacity Framework – Provider List. This is a lengthy list of private health companies including Operose Health (plus 2 London NHS hospitals), that NHS hospitals can contract to help clear the huge waiting list for elective hospital care – particularly for cancer diagnosis and treatment – that has built up because of the government’s response to Covid19.

NHS hospitals can pay the Increasing Capacity Framework providers to carry out:

  • NHS inpatient and day case services (including full supporting pathology and imaging) and urgent elective care and cancer treatment in line with nationally set criteria;
  • NHS Diagnostic Services;
  • Clinical facilities and related services (the ‘Services’).

One comment

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.