Study: Higher Death Rates and Taxpayer Costs at Nursing Homes Owned by Private Equity

About 1 in 10 nursing homes in California and nationwide are owned by private equity (PE) investors, and new research suggests that death rates for residents of those facilities are substantially higher than at institutions with different forms of ownership.

Essential Coverage

Researchers from New York University, the University of Chicago, and the University of Pennsylvania found that the combination of subsidies from Medicare and Medicaid alongside incentives for PE owners to increase the value of their investments “could lead high-powered for-profit incentives to be misaligned with the social goal of affordable, quality care [PDF].” The researchers — Atul Gupta, Constantine Yannelis, Sabrina Howell, and Abhinav Gupta — reported that nursing homes owned by private equity entities were associated with a 10% increase in the short-term death rate of Medicare patients over a 12-year period. That means more than 20,000 people likely died prematurely in homes run by PE companies, according to their study, which was published in February by the National Bureau of Economic Research (NBER).

In addition to the higher short-term death rates, these homes were found to have sharper declines in measures of patient well-being, including lower mobility, increased pain intensity, and increased likelihood of taking antipsychotic medications, which the study said are discouraged in the elderly because the drugs increase mortality in this age group. Meanwhile, the study found that taxpayer spending per patient episode was 11% higher in PE-owned nursing homes.

Double-Checked, Triple-Checked, Quadruple-Checked

The researchers were stunned by the data. “You don’t expect to find these types of mortality effects. And so, you know, we double-checked it, triple-checked it, quadruple-checked it,” Atul Gupta, a coauthor of the NBER study, told NPR reporter Gabrielle Emanuel.

There’s nothing new about for-profit nursing homes, but private equity firms are a unique subset that in recent years has made significant investments in the industry, Dylan Scott reported in Vox. PE firms typically buy companies in pursuit of higher profits for shareholders than could be obtained by investing in the shares of publicly traded stocks. They then sell their investments at a profit, often within seven years of purchase. They often take on debt to buy a company and then put that debt on the newly acquired company’s balance sheet.

They also have purchased a mix of large chains and independent facilities — “making it easier to isolate the specific effect of private equity acquisitions, rather than just a profit motive, on patient welfare.” About 11% of for-profit nursing homes are owned by PE, according to David Grabowski, professor of health care policy at Harvard Medical School. The NBER study covered 1,674 nursing homes acquired in 128 unique transactions.

While the owners of many nursing homes may not be planning to sell them, they also have strong incentives to keep costs low, which may not be good for patients. A study funded by CHCF, for instance, found that “early in the pandemic, for-profit nursing homes had COVID-19 case rates five to six times higher than those of nonprofit and government-run nursing homes. This was true of both independent nursing homes and those that are part of a corporate chain.”

Nationallyabout 70% of nursing homes are operated by for-profit corporations, 24% of nursing homes are nonprofit, and 7% are government-owned. Corporate chains own 58%. In California, 84% of nursing homes are for-profit, 12% are nonprofit, and 3% are government-owned, according to the CHCF report.

Growing PE Investment in Health Care

Given the dramatic increase in PE ownership of nursing facilities coming out of the COVID-19 pandemic, the higher death rates are troubling. The year-over-year growth between 2019 and 2020 is especially striking. Before the pandemic, 2019 saw 33 private equity acquisitions of nursing homes valued at just over $483 million. In 2020, there were 43 deals valued at more than $1.5 billion, according to Bloomberg Law reporter Tony Pugh.

And PE interest in health care is not restricted to nursing homes, explained Gretchen Morgenson and Emmanuelle Saliba at NBC News. “Private equity’s purchases have included rural hospitals, physicians’ practices, nursing homes and hospice centers, air ambulance companies and health care billing management and debt collection systems.” Overall, PE investments in health care have increased more than 1,900% over the past two decades. In 2000, PE invested less than $5 billion. By 2017, investment had jumped to $100 billion.

Industry advocates argue that the investments are in nursing homes that would fail without an influx of PE capital. The American Investment Council said private equity firms invest in “nursing homes to help rescue, build, or grow businesses, often providing much-needed capital to strengthen struggling companies and employ Americans,” according to Bloomberg Law.

