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Ferneini EM. The Impact of Private Equity's Involvement in Our Specialty. J Oral Maxillofac Surg 2024; 82:615-616. [PMID: 38825384 DOI: 10.1016/j.joms.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
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Haleem A, Garcia A, Khan S, Shakelly P, Lee DJ. Access to Sudden Sensorineural Hearing Loss Care at Private Equity-Owned Otolaryngology Clinics. Otolaryngol Head Neck Surg 2024; 170:1705-1711. [PMID: 38327257 DOI: 10.1002/ohn.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/14/2023] [Accepted: 01/13/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Characterizing access to sudden sensorineural hearing loss (SSNHL) care at private practice otolaryngology clinics of varying ownership models. STUDY DESIGN Cross-sectional prospective review. SETTING Private practice otolaryngology clinics. METHODS We employed a Secret Shopper study design with private equity (PE) owned and non-PE-owned clinics within 15 miles of one another. Using a standardized script, researchers randomly called 50% of each clinic type between October 2021 and January 2022 requesting an appointment on behalf of a family member enrolled in either Medicaid or private insurance (PI) experiencing SSNHL. Access to timely care was assessed between clinic ownership and insurance type. RESULTS Seventy-eight total PE-owned otolaryngology clinics were identified across the United States. Only 40 non-PE clinics could be matched to the PE clinics; 39 PE and 28 non-PE clinics were called as Medicaid patients; 39 PE and 25 non-PE clinics were called as PI patients; 48.7% of PE and 28.6% of non-PE clinics accepted Medicaid. The mean wait time to new appointment ranged between 9.55 and 13.21 days for all insurance and ownership types but did not vary significantly (P > .480). Telehealth was significantly more likely to be offered for new Medicaid patients at non-PE clinics compared to PE clinics (31.8% vs 0.0%, P = .001). The mean cost for an appointment was significantly greater at PE clinics than at non-PE clinics ($291.18 vs $203.75, P = .004). CONCLUSIONS Patients seeking SSNHL care at PE-owned otolaryngology clinics are likely to face long wait times prior to obtaining an initial appointment and reduced telehealth options.
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Affiliation(s)
- Afash Haleem
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Alejandro Garcia
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Sophia Khan
- Department of Biology, The College of New Jersey, Ewing, New Jersey, USA
| | - Purvi Shakelly
- Department of Biology, The College of New Jersey, Ewing, New Jersey, USA
| | - Daniel J Lee
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Tewfik G, Grech D, Laham L, Chaudhry F, Naftalovich R. The Risks and Benefits of Physician Practice Acquisition and Consolidation: A Narrative Review of Peer-Reviewed Publications Between 2009 and 2022 in the United States. J Multidiscip Healthc 2024; 17:2271-2279. [PMID: 38765617 PMCID: PMC11102090 DOI: 10.2147/jmdh.s463618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024] Open
Abstract
The objective of this narrative review was to assess current literature regarding acquisition and consolidation of physician practices in the United States (US). The acquisition and consolidation of physician practices is a trend affecting patient care, quality of services, healthcare economics and the daily practice of physicians. As practices are acquired by fellow physician groups, private equity investors and entities such as hospitals or large healthcare systems, it is important to better understand the underlying forces driving these transactions and their effects. This is a narrative review of peer-reviewed publications to determine what current literature has covered regarding the acquisition and consolidation of physician practices in the US regarding risks and benefits of this trend. Sources included the SCOPUS, Medline- PUBMED and Web of Science databases. Peer reviewed publications from 2009 to 2022 were included for initial review and curation for relevance using the search terms "physician" and "practice" with either "acquisition" or "consolidation". Synthesis conducted after narrowing down of relevant articles did not use quantitative measurements, but instead examined overall trends, as well as risk and benefits of ongoing acquisition and consolidation in a narrative format. Journal articles focused on physician consolidation in the US often reported increases in physician numbers with decreases in numbers of individual practices. Private equity quantitative analyses reported rapidly accelerating acquisitions driven by these investors, and vertical integration scholarly work reported frequent geographic consolidation of nearby practitioners. Risks associated with these transactions included such items as decreased physician autonomy and higher cost of care. Benefits included practice stability, improved negotiation with insurers and improved access to resources.
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Affiliation(s)
- George Tewfik
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA
| | - Dennis Grech
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA
| | - Linda Laham
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA
| | - Faraz Chaudhry
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA
| | - Rotem Naftalovich
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA
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Colenda CC, Applegate WB. Gluing Together a Fragmented Healthcare System for Geriatrics Will Be Hard. It's Time for United Action. Am J Geriatr Psychiatry 2024; 32:393-404. [PMID: 38503539 DOI: 10.1016/j.jagp.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
"Gluing" together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: 1) the US's historical fee for service (FFS) reimbursement system; 2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and 3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: 1) local political advocacy to implement health policy legislation; 2) expand geriatric physician and health professional workforce by nontraditional means; and 3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.
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Affiliation(s)
- Christopher C Colenda
- President Emeritus, West Virginia University Health System, Former Chancellor for Health Sciences, West Virginia University, Adjunct Professor of Gerontology and Geriatrics, Department of Internal Medicine, Wake Forest University School of Medicine (CCC), Morgantown, WV
| | - William B Applegate
- President and Dean Emeritus, Wake Forest University Health Sciences, Professor of Gerontology and Geriatrics, Department of Internal Medicine, Wake Forest University School of Medicine (WBA), Winston-Salem, NC
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Colenda CC, Applegate WB. Gluing together a fragmented healthcare system for geriatrics will be hard. It's time for united action. J Am Geriatr Soc 2024; 72:993-1003. [PMID: 38494999 DOI: 10.1111/jgs.18814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024]
Abstract
"Gluing" together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: (1) the US's historical fee for service (FFS) reimbursement system; (2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and (3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: (1) local political advocacy to implement health policy legislation; (2) expand geriatric physician and health professional workforce by nontraditional means; and (3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.