The Debate Over Staffing

A bare-bones nursing staff is implicated in poorer quality at PE-owned nursing homes, both before and during the COVID-19 pandemic. Staff is generally the greatest expense in nursing homes and a key place to save money. “Labor is the main cost of any health care facility — accounting for nearly half of its operating costs — so cutting it to a minimum is the fastest profit-making measure owners can take, along with paying lower salaries,” journalist Annalisa Merelli explained in Quartz.

Staffing shrinks by 1.4% after a PE purchase, the NBER study found.

The federal government does not set specific patient-to-nurse ratios. California and other states have set minimum standards, but they are generally “well below the levels recommended by researchers and experts to consistently meet the needs of each resident,” according to the journal Policy, Politics, & Nursing Practice.

According to nursing assistant Adelina Ramos, “understaffing was so significant [during the pandemic] that she and her colleagues . . . often had to choose which dying or severely ill patient to attend first, leaving the others alone.”

Ramos worked at the for-profit Genesis Healthcare, the nation’s largest chain of nursing homes, which accepted $180 million in state and federal funds during the COVID-19 crisis but remained severely understaffed. She testified before the US Senate Finance Committee in March as a part of a week long look into how the pandemic affected nursing homes.Before the pandemic, we had this problem,” she said of staffing shortages. “And with the pandemic, it made things worse.”

$12.46 an Hour

In addition, low pay at nursing homes compounds staffing shortages by leading to extremely high rates of turnover. Ramos and her colleagues were paid as little as $12.46 an hour.

“The average nursing home in the US has their entire nursing home staff change over the course of the calendar year. This is a horrible way to provide good, quality nursing home care,” Grabowski told NPR, speaking of his March 2021 study in Health Affairs.

Loss of front-line staff leads to reductions in therapies for healthier patients, which leads to higher death rates, according to the NBER study. The effect of these cuts is that front-line nurses spend fewer hours per day providing basic services to patients. “Those services, such as bed turning or infection prevention, aren’t medically intensive, but they can be critical to health outcomes,” wrote Scott at Vox.

Healthier patients tend to suffer the most from this lack of basic nursing. “Sicker patients have more regimented treatment that will be adhered to no matter who owns the facility,” the researchers said, “whereas healthier people may be more susceptible to the changes made under private equity ownership.”

Growing Interest on Capitol Hill

In addition to the Senate Finance Committee hearings, the House Ways and Means Committee held a hearing at the end of last month about the excess deaths in nursing homes owned by PE. “Private equity’s business model involves buying companies, saddling them with mountains of debt, and then squeezing them like oranges for every dollar,” said Representative Bill Pascrell (D-New Jersey), who chairs the House Ways and Means Committee’s oversight subcommittee.

The office of Senator Elizabeth Warren (D-Massachusetts) will investigate the effects of nursing-home ownership on residents, she announced on March 17.

The hope is that the pandemic’s effect on older people will bring more attention to the issues that lead to substandard nursing home care. “Much more is needed to protect nursing home residents,” Denise Bottcher, the state director of AARP’s Louisiana office, told the Senate panel. “The consequence of not acting is that someone’s mother or father dies.”

Risking lives in pursuit of profits

https://mailchi.mp/05e4ff455445/the-weekly-gist-february-26-2021?e=d1e747d2d8

Benefit of Private Equity in Healthcare? Lessons from Nursing Homes

Finding a good long-term care facility for a loved one has always been a difficult process. A new National Bureau of Economic Research working paper suggests that families should also be paying attention to who owns the facility, finding a significant increase in mortality in nursing homes owned by private equity investors.

Examining Medicare data from over 18,000 nursing homes, 1,674 of which were owned by private equity (PE) firms, researchers found that PE ownership increased Medicare patient mortality by 10 percent—translating to a possible 20,150 additional lives lost. PE-owned facilities were also 11 percent more expensive.

Counterintuitively, lower-acuity patients had the greatest increase in mortality. Researchers found staffing decreased by 1.4 percent in PE-owned facilities, suggesting that shorter-staffed facilities may be forced to shift attention to sicker patients, leading to greater adverse effects on patients requiring less care.

Antipsychotic use, which carries a higher risk in the elderly, was also a whopping 50 percent higher.

Nursing homes are low-margin businesses, with profits of just 1-2 percent per year—and PE ownership did not improve financial performance.

Researchers found private equity profited from three strategies: “monitoring fees” paid to services also owned by the PE firm, lease payments after real estate sales, and tax benefits from increased interest payments, concluding that PE is shifting operating costs away from patient care in order to increase return on investment. Private equity investment in care delivery assets has skyrocketed over the past decade.