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Affiliation(s)
- Christopher C Colenda
- Department of Internal Medicine, Section of Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - William B Applegate
- Department of Internal Medicine, Section of Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Abdelhadi O, Fulton BD, Alexander L, Scheffler RM. Private Equity-Acquired Physician Practices And Market Penetration Increased Substantially, 2012-21. Health Aff (Millwood) 2024; 43:354-362. [PMID: 38437602 DOI: 10.1377/hlthaff.2023.00152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
Private equity (PE) firms have been acquiring physician practices at an increasing rate, raising concerns about such firms' penetration at the physician level into local markets and the impact on health care quality and prices. However, limited knowledge exists about the extent of PE firms' control in local markets. By linking data on PE acquisitions to physician data and using full-time-equivalent physicians as the base of assessment, we estimated the local market share of each PE firm within ten physician specialties at the Metropolitan Statistical Area (MSA) level. PE-acquired physician practice sites increased from 816 across 119 MSAs in 2012 to 5,779 across 307 MSAs in 2021. Single PE firms had significant market share, exceeding 30 percent in 108 MSA specialty markets and exceeding 50 percent in 50 of those markets. The findings raise concerns about competition and call for closer scrutiny by the Federal Trade Commission, state regulators, and policy makers.
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Affiliation(s)
- Ola Abdelhadi
- Ola Abdelhadi , University of California Berkeley, Berkeley, California
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Braun RT, Lelli GJ, Pandey A, Zhang M, Winebrake JP, Casalino LP. Association of Private Equity Firm Acquisition of Ophthalmology Practices with Medicare Spending and Use of Ophthalmology Services. Ophthalmology 2024; 131:360-369. [PMID: 37777118 PMCID: PMC10922192 DOI: 10.1016/j.ophtha.2023.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/02/2023] Open
Abstract
PURPOSE Private equity (PE) firms increasingly are acquiring ophthalmology practices; little is known of their influence on care use and spending. We studied changes in use and Medicare spending after PE acquisition. DESIGN Retrospective cohort study. PARTICIPANTS Seven hundred sixty-two clinicians in 123 practices acquired by PE between 2017 and 2018 and 34 807 clinicians in 20 549 never-acquired practices. METHODS We analyzed Medicare fee-for-service claims (2012-2019) combined with a novel national database of PE acquisitions of ophthalmology practices using a difference-in-differences method within an event study framework to compare changes after a practice was acquired with changes in practices that were not acquired. MAIN OUTCOME MEASURES Numbers of beneficiaries seen; intravitreal injections and medications used for injections; and spending on ophthalmologist and optometrist services, ancillary services, and intravitreal injections. RESULTS Comparing PE-acquired with nonacquired practices showed a 23.92% increase (n = 4.20 beneficiaries; 95% confidence interval [CI], 1.73-6.67) in beneficiaries seen per PE optometrist per quarter and no change for ophthalmologists, while spending per beneficiary increased 5.06% ($9.66; 95% CI, -2.82 to 22.14). Spending on clinician services decreased 1.62% (-$2.37; 95% CI, -5.78 to 1.04), with ophthalmologist services increasing 5.46% ($17.70; 95% CI, -2.73 to 38.15) and optometrists decreasing 4.60% (-$5.76; 95% CI, -9.17 to -2.34) per beneficiary per quarter. Ancillary services decreased 7.56% (-$2.19; 95% CI, 4.19 to -0.22). Intravitreal injection costs increased 25.0% ($20.02; 95% CI, -1.38 to 41.41) with the number increasing 5.10% (1.83; 95% CI, -0.1 to 3.80). There was a 74.09% increase (8.38 injections; 95% CI, 0.01-16.74) in ranibizumab and a 12.91% decrease (-3.40 injections; 95% CI, -6.86 to 0.07) in bevacizumab after acquisition. The event study showed consistent and often statistically significant increases in ranibizumab injections and decreases in bevacizumab injections after acquisition. CONCLUSIONS Although not all results reached statistical significance, this study suggested that PE acquisition of practices showed little or no overall effect on use or total spending, but increased the number of unique patients seen per optometrist and the use of expensive intravitreal injections. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Robert Tyler Braun
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, New York.
| | - Gary Joseph Lelli
- Department of Ophthalmology, Weill Cornell Medical College, New York, New York
| | - Abhinav Pandey
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Manyao Zhang
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, New York
| | - James P Winebrake
- Department of Ophthalmology, Weill Cornell Medical College, New York, New York
| | - Lawrence P Casalino
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, New York
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Hewitt AM. The Coproduction of Health Framework: Seeking Instructive Management Models and Theories. Adv Health Care Manag 2024; 22:181-210. [PMID: 38262016 DOI: 10.1108/s1474-823120240000022009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
At the beginning of the 21st century, multiple and diverse social entities, including the public (consumers), private and nonprofit healthcare institutions, government (public health) and other industry sectors, began to recognize the limitations of the current fragmented healthcare system paradigm. Primary stakeholders, including employers, insurance companies, and healthcare professional organizations, also voiced dissatisfaction with unacceptable health outcomes and rising costs. Grand challenges and wicked problems threatened the viability of the health sector. American health systems responded with innovations and advances in healthcare delivery frameworks that encouraged shifts from intra- and inter-sector arrangements to multi-sector, lasting relationships that emphasized patient centrality along with long-term commitments to sustainability and accountability. This pathway, leading to a population health approach, also generated the need for transformative business models. The coproduction of health framework, with its emphasis on cross-sector alignments, nontraditional partner relationships, sustainable missions, and accountability capable of yielding return on investments, has emerged as a unique strategy for facing disruptive threats and challenges from nonhealth sector corporations. This chapter presents a coproduction of health framework, goals and criteria, examples of boundary spanning network alliance models, and operational (integrator, convener, aggregator) strategies. A comparison of important organizational science theories, including institutional theory, network/network analysis theory, and resource dependency theory, provides suggestions for future research directions necessary to validate the utility of the coproduction of health framework as a precursor for paradigm change.
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Kannan S, Bruch JD, Song Z. Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition. JAMA 2023; 330:2365-2375. [PMID: 38147093 PMCID: PMC10751598 DOI: 10.1001/jama.2023.23147] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 10/22/2023] [Indexed: 12/27/2023]
Abstract
Importance The effects of private equity acquisitions of US hospitals on the clinical quality of inpatient care and patient outcomes remain largely unknown. Objective To examine changes in hospital-acquired adverse events and hospitalization outcomes associated with private equity acquisitions of US hospitals. Design, Setting, and Participants Data from 100% Medicare Part A claims for 662 095 hospitalizations at 51 private equity-acquired hospitals were compared with data for 4 160 720 hospitalizations at 259 matched control hospitals (not acquired by private equity) for hospital stays between 2009 and 2019. An event study, difference-in-differences design was used to assess hospitalizations from 3 years before to 3 years after private equity acquisition using a linear model that was adjusted for patient and hospital attributes. Main Outcomes and Measures Hospital-acquired adverse events (synonymous with hospital-acquired conditions; the individual conditions were defined by the US Centers for Medicare & Medicaid Services as falls, infections, and other adverse events), patient mix, and hospitalization outcomes (including mortality, discharge disposition, length of stay, and readmissions). Results Hospital-acquired adverse events (or conditions) were observed within 10 091 hospitalizations. After private equity acquisition, Medicare beneficiaries admitted to private equity hospitals experienced a 25.4% increase in hospital-acquired conditions compared with those treated at control hospitals (4.6 [95% CI, 2.0-7.2] additional hospital-acquired conditions per 10 000 hospitalizations, P = .004). This increase in hospital-acquired conditions was driven by a 27.3% increase in falls (P = .02) and a 37.7% increase in central line-associated bloodstream infections (P = .04) at private equity hospitals, despite placing 16.2% fewer central lines. Surgical site infections doubled from 10.8 to 21.6 per 10 000 hospitalizations at private equity hospitals despite an 8.1% reduction in surgical volume; meanwhile, such infections decreased at control hospitals, though statistical precision of the between-group comparison was limited by the smaller sample size of surgical hospitalizations. Compared with Medicare beneficiaries treated at control hospitals, those treated at private equity hospitals were modestly younger, less likely to be dually eligible for Medicare and Medicaid, and more often transferred to other acute care hospitals after shorter lengths of stay. In-hospital mortality (n = 162 652 in the population or 3.4% on average) decreased slightly at private equity hospitals compared with the control hospitals; there was no differential change in mortality by 30 days after hospital discharge. Conclusions and Relevance Private equity acquisition was associated with increased hospital-acquired adverse events, including falls and central line-associated bloodstream infections, along with a larger but less statistically precise increase in surgical site infections. Shifts in patient mix toward younger and fewer dually eligible beneficiaries admitted and increased transfers to other hospitals may explain the small decrease in in-hospital mortality at private equity hospitals relative to the control hospitals, which was no longer evident 30 days after discharge. These findings heighten concerns about the implications of private equity on health care delivery.
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Affiliation(s)
- Sneha Kannan
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Joseph Dov Bruch
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Zirui Song
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- Center for Primary Care, Harvard Medical School, Harvard University, Boston, Massachusetts
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Faraj KS, Kaufman SR, Herrel LA, Maganty A, Oerline M, Caram MEV, Shahinian VB, Hollenbeck BK. The immediate effects of private equity acquisition of urology practices on the management of newly diagnosed prostate cancer. Cancer Med 2023; 12:22325-22332. [PMID: 38100144 PMCID: PMC10757152 DOI: 10.1002/cam4.6788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/22/2023] [Accepted: 11/23/2023] [Indexed: 12/31/2023] Open
Abstract
INTRODUCTION Some worry that physician practices acquired by private equity may increase the use of services to maximize revenue. We assessed the effects of private equity acquisition on spending, use of treatment, and diagnostic testing in men with prostate cancer. METHODS We used a 20% sample of national Medicare claims to perform a retrospective cohort study of men with prostate cancer diagnosed from 2014 through 2019. The primary outcome was prostate cancer spending in the first 12 months after diagnosis. Secondary outcomes included the use of treatment and a composite measure of diagnostic testing (e.g., imaging, genomics) in the first 12 months after diagnosis. Multilevel modeling was used to adjust for differences in patient and market characteristics. The effect of practice acquisition on each outcome was assessed using a difference-in-differences design. RESULTS There were 409 and 4021 men with prostate cancer managed by urologists in acquired and nonacquired practices, respectively. After acquisition, prostate cancer spending was comparable between acquired and nonacquired practices (difference-in-differences estimate $1182, p = 0.36). Acquisition did not affect the use of treatment (difference-in-differences estimate 3.7%, p = 0.30) or the use of diagnostic testing in men who were treated (difference-in-differences -5.5%, p = 0.12) and those managed conservatively (difference-in-differences -2.0%, p = 0.82). CONCLUSIONS In the year following acquisition of urology practices, private equity did not increase prostate cancer spending, the use of treatment or diagnostic testing in men with prostate cancer. Future work should evaluate the effects of private equity acquisition on practice patterns and quality over a longer time horizon.
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Affiliation(s)
- Kassem S Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mary Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan E V Caram
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vahakn B Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brent K Hollenbeck
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Faraj KS, Kaufman SR, Herrel LA, Maganty A, Oerline M, Caram MEV, Shahinian VB, Hollenbeck BK. Acquisition of Urology Practices by Private Equity Firms and Performance in the Merit-based Incentive Payment System. UROLOGY PRACTICE 2023; 10:597-603. [PMID: 37856709 PMCID: PMC10593488 DOI: 10.1097/upj.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/20/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Private equity is increasingly engaged in the acquisition of urology practices. The implications of strategies to enhance practice value deployed by these firms for patients are unclear. METHODS We conducted a retrospective study of urologist performance in the MIPS (Merit-based Incentive Payment System) program for 2017 to 2020 using national Medicare data from the Quality Payment Program file. The primary outcome was the overall MIPS score. Secondary outcomes included MIPS component scores (ie, quality, interoperability, improvement activities, cost) and the percentage of urologists receiving a bonus payment. Generalized estimating equations were used to estimate the relationship between private equity acquisition and outcomes using a difference-in-differences framework. RESULTS Between 2017 and 2020, 181 urologists were in a urology practice acquired by private equity with MIPS data available the year before and after acquisition. Compared to urologists in practices not acquired by private equity, those in acquired practices had worse overall MIPS performance after acquisition (difference-in-differences estimate, -14 points, P = .04). The decrease in the overall score was driven by worse performance in the quality score (difference-in-differences estimate, -28 points, P < .001). Finally, acquisition resulted in a decrease in the percentage of urologists receiving bonus payments (difference-in-differences estimate, -43%, P < .001). CONCLUSIONS Private equity acquisition of urology practices was associated with significantly lower MIPS performance. As private equity acquisition of urology practices becomes more prevalent, key stakeholders should ensure that the quality of patient care is maintained and that the involvement of for-profit entities in health care is being made transparent to patients.