This study draws the most direct correlation between PE investment and an adverse impact on patient outcomes that we’ve seen so far, highlighting the need for increased regulatory scrutiny to ensure that patient safety isn’t sacrificed for investor returns.

‘Shkreli Awards’ Shame Healthcare Profiteers

Lown Institute berates greedy pricing, ethical lapses, wallet biopsies, and avoidable shortages.

Greedy corporations, uncaring hospitals, individual miscreants, and a task force led by Jared Kushner were dinged Tuesday in the Lown Institute‘s annual Shkreli awards, a list of the top 10 worst offenders for 2020.

Named after Martin Shkreli, the entrepreneur who unapologetically raised the price of an anti-parasitic drug by a factor of 56 in 2015 (now serving a federal prison term for unrelated crimes), the list of shame calls out what Vikas Saini, the institute’s CEO, called “pandemic profiteers.” (Lown bills itself as “a nonpartisan think tank advocating bold ideas for a just and caring system for health.”)

Topping the list was the federal government itself and Jared Kushner, President’s Trump’s son-in-law, who led a personal protective equipment (PPE) procurement task force. The effort, called Project Airbridge, was to “airlift PPE from overseas and bring it to the U.S. quickly,” which it did.

“But rather than distribute the PPE to the states, FEMA gave these supplies to six private medical supply companies to sell to the highest bidder, creating a bidding war among the states,” Saini said. Though these supplies were supposed to go to designated pandemic hotspots, “no officials from the 10 hardest hit counties” said they received PPE from Project Airbridge. In fact, federal agencies outbid states or seized supplies that states had purchased, “making it much harder and more expensive” for states to get supplies, he said.

Number two on the institute’s list: vaccine maker Moderna, which received nearly $1 billion in federal funds to develop its mRNA COVID-19 preventive. It set a price of between $32 and $37 per dose, more than the U.S. agreed to pay for other COVID vaccines. “Although the U.S. has placed an order for $1.5 billion worth of doses at a discount, a price of $15 per dose, given the upfront investment by the U.S. government, we are essentially paying for the vaccine twice,” said Lown Institute Senior Vice President Shannon Brownlee.

Webcast panelist Don Berwick, MD, former acting administrator for the Centers for Medicare & Medicaid Services, noted that a lot of work went into producing the vaccine at an impressive pace, “and if there’s not an immune breakout, we’re going to be very grateful that this happened.” But, he added, “I mean, how much money is enough? Maybe there needs to be some real sense of discipline and public spirit here that goes way beyond what any of these companies are doing.”

In third place: four California hospital systems that refused to take COVID-19 patients or delayed transfers from hospitals that were out of beds. Wall Street Journal investigation found that these refusals or delays were based on the patients’ ability to pay; many were on Medicaid or were uninsured.

“In the midst of such a pandemic, to continue that sort of behavior is mind boggling,” said Saini. “This is more than the proverbial wallet biopsy.”

The remaining seven offenders:

4. Poor nursing homes decisions, especially one by Soldiers’ Home for Veterans in western Massachusetts, that worsened an already terrible situation. At Soldiers’ Home, management decided to combine the COVID-19 unit with a dementia unit because they were low on staff, said Brownlee. That allowed the virus to spread rapidly, killing 76 residents and staff as of November. Roughly one-third of all COVID-19 deaths in the U.S. have been in long-term care facilities.

5. Pharmaceutical giants AstraZeneca, GlaxoSmithKline, Pfizer, and Johnson & Johnson, which refused to share intellectual property on COVID-19, instead deciding to “compete for their profits instead,” Saini said. The envisioned technology access pool would have made participants’ discoveries openly available “to more easily develop and distribute coronavirus treatments, vaccines, and diagnostics.”

Saini added that he was was most struck by such an attitude of “historical blindness or tone deafness” at a time when the pandemic is roiling every single country.

Berwick asked rhetorically, “What would it be like if we were a world in which a company like Pfizer or Moderna, or the next company that develops a really great breakthrough, says on behalf of the well-being of the human race, we will make this intellectual property available to anyone who wants it?”

6. Elizabeth Nabel, MD, CEO of Brigham and Women’s Hospital in Boston, because she defended high drug prices as a necessity for innovation in an op-ed, without disclosing that she sat on Moderna’s board. In that capacity, she received $487,500 in stock options and other payments in 2019. The value of those options quadrupled on the news of Moderna’s successful vaccine. She sold $8.5 million worth of stock last year, after its value nearly quadrupled. She resigned from Moderna’s board in July and, it was announced Tuesday, is leaving her CEO position to join a biotech company founded by her husband.

7. Hospitals that punished clinicians for “scaring the public,” suspending or firing them, because they “insisted on wearing N95 masks and other protective equipment in the hospital,” said Saini. Hospitals also fired or threatened to fire clinicians for speaking out on COVID-19 safety issues, such as the lack of PPE and long test turnaround times.

Webcast panelist Mona Hanna-Attisha, MD, the Flint, Michigan, pediatrician who exposed the city’s water contamination, said that healthcare workers “have really been abandoned in this administration” and that the federal Occupational Safety and Health Administration “has pretty much fallen asleep at the wheel.” She added that workers in many industries such as meatpacking and poultry processing “have suffered tremendously from not having the protections or regulations in place to protect [them].”

8. Connecticut internist Steven Murphy, MD, who ran COVID-19 testing sites for several towns, but conducted allegedly unnecessary add-ons such as screening for 20 other respiratory pathogens. He also charged insurers $480 to provide results over the phone, leading to total bills of up to $2,000 per person.

“As far as I know, having an MD is not a license to steal, and this guy seemed to think that it was,” said Brownlee.

9. Those “pandemic profiteers” who hawked fake and potentially harmful COVID-19 cures. Among them: televangelist Jim Bakker sold “Silver Solution,” containing colloidal silver, and the “MyPillow Guy,” Mike Lindell, for his boostering for oleandrin.

Colloidal silver has no known health benefits and can cause seizures and organ damage. Oleandrin is a biological extract from the oleander plant and known for its toxicity and ingesting it can be deadly,” said Saini.

Others named by the Lown Institute include Jennings Ryan Staley, MD — now under indictment — who ran the “Skinny Beach Med Spa” in San Diego which sold so-called COVID treatment packs containing hydroxychloroquine, antibiotics, Xanax, and Viagra, all for $4,000.

Berwick commented that such schemes indicate a crisis of confidence in science, adding that without facts and science to guide care, “patients get hurt, costs rise without any benefit, and confusion reigns, and COVID has made that worse right now.”

Brownlee mentioned the “huge play” that hydroxychloroquine received and the FDA’s recent record as examples of why confidence in science has eroded.

10. Two private equity-owned companies that provide physician staffing for hospitalsTeam Health and Envision, that cut doctors’ pay during the first COVID-19 wave while simultaneously spending millions on political ads to protect surprise billing practices. And the same companies also received millions in COVID relief funds under the CARES Act.

Berwick said surprise billing by itself should receive a deputy Shkreli award, “as out-of-pocket costs to patients have risen dramatically and even worse during the COVID pandemic… and Congress has failed to act. It’s time to fix this one.”

Northwell CEO Urging Healthcare Providers to Mobilize for Gun Control

https://www.healthleadersmedia.com/strategy/northwell-ceo-urging-healthcare-providers-mobilize-gun-control

Image result for Gun Control

The prominent executive is pushing beyond a letter he released last week and is now seeking to rally his peers around solving what he sees as a public health crisis.


KEY TAKEAWAYS

‘All of us have allowed this crisis to grow,’ he wrote in a letter published Thursday in The New York Times.

Healthcare CEOs should put pressure on politicians without resorting to ‘blatant partisanship,’ he said.

Northwell Health President and CEO Michael J. Dowling isn’t done pushing fellow leaders of healthcare provider organizations to take political action in the aftermath of deadly mass shootings.

Dowling addressed healthcare CEOs in a call to action published online last week by the Great Neck, New York–based nonprofit health system. Now he’s published a full-page print version of that letter in Thursday’s national edition of The New York Times, while reaching out directly to peers who could join him in a to-be-determined collective action plan to curb gun violence.

“To me, it’s an obligation of people who are in leadership positions to take some action, speak out, and prepare their organizations to address this as a public health issue,” Dowling tells HealthLeaders.

Wading into such a politically charged topic is sure to give some healthcare CEOs pause. Even if they keep their advocacy within all legal and ethical bounds, they could face rising distrust from community members who oppose further restrictions on firearms. But leaders have a responsibility to thread that needle for the sake of community health, Dowling says.