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Affiliation(s)
- Kassem S Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Mary Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Vahakn B Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
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Zhu JM, Aderman CM. Private equity in ophthalmology: taking the long view. Curr Opin Ophthalmol 2023; 34:390-395. [PMID: 37326217 DOI: 10.1097/icu.0000000000000976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE OF REVIEW Private equity's momentum in eye care remains controversial, even as investment continues to hasten the consolidation of ophthalmology and optometry practices. In this review, we discuss the growing implications of private equity activity in ophthalmology, drawing on updated empirical findings from the literature. We also examine recent legal and policy efforts to address private equity investment in healthcare, with implications for ophthalmologists considering sales to private equity. RECENT FINDINGS Concerns about private equity centres around evidence that some investment entities are not just valuable sources of capital or business expertise, but that they take outright ownership and control of acquired practices in order to drive high returns on investment. Although practices may receive considerable benefits from private equity investment, empirical evidence suggests that private equity's most consistent effect on acquired practices is to increase spending and utilization without commensurate benefits on patient health. Although data on workforce effects are limited, an early study on workforce composition changes in private equity-acquired practices demonstrates that physicians were more likely to enter and exit a given practice than their counterparts in nonacquired practices, suggesting some degree of workforce flux. State and federal oversight of private equity's impact on healthcare may be ramping up in response to these demonstrated changes. SUMMARY Private equity will continue to broaden their footprint in eye care, necessitating ophthalmologists to take the long view of private equity's net effects. For practices considering a private equity sale, recent policy developments highlight the importance of identifying and vetting a well aligned investment partner, with safeguards to preserve clinical decision-making and physician autonomy.
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Affiliation(s)
- Jane M Zhu
- Division of General Internal Medicine, Oregon Health & Science University
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Borsa A, Bejarano G, Ellen M, Bruch JD. Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review. BMJ 2023; 382:e075244. [PMID: 37468157 DOI: 10.1136/bmj-2023-075244] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To review the evidence on trends and impacts of private equity (PE) ownership of healthcare operators. DESIGN Systematic review. DATA SOURCES PubMed, Web of Science, Embase, Scopus, and SSRN. ELIGIBILITY CRITERIA FOR STUDY SELECTION Empirical research studies of any design that evaluated PE owned healthcare operators. MAIN OUTCOME MEASURES The main outcome measures were impact of PE ownership on health outcomes, costs to patients or payers, costs to operators, and quality. The secondary outcome measures were trends and prevalence of PE ownership of healthcare operators. DATA SYNTHESIS Studies were classified as finding either beneficial, harmful, mixed, or neutral impacts of PE ownership on main outcome measures. Results across studies were narratively synthesized and reported. Risk of bias was evaluated using ROBINS-I (Risk Of Bias In Non-randomised Studies of Interventions). RESULTS The electronic search identified 1778 studies, with 55 meeting the inclusion criteria. Studies spanned eight countries, with most (n=47) analyzing PE ownership of healthcare operators in the US. Nursing homes were the most commonly studied healthcare setting (n=17), followed by hospitals and dermatology settings (n=9 each); ophthalmology (n=7); multiple specialties or general physician groups (n=5); urology (n=4); gastroenterology and orthopedics (n=3 each); surgical centers, fertility, and obstetrics and gynecology (n=2 each); and anesthesia, hospice care, oral or maxillofacial surgery, otolaryngology, and plastics (n=1 each). Across the outcome measures, PE ownership was most consistently associated with increases in costs to patients or payers. Additionally, PE ownership was associated with mixed to harmful impacts on quality. These outcomes held in sensitivity analyses in which only studies with moderate risk of bias were included. Health outcomes showed both beneficial and harmful results, as did costs to operators, but the volume of studies for these outcomes was too low for conclusive interpretation. In some instances, PE ownership was associated with reduced nurse staffing levels or a shift towards lower nursing skill mix. No consistently beneficial impacts of PE ownership were identified. CONCLUSIONS Trends in PE ownership rapidly increased across almost all healthcare settings studied. Such ownership is often associated with harmful impacts on costs to patients or payers and mixed to harmful impacts on quality. Owing to risk of bias and frequent geographic focus on the US, conclusions might not be generalizable internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022329857.
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Affiliation(s)
- Alexander Borsa
- Department of Sociomedical Sciences, Columbia University, New York, NY, USA
| | - Geronimo Bejarano
- Department of Epidemiology, University of Texas School of Public Health (UTHealth), Austin, TX, USA
| | - Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Department of Health Policy Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Joseph Dov Bruch
- Department of Public Health Sciences, University of Chicago, Chicago, IL 60637, USA
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14
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Busam JA, Shah ED. The Rise of Private Equity in Gastroenterology Practices. Gastroenterol Hepatol (N Y) 2023; 19:264-271. [PMID: 37799457 PMCID: PMC10548246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Private equity (PE) investment in gastroenterology practices has significantly increased over the past several years. Because PE firms are prevented legally from owning a medical practice in many states, they usually form a management services organization to oversee all nonclinical aspects of the practice, leaving all clinical functions to the physician owners. Gastroenterology practices have become attractive investments to PE firms because of the willingness of gastroenterologists to join a PE-backed practice and the potential to earn profits through consolidating the market. Research has started to examine the effects of PE-backed practices on patients and on the gastroenterology specialty specifically. Questions remain regarding the benefits for physicians. This article examines PE investment in gastroenterology practices and how this may impact the specialty in the future.
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Affiliation(s)
- Jonathan A. Busam
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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15
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Bruch JD, Foot C, Singh Y, Song Z, Polsky D, Zhu JM. Workforce Composition In Private Equity-Acquired Versus Non-Private Equity-Acquired Physician Practices. Health Aff (Millwood) 2023; 42:121-129. [PMID: 36623222 DOI: 10.1377/hlthaff.2022.00308] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Despite growth in private equity (PE) acquisitions of physician practices in the US, little is known about how changes in ownership influence workforce composition. Using clinician-level data linked to practice acquisition information, we estimated changes in clinician workforce composition in PE-acquired practice sites relative to non-PE-acquired independent practice sites for dermatology, ophthalmology, and gastroenterology specialties. We calculated a clinician replacement ratio (cumulative number of entering clinicians during 2014-19 divided by the cumulative number of exiting clinicians) across 213 PE-acquired practices and 995 matched non-PE-acquired practices. Using a difference-in-differences approach, we also examined practice-level changes in yearly clinician counts at PE-acquired practices before and after acquisition compared with non-PE-acquired controls. In aggregate and across the study period, the clinician replacement ratio was higher for PE-acquired practices compared with non-PE-acquired controls (1.75 versus 1.37), as well as within each specialty and clinician type (physician versus advanced practice provider). Relative to non-PE-acquired control practices, we also found significant yearly increases in the number of advanced practice providers at PE-acquired practices after acquisition. Taken together, these findings suggest differential changes in workforce composition at PE-acquired practices, especially a shift toward advanced practice providers for care delivery.