“I do anticipate that there’ll be criticism about this, but then again, if you’re in a leadership role, criticism is what you’ve got to deal with,” he says.

Dowling argues that healthcare leaders have successfully spoken out about other public health crises, such as smoking and drug use. But they have largely failed to respond adequately as gun violence inflicts considerable harm—both physical and emotional—on the communities they serve, he says.

“It is easy to point fingers at members of Congress for their inaction, the vile rhetoric of some politicians who stoke the flames of hatred, the lax laws that provide far-too-easy access to firearms, or the NRA’s intractable opposition to common sense legislation,” Dowling wrote in the print version of his letter. “It is far more difficult to look in the mirror and see what we have or haven’t done. All of us have allowed this crisis to grow. Sadly, as a nation, we have become numb to the bloodshed.”

His letter proposes a four-part agenda for healthcare leaders to tackle together:

  1. Put pressure on elected officials who “fail to support sensible gun legislation.” He urged healthcare CEOs to increase their political activity but avoid “blatant partisanship.” The online version of his letter links to OpenSecrets.org‘s repository of information on campaign contributions from gun rights interest groups to politicians.
  2. Invest in mental health without stigmatizing. Most mass murderers aren’t “psychotic or delusional,” Dowling wrote. Rather, they’re usually just disgruntled people who let their anger erupt into violence, which is why firearms sales to people at risk of harming themselves or others should be prohibited, he wrote.
  3. Increase awareness and training. Individuals shouldn’t be allowed to buy or access certain types of firearms “that serve no other purpose than to inflict mass casualties,” he wrote. Healthcare leaders should support efforts to spot risk factors and better understand so-called “red flag” laws that empower officials to take guns away from people deemed to be a potential threat to themselves or others, he wrote.
  4. Support universal background checks. In the same way that doctors shouldn’t write prescriptions without knowing a patient’s medical history to ensure the drug will do no harm, gun sellers shouldn’t be allowed to complete a transaction without having a background check conducted on the buyer, Dowling wrote, adding that a majority of Americans support this idea.

The letter notes that the U.S. has nearly 40,000 firearms-related deaths each year and that several dozen people have died in mass shootings thus far in 2019, including 31 earlier this month in separate shootings in El Paso, Texas, and Dayton, Ohio.

Corporate Responsibility

The way for-profit companies think about their relationship with the communities in which they operate has been shifting for some time. The most recent evidence of that shift came earlier this week, when the influential Business Roundtable released a revised statement on the principles of corporate governance, responding to criticism over the so-called “primacy of shareholders.”

The 181 CEOs who signed onto the new statement said they would run their business not just for the good of their shareholders but also for the good of customers, employees, suppliers, and communities. There’s some similarity between that updated notion of corporate responsibility and the sort of advocacy work Dowling wants to see from his for-profit and nonprofit peers alike.

Every single organization has a social mission, and large organizations that have sway in a local community have a responsibility to the community’s health, Dowling says.

“A healthy community helps and creates a healthy organization,” he says.

One major factor that may be pushing more CEOs to take a public stance on politically sensitive issues—or at least giving them the cover to do so confidently—is the generational shift in the U.S. workforce. Although most Americans overall say CEOs shouldn’t speak out, younger workers overwhelmingly support such action, as Fortune‘s Alan Murray reported, citing the magazine’s own polling.

Dowling says he has received hundreds of letters, emails, and phone calls from members of Northwell Health’s 70,000-person workforce expressing support in light of his original letter published online last week.

“The feedback has been absolutely universal in support,” he says.

But Which Policies?

Even among healthcare professionals who agree it’s appropriate to speak out on politically charged topics, there’s sharp disagreement over which policies lawmakers should enact and whether those policies would infringe on the public’s Second Amendment rights.

The group Doctors for Responsible Gun Ownership (DRGO) rejects the premise of Dowling’s argument: “Firearms are not a public health issue,” the DRGO website states, arguing that responsible gun ownership has been shown to benefit the public health by preventing violent crime.

Dennis Petrocelli, MD, a psychiatrist in Virginia, wrote a DRGO article that called Virginia’s proposed red flag law “misguided” and perhaps “the single greatest threat to our constitutional freedoms ever introduced in the Commonwealth of Virginia.” His concern is that the government might be able to take guns away without any real evidence of a threat.

While gun rights advocates may see Dowling as merely their latest political foe, Dowling contends that he’s pushing for a cause that can peaceably coexist with the constitutional right to bear arms.

“You can have effective, reasonable legislative action around guns that still protects the essence of what many people believe to be the core of the Second Amendment,” Dowling says. “It’s not an either/or situation.”

Others Speaking Out

Dowling isn’t, of course, the only healthcare leader speaking out about gun violence.

On the same day last week that Northwell Health published Dowling’s online call to action, Ascension published a similar letter from President and CEO Joseph R. Impicciche, JD, MHA, who referred to gun violence in American society as a “burgeoning public health crisis.”

“Silence in the face of such tragedy and wrongdoing falls short of our mission to advocate for a compassionate and just society,” Impicciche wrote, citing the health system’s Catholic commitment to defend human dignity.

The American Medical Association (AMA) and American College of Emergency Physicians (ACEP) each issued statements this month calling for public policy changes in response to these recent shootings, continuing their long-running advocacy work on the topic.

American Hospital Association 2019 Chairman Brian Gragnolati, who is president and CEO of Atlantic Health System in Morristown, New Jersey, said in a statement this month that hospitals and health systems “play a role in the larger conversation and are determined to use our collective voice to prevent more senseless tragedies.”

 

 

 

Coalition of 181 CEOs say society should matter alongside profit

Chief executives who are members of the Business Roundtable, include, left to right, front row: Julie Sweet of Accenture North America, Brian Moynihan of Bank of America, Tim Cook of Apple, Robert F. Smith of Vista Equity Partners of Austin. Back row: Jeff Bezos of Amazon, Mary Barra of General Motors and Larry Fink of BlackRock.

Nearly 200 chief executives, including the leaders of Apple, Pepsi and Walmart, tried on Monday to redefine the role of business in society — and how companies are perceived by an increasingly skeptical public.

Breaking with decades of long-held corporate orthodoxy, the Business Roundtable issued a statement on “the purpose of a corporation,” arguing that companies should no longer advance only the interests of shareholders. Instead, the group said, they must also invest in their employees, protect the environment and deal fairly and ethically with their suppliers.

“While each of our individual companies serves its own corporate purpose, we share a fundamental commitment to all of our stakeholders,” the group, a lobbying organization that represents many of America’s largest companies, said in a statement. “We commit to deliver value to all of them, for the future success of our companies, our communities and our country.”

The shift comes at a moment of increasing distress in corporate America, as big companies face mounting global discontent over income inequality, harmful products and poor working conditions.

On the Democratic presidential campaign trail, Senators Bernie Sanders and Elizabeth Warren have been vocal about the role of big business in perpetuating problems with economic mobility and climate change. Lawmakers are looking into the dominance of technology companies like Amazon and Facebook.

There was no mention at the Roundtable of curbing executive compensation, a lightning-rod topic when the highest-paid 100 chief executives make 254 times the salary of an employee receiving the median pay at their company. And hardly a week goes by without a major company getting drawn into a contentious political debate. As consumers and employees hold companies to higher ethical standards, big brands increasingly have to defend their positions on worker pay, guns, immigration, President Trump and more.

“They’re responding to something in the zeitgeist,” said Nancy Koehn, a historian at Harvard Business School. “They perceive that business as usual is no longer acceptable. It’s an open question whether any of these companies will change the way they do business.”

The Business Roundtable did not provide specifics on how it would carry out its newly stated ideals, offering more of a mission statement than a plan of action. But the companies pledged to compensate employees fairly and provide “important benefits,” as well as training and education. They also vowed to “protect the environment by embracing sustainable practices across our businesses” and “foster diversity and inclusion, dignity and respect.”

It was an explicit rebuke of the notion that the role of the corporation is to maximize profits at all costs — the philosophy that has held sway on Wall Street and in the boardroom for 50 years. Milton Friedman, the University of Chicago economist who is the doctrine’s most revered figure, famously wrote in The New York Times in 1970 that “the social responsibility of business is to increase its profits.”

This mind-set informed the corporate raiders of the 1980s and contributed to an unswerving focus on quarterly earnings reports. It found its way into pop culture, when in the 1987 movie “Wall Street,” Gordon Gekko declared, “Greed is good.” More recently, it inspired a new generation of activist investors who pushed companies to slash jobs as a way to enrich themselves.