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Affiliation(s)
| | - Canyon Foot
- Canyon Foot, Oregon Health & Science University, Portland, Oregon
| | | | - Zirui Song
- Zirui Song, Harvard University, Boston, Massachusetts
| | | | - Jane M Zhu
- Jane M. Zhu , Oregon Health & Science University
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16
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Landon BE. Alternative Payments and Physician Organizations. Adv Health Care Manag 2022; 21:133-150. [PMID: 36437620 DOI: 10.1108/s1474-823120220000021007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
There are longstanding concerns about the sustainability of the US health care system. Payment reform has been seen over the last decade as a key strategy to reorienting the US health care system around value. Alternative payment models (APMs) that seek to accomplish this goal have become increasingly prevalent in the US, yet there is a perception that physicians are resistant to their use and that organizations have been slow to adopt such models. The reasons for the limited effectiveness of APM programs are multifactorial and include aspects related to the design and implementation of these programs and lack of alignment and coordination across different payers and health care sectors. Most importantly, however, is that the current organizational structures in US health care serve to dampen the direct impact of these incentives, often because health care delivery organizations face conflicting incentives themselves. Organizations filter and refine the incentives from multiple external payment contracts and develop internal incentive systems that best reflect the amalgamation of the incentives embedded across their contracts, and thus the fragmented nature of the US health care system serves to undermine efforts to transform care under value-based contracts. In addition to organizations having conflicting incentives, there also are fundamental problems with the design and implementation of APMs that hinder their acceptance among physicians and the organizations in which they work. Moreover, much remains to be learned about how organizations can best adapt to succeed under these models, and how organizational culture can be leveraged to transform care.
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17
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Nolte TN, Miedaner F, Sülz S. Physicians' Perspectives Regarding Private Equity Transactions in Outpatient Health Care-A Scoping Review and Qualitative Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192315480. [PMID: 36497553 PMCID: PMC9737937 DOI: 10.3390/ijerph192315480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 05/26/2023]
Abstract
Private equity (PE) investments in health care have increased drastically over the last decade, and the profit interests of these companies have triggered a vivid discussion among medical professions. However, what are the key underlying perceptions among physicians regarding this trend? Unravelling the argumentative structure of this debate is the purpose of this paper. With physicians being a major stakeholder group in the outpatient health care setting, this paper explores physicians' perspectives regarding increasing PE activities. We systematically searched, selected, and synthesized existing knowledge in a scoping review and complemented the findings through 14 semi-structured interviews with physicians working in the outpatient health care sector in Germany. The results outline a complex network of arguments, concerns, and fears whereby the first intuitive perception of physicians is of critical nature. Arguments cluster around central perceptions of how PE involvement affects the individual autonomy of physicians in their daily work and decision-making, the impact on quality of care, work-life balance considerations, PE investment strategies, lack of medical vs. managerial expertise, and taxation issues. The high number of opinion papers among the literature underlines the actuality of the topic and emphasizes the need for empirical research.
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Affiliation(s)
- Tim N. Nolte
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Postbus 1738, 3000 DR Rotterdam, The Netherlands
| | - Felix Miedaner
- Faculty of Health and Health Care Sciences, Ostfalia University of Applied Sciences, Rothenfelder Str. 10, 38440 Wolfsburg, Germany
| | - Sandra Sülz
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Postbus 1738, 3000 DR Rotterdam, The Netherlands
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18
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Singh Y, Song Z, Polsky D, Bruch JD, Zhu JM. Association of Private Equity Acquisition of Physician Practices With Changes in Health Care Spending and Utilization. JAMA HEALTH FORUM 2022; 3:e222886. [PMID: 36218927 PMCID: PMC9440392 DOI: 10.1001/jamahealthforum.2022.2886] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Question Findings Meaning Importance Objective Design, Settings, and Participants Exposures Main Outcomes and Measures Results Conclusions and Relevance
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Affiliation(s)
- Yashaswini Singh
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Zirui Song
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Daniel Polsky
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Carey Business School, Johns Hopkins University, Baltimore, Maryland
| | - Joseph D. Bruch
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jane M. Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland
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19
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Brill D, Luo S, Sridhar J, Williams BK. Private equity in ophthalmology: lessons from other specialties. Curr Opin Ophthalmol 2022; 33:352-361. [PMID: 35916564 DOI: 10.1097/icu.0000000000000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In the absence of long-term data of the effects of private equity in ophthalmology, this article reviews the role of private equity in other medical specialties as a guide to the future for ophthalmology. RECENT FINDINGS Across an array of medical specialties, including anesthesiology, dermatology, emergency medicine, ophthalmology/optometry, radiology, and urology, medical practices are being consolidated into a few larger platform groups. Although there has been a short-term financial success for both private equity firms and senior medical practice partners, there exists broad skepticism from peer-reviewed publications and the national media. SUMMARY Although the impact of private equity on ophthalmology is largely speculative, ophthalmology may follow some of the trends observed in other medical specialties. These trends include increased volume of services, increased profits, improved payer mix, increased payment per patient visit, increased use of midlevel practitioners, decreased physician autonomy, and decreased physician salaries.