“The ideology of shareholder primacy has contributed to the economic inequality we see today in America,” Darren Walker, the president of the Ford Foundation and a Pepsi board member, said in an interview. “The Chicago school of economics is so embedded in the psyche of investors and legal theory and the C.E.O. mind-set. Overcoming that won’t be easy.”

The Business Roundtable included its own articulation of the theory in an official doctrine in 1997, writing that “the paramount duty of management and of boards of directors is to the corporation’s stockholders.” Each version of its principles published over the last 20 years has stated that corporations exist principally to serve their shareholders.

But by last year, the Business Roundtable’s language was out of step with the times. Many chief executives, including BlackRock’s Larry Fink, had begun calling on companies to be more responsible. Businesses were pledging to fight climate change, reduce income inequality and improve public health. And at gatherings like the World Economic Forum in Davos, Switzerland, the discussions often centered on how businesses could help solve thorny global problems.

“The threshold has moved substantially for what people expect from a company,” Klaus Schwab, the chairman of the World Economic Forum, said in an interview. “It’s more than just producing profits for the shareholders.”

Last year, Jamie Dimon, the chief executive of JPMorgan Chase and the chairman of the Business Roundtable, began an effort to update its principles. “We looked at this thing that was written in 1997 and we didn’t agree with it,” Mr. Dimon said in an interview. “It didn’t fairly describe what we think our jobs are.”

Mr. Dimon proposed making a formal revision to the annual statement at a Business Roundtable board meeting in Washington this spring. It then fell to Alex Gorsky, the chief executive of Johnson & Johnson, who runs the group’s governance committee, to create the language.

“There were times when I felt like Thomas Jefferson,” Mr. Gorsky said in an interview.

While the group cast the change in language as an embrace of new corporate ideals, it was also a tacit acknowledgment of the heightened pressures facing companies across the country — including many that signed the document.

In 2017, after the president’s initially tepid response to the violent white supremacist protests in Charlottesville, Va., the chief executives of several major companies disbanded White House business advisory groups in protest. Walmart, the nation’s largest gun seller, is under pressure after a series of mass shootings, including the recent massacre at its store in El Paso. Amazon, the giant online retailer, is facing scrutiny from lawmakers who say it avoids paying taxes and uses its dominance to hurt competitors.

And protesters have mobilized across the country to call for a higher minimum wage.

For companies to truly make good on their lofty promises, they will need Wall Street to embrace their idealism, too. Until investors start measuring companies by their social impact instead of their quarterly returns, systemic change may prove elusive.

Nowhere has the new scrutiny on corporations been more pronounced than on the presidential campaign trail. On Monday, Mr. Sanders said in an interview that the Business Roundtable was “feeling the pressure from working families all over the country.”

“I don’t believe what they’re saying for a moment,” he said. “If they were sincere, they would talk about raising the minimum wage in this country to a living wage, the need for the rich and powerful to pay their fair share of taxes.”

In a statement Monday, Ms. Warren called the announcement “a welcome change” but cautioned that “without real action, it’s meaningless.

“These big corporations can start following through on their words by paying workers more instead of spending billions on buybacks,” she said.

While the new statement of purpose represents a sizable shift from the group’s longstanding principles, it was not the first time Business Roundtable had taken a position on a social issue. Last August, the group denounced President Trump’s immigration policies, describing family separations as “cruel and contrary to American values.”

Monday’s statement represented an even broader shift, signaling companies’ willingness to engage on issues of pay, diversity and environmental protection. Several of the executives who signed the letter said the group would soon offer more detailed proposals on how corporations can live up to the ideals it outlined, rather than focusing purely on economic policies.

“It’s a real divergence considering everything we’ve done in the past has been around policy,” said Chuck Robbins, the chief executive of Cisco, who is on the group’s board, adding, “This is just the first piece.”

The executives quickly pointed out that they had not forgotten about investors.

“You can provide great returns for your shareholders and great benefits for your employees and run your business in a responsible way,” said Brian Moynihan, the chief executive of Bank of America.

But the statement’s lack of specific proposals also drew skepticism.

“If the Business Roundtable is serious, it should tomorrow throw its weight behind legislative proposals that would put the teeth of the law into these boardroom platitudes,” said Anand Giridharadas, the author of “Winners Take All: The Elite Charade of Changing the World.” “Corporate magnanimity and voluntary virtue are not going to solve these problems.”