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Affiliation(s)
- Daniel Brill
- Department of Ophthalmology, University of Cincinnati College of Medicine
- Cincinnati Eye Institute, Cincinnati, Ohio, USA
| | - Shiming Luo
- Department of Ophthalmology, University of Cincinnati College of Medicine
| | - Jayanth Sridhar
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Basil K Williams
- Department of Ophthalmology, University of Cincinnati College of Medicine
- Cincinnati Eye Institute, Cincinnati, Ohio, USA
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20
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Shahinian VB. EDITORIAL COMMENT. Urology 2022; 167:126-127. [PMID: 36153093 DOI: 10.1016/j.urology.2022.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Vahakn B Shahinian
- Departments of Internal Medicine and Urology, University of Michigan, Ann Arbor, MI
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21
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Bruch JD, Nair-Desai S, Orav EJ, Tsai TC. Private Equity Acquisitions Of Ambulatory Surgical Centers Were Not Associated With Quality, Cost, Or Volume Changes. Health Aff (Millwood) 2022; 41:1291-1298. [PMID: 36067436 DOI: 10.1377/hlthaff.2021.01904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ambulatory surgical centers (ASCs) are increasingly being acquired by private equity firms, yet the implications for patients remain understudied. In this study we employed a quasi-experimental difference-in-differences design within an event study framework to assess changes in outcomes associated with the acquisition of ASCs by private equity entities. Using a two-way fixed effects model, we assessed the baseline probability of an unplanned hospital visit, total costs, and total encounters three years preacquisition compared with three years postacquisition in ASCs acquired by private equity versus those acquired by non-private equity entities. We identified ninety-one ASCs acquired by private equity and fifty-seven ASCs acquired by non-private equity entities during the period 2011-14. There was no statistically significant observed change in the probability of an unplanned hospital visit, total costs, or total encounters after acquisition by private equity relative to acquisition by non-private equity entities. When we compared private equity-acquired ASCs with matched ASCs that were never acquired, we also found no statistically significant relative change in the probability of an unplanned hospital visit, total costs, or total encounters. Regulators should ensure that data on private equity acquisitions are transparent and that data are available to track the long-term quality and financial implications of these acquisitions.
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Affiliation(s)
| | | | - E John Orav
- E. John Orav, Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
| | - Thomas C Tsai
- Thomas C. Tsai , Harvard University and Brigham and Women's Hospital
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22
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Patel V, Nijm LM. Contractual considerations in the private equity era. Curr Opin Ophthalmol 2022; 33:389-393. [PMID: 35838254 DOI: 10.1097/icu.0000000000000888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Private equity (PE) has grown rapidly in medicine. The reintroduction of PE in ophthalmology has necessitated a greater understanding of the potential contractual relationships with PE firms from both a practice owner and an employee physician perspective. There are contractual obligations that need to be met as PE agreements are designed to ensure clear investment patterns and abide by legal mandates. A practice owner entering into a PE contract needs to consider how the practice is being valued, what their obligations are to the PE entity after the sale has been completed to attain full compensation and understand their new role at the practice. On the other hand, employee ophthalmologists must carefully evaluate the compensation package being offered in terms of the type of equity, vesting of shares, obligations to the PE firm under the agreement such as a noncompete clause, and what occurs under a subsequent sale of the practice. Overall, contractual considerations in the private equity era need to be carefully evaluated in order to ensure the agreement is in the best interest for the clinician, practice, and their patients.
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Affiliation(s)
- Veshesh Patel
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Lisa M Nijm
- Warrenville EyeCare & LASIK, Warrenville
- University of Illinois Eye and Ear Infirmary, Chicago, IL, USA
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23
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Gastroenterology Practice Consolidation Between 2012 and 2020. Dig Dis Sci 2022; 67:3568-3575. [PMID: 35194705 DOI: 10.1007/s10620-022-07417-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 11/23/2021] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Multiple studies have indicated physicians are practicing medicine in increasingly larger groups. However, specialty-specific data on the extent of consolidation are lacking for many specialties, including gastroenterology. We aim to determine the extent of consolidation for gastroenterology in recent years. METHODS The Physician Compare database was used to gather information at both an individual and group level. This information included location and number of providers for each group. Cochran-Armitage tests were used to test for differences between practice sizes in 2012 and 2020. RESULTS Between 2012 and 2020, the number of physicians increased from 12,766 to 13,934, while the total number of practices decreased from 4517 to 3865. The total number of physicians who practice in groups of less than 9 physicians decreased by 23.9%, while the total number of physicians in practices of 100 + increased by 16.8%. DISCUSSION Significant consolidation has occurred in the field of gastroenterology in every geographic region of the USA. The causes of consolidation are multi-faceted and include the legislative environment, private equity and hospital acquisition of private groups, individual physician lifestyle preferences, and economic benefits of economies of scale. However, the consequences of consolidation are still unclear. CONCLUSION Over the last eight years, gastroenterologists have been practicing in increasingly larger groups. This trend has been consistent in each area of the country. Future research should focus on the impact of consolidation on patient care and physician wellbeing.
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24
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Singh Y, Zhu JM, Polsky D, Song Z. Geographic Variation in Private Equity Penetration Across Select Office-Based Physician Specialties in the US. JAMA HEALTH FORUM 2022; 3:e220825. [PMID: 35977319 PMCID: PMC9055458 DOI: 10.1001/jamahealthforum.2022.0825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/10/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yashaswini Singh
- Bloomberg School of Public Health, Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland
| | - Jane M. Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland
| | - Daniel Polsky
- Bloomberg School of Public Health, Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland
| | - Zirui Song
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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25
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Zahner GJ, Croughan PW, Blumenthal DM. A Potential Path to Universal Coverage With Medicare Advantage for All-Reply. JAMA 2022; 327:1616-1617. [PMID: 35471517 DOI: 10.1001/jama.2022.3156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Greg J Zahner
- Department of Medicine, Massachusetts General Hospital, Boston
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26
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Recent Trends in Private Equity Acquisition of Orthopaedic Practices in the United States. J Am Acad Orthop Surg 2022; 30:e664-e672. [PMID: 35077400 DOI: 10.5435/jaaos-d-21-00783] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/24/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Private equity acquisition of medical specialty practices has increased in recent years. With the projected increase in the volume of elective, ambulatory orthopaedic procedures, especially in the outpatient setting, private equity firms are increasingly investing in orthopaedic practices. The purpose of this cross-sectional study was to report recent trends and variations in acquisitions of US orthopaedic practices by private equity firms and other institutional investors (venture capital firms, trusts, and large investment companies). METHODS Acquisition data through January 1, 2020, were collected and analyzed using various financial databases, supplemented with publicly available information from financial news outlets, press releases, and financial analyst and industry reports. Disclosed financing data were also included, in addition to pertinent geographic information (state, city, and zip code) of the target practices. RESULTS Between 2004 and 2019, 41 orthopaedic practices and surgeon groups across 22 states were acquired by 34 private equity and other investment firms. A significant increase was observed in the number of acquisitions between 2017 and 2019, consisting of 70.7% of total transactions during the study period, with a statistically significant upward yearly trend (P = 0.002). The compound annual growth rate in acquisition volume was 29.2% during the study period. A disproportionate share of private equity acquisitions took place in the South, where more than half (51.2%) of the total transactions took place. Firms were markedly more likely to acquire or invest in practices located in major metropolitan areas (population more than 1 million) compared with those in mid-sized or rural areas (70.7%, 17.1%, 12.2%, respectively; P < 0.001). CONCLUSIONS Private equity acquisition of orthopaedic surgery practices has increased markedly in recent years. The effect of private equity acquisition on physician independence, practice management, and procedure reimbursement remains unclear and may be important to explore as practice management evolves. LEVEL OF EVIDENCE Prognostic Level III.
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Cerullo M, Lin YL, Rauh-Hain JA, Ho V, Offodile AC. Financial Impacts And Operational Implications Of Private Equity Acquisition Of US Hospitals. Health Aff (Millwood) 2022; 41:523-530. [PMID: 35377756 DOI: 10.1377/hlthaff.2021.01284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although private equity acquisition of short-term acute care hospitals purportedly improves efficiency and cost-effectiveness, financial performance after acquisition remains unexamined. We compared changes in the financial performance of 176 hospitals acquired during 2005-14 versus changes in matched control hospitals. Acquisition was associated with a $432 decrease in cost per adjusted discharge and a 1.78-percentage-point increase in operating margin. The majority of acquisitions-134 members of the Hospital Corporation of America, acquired in 2006-were associated with a $559 decrease in cost per adjusted discharge but no change in operating margin. Conversely, non-HCA hospitals exhibited a 3.27-percentage-point increase in operating margin without a concomitant change in cost per adjusted discharge. When we examined markers of hospital capacity, operational efficiency, and costs, we found that private equity acquisition was associated with decreases in total beds, ratio of outpatient to inpatient charges, and staffing (total personnel and nursing full-time equivalents and total full-time equivalents per occupied bed). Therefore, financial performance improved after acquisition, whereas patient throughput and inpatient utilization increased and staffing metrics decreased. Future research is needed to identify any unintended trade-offs with safety and quality.
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Affiliation(s)
- Marcelo Cerullo
- Marcelo Cerullo, Duke University Hospital, Durham, North Carolina
| | - Yu-Li Lin
- Yu-Li Lin, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Vivian Ho
- Vivian Ho, Rice University and Baylor College of Medicine, Houston, Texas
| | - Anaeze C Offodile
- Anaeze C. Offodile II , University of Texas MD Anderson Cancer Center and Rice University
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Rotenstein LS, Apathy N, Landon B, Bates DW. Assessment of Satisfaction With the Electronic Health Record Among Physicians in Physician-Owned vs Non-Physician-Owned Practices. JAMA Netw Open 2022; 5:e228301. [PMID: 35446397 PMCID: PMC9024386 DOI: 10.1001/jamanetworkopen.2022.8301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite known benefits, electronic health records (EHRs) have had drawbacks for daily practice and the physician experience. There is evidence that physicians practicing in solo or physician-owned practices are more likely to be satisfied with the EHR and experience lower burnout than those practicing in other ownership arrangements; however, it is unclear how practice ownership patterns interact with physicians' experiences with the EHR and documentation in the EHR now that use of these systems is widespread. OBJECTIVE To examine the association between practice ownership and physician perceptions of the EHR. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included non-federally employed physicians who provided office-based patient care in 2019 and completed the 2019 National Electronic Health Records Survey. The 2019 survey sample consisted of 1524 eligible responses (41.0% unweighted response rate representing 301 603 physicians); of those, 1368 physicians who reported having an EHR and answered questions regarding location ownership were included in the analysis. Data for the 2019 National Electronic Health Records Survey were collected by RTI International from June 14 to December 11, 2019; the current cross-sectional analysis was conducted from October 1 to November 30, 2021. MAIN OUTCOMES AND MEASURES Satisfaction with the EHR, perceptions of time spent on clinical documentation, and presence of staff support for documentation. RESULTS Among 1368 respondents (weighted, 270 813 respondents) included in the analysis, 960 respondents (weighted: 185,385 respondents [68.5%]) were male, and 951 respondents (weighted: 200,622 respondents [74.1%]) were over 50 years of age; 766 respondents (weighted, 161 226 respondents [59.5%]) were working in a practice owned by a physician or physician group, and 700 respondents (weighted, 131 284 respondents [48.5%]) were primary care physicians. A total of 602 respondents (weighted, 109 587 physicians [40.5%]) were working in a non-physician-owned practice. Overall, 529 respondents (weighted, 108 093 respondents [68.1%]) working in physician-owned practices reported being satisfied with their EHR vs 320 respondents (weighted, 63 988 respondents [58.5%]) working in non-physician-owned practices (P = .03). Among those working in physician-owned practices, perceptions that time spent on documentation was appropriate (328 physicians [weighted, 71 827 physicians (44.8%)] vs 191 physicians [weighted, 35 447 physicians (32.4%)]; P = .005) and that staff support for documentation was available (289 physicians [weighted, 57 702 physicians (36.0%)] vs 146 physicians [weighted, 29 267 physicians (26.7%)]; P = .02) were significantly higher compared with those working in non-physician-owned practices. Physicians' perceptions of the appropriateness of time spent and the availability of staff support only partially explained the association between practice ownership type and EHR satisfaction. CONCLUSIONS AND RELEVANCE The results of this nationally representative cross-sectional study suggest that physicians working in physician-owned practices are more likely to be satisfied with the EHR, to have positive perceptions of time spent on documentation, and to have staff support for documentation compared with their counterparts working in non-physician-owned practices. The workflow and cultural forces underlying these differences are important to understand in the setting of known differences in burnout by practice ownership type and ongoing physician group consolidation and acquisition by health care systems.
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Affiliation(s)
- Lisa S. Rotenstein
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Nate Apathy
- Leonard Davis Institute of Health Economics, Wharton School, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania
- Regenstrief Institute, Indianapolis, Indiana
| | - Bruce Landon
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David W. Bates
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
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La Forgia A, Bond AM, Braun RT, Yao LZ, Kjaer K, Zhang M, Casalino LP. Association of Physician Management Companies and Private Equity Investment With Commercial Health Care Prices Paid to Anesthesia Practitioners. JAMA Intern Med 2022; 182:396-404. [PMID: 35226052 PMCID: PMC8886444 DOI: 10.1001/jamainternmed.2022.0004] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Physician management companies (PMCs), often backed by private equity (PE), are increasingly providing staffing and management services to health care facilities, yet little is known of their influence on prices. OBJECTIVE To study changes in prices paid to practitioners (anesthesiologists and certified registered nurse anesthetists) before and after an outpatient facility contracted with a PMC. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used difference-in-differences methods to compare price changes before and after a facility contracted with a PMC with facilities that did not and to compare differences between PMCs with and without PE investment. Commercial claims data (2012-2017) from 3 large national insurers in the Health Care Cost Institute database were combined with a novel data set of PMC facility contracts to identify prices paid to anesthesia practitioners in hospital outpatient departments and ambulatory surgery centers. The cohort included 2992 facilities that never contracted with a PMC and 672 facilities that contracted with a PMC between 2012 and 2017, collectively representing 2 255 933 anesthesia claims. EXPOSURES Temporal variation in facility-level exposure to PMC contracts for anesthesia services. MAIN OUTCOMES AND MEASURES Main outcomes were (1) allowed amounts and the unit price (allowed amounts standardized per unit of service) paid to anesthesia practitioners; and (2) the probability that a practitioner was out of network. RESULTS From before to after the PMC contract period, allowed amounts increased by 16.5% (+$116.39; 95% CI, $76.11 to $156.67; P < .001), and the unit price increased by 18.7% (+$18.79; 95% CI, $12.73 to $24.84; P < .001) in PMC facilities relative to non-PMC facilities. Results did not show evidence that anesthesia practitioners were moved out of network (+2.25; 95% CI, -2.56 to 7.06; P < .36). In subsample analyses, PMCs without PE investment increased allowed amounts by 12.9% (+$89.88; 95% CI, $42.07 to $137.69; P < .001), while PE-backed PMCs (representing half of the PMCs in the sample) increased allowed amounts by 26.0% ($187.06; 95% CI, $133.59 to $240.52; P < .001). Similar price increases were observed for unit prices. CONCLUSIONS AND RELEVANCE In this cohort study, prices paid to anesthesia practitioners increased after hospital outpatient departments and ambulatory surgery centers contracted with a PMC and were substantially higher if the PMC received PE investment. This research provides insights into the role of corporate ownership in health care relevant to policy makers, payers, practitioners, and patients.
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Affiliation(s)
- Ambar La Forgia
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York
| | - Amelia M Bond
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Robert Tyler Braun
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Leah Z Yao
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Klaus Kjaer
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Manyao Zhang
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Lawrence P Casalino
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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Fogel AL, Hogan S, Dover J. Surgical Dermatology and Private Equity: A Review of the Literature and Discussion. Dermatol Surg 2022; 48:339-343. [PMID: 34985045 DOI: 10.1097/dss.0000000000003363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While there has been substantial investment in dermatology by private equity (PE), the relevance of this trend to the dermatologic surgeon has not been assessed. OBJECTIVE The literature on PE investment in medicine was reviewed to provide interdisciplinary data relevant to the dermatologic surgeon. MATERIALS AND METHODS The PubMed database was queried for all peer-reviewed articles containing the term "private equity" and identified 70 unique articles across 18 medical specialties, comprising 20 original research articles and 50 commentary articles. RESULTS Significant PE growth across multiple medical specialties occurred in the 2010s. Private equity ownership was associated with higher levels of nonphysician providers relative to physicians. Pooled data suggest that PE ownership is associated with lower staffing levels, particularly for non-revenue-generating staff, as well as potentially lower levels of medical supplies on hand. Data on financial performance suggests that PE-ownership results in higher profits, revenues, and costs. Surveys of physicians demonstrate concern about autonomy, ethics, and career prospects. CONCLUSION For the dermatologic surgeon, issues related to consolidation, provider scope of practice, support staff availability, and supply management are important due to the nature of procedural intervention and the increased risk of adverse events.
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Affiliation(s)
- Alexander L Fogel
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Sara Hogan
- Division of Dermatology, University of California Los Angeles, Los Angeles, California
| | - Jeffrey Dover
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
- Skin Care Physicians, Boston, Massachusetts
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Henretty KN, He F. Trends in Orthopedic Surgeon Practice Consolidation From 2008 to 2019. J Arthroplasty 2022; 37:409-413. [PMID: 34780926 DOI: 10.1016/j.arth.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In the past decade, physician practices have merged into larger group practices (ie, horizontal consolidation) and have been acquired by hospitals and health systems (ie, vertical consolidation), leaving fewer practices independent. The implications of these changes can be profound, affecting the prices for and spending on physician services, access to care, patients' choice of providers, and quality of care. METHODS We used IQVIA data on orthopedic surgeon practice sites that included information on health system or hospital ownership, group medical practice participation, and average patient volume. We calculated the number and size of group medical practices as measures of horizontal consolidation and the percentage of practice sites owned by a health system or hospital as a measure of vertical consolidation. We also calculated the Herfindahl-Hirschman Index to measure market concentration. RESULTS We found significant horizontal and vertical consolidation nationally and across all regions of the United States. This consolidation has led to much more concentrated markets, as measured by Herfindahl-Hirschman Index, for orthopedic surgeon services. These trends are consistent with studies looking at consolidation of other types of providers. CONCLUSION Orthopedic surgeon practices, like other provider types, have consolidated at a rapid rate over the past decade. A variety of factors may have contributed, including the move away from fee-for-service to alternative payment arrangements, changes in Medicare payment policies, private equity activity, and evolving physician preferences. Due to the potential impacts of this consolidation, more research is needed to examine some of these contributing factors.
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Affiliation(s)
| | - Fang He
- RTI International, Chicago, IL
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Borsa A, Bruch JD. Prevalence and performance of private equity-affiliated fertility practices in the United States. Fertil Steril 2022; 117:124-130. [PMID: 34538462 PMCID: PMC8714667 DOI: 10.1016/j.fertnstert.2021.08.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To quantify the proportion of annual assisted reproductive technology (ART) cycles performed at private equity-affiliated fertility practices and to test for differences in services and success rates between private equity-affiliated and nonaffiliated practices. DESIGN Cross-sectional analysis of national data set. SETTING Not applicable. PATIENT(S) None. INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) The primary outcome measures were the volume of ART cycles performed, the percentage of retrievals resulting in live births, and the percentage of transfers resulting in live births. The secondary outcomes included the median income of the practice location, the use of preimplantation genetic testing, the clinical service availability, and the patient reasons for seeking treatment. RESULT(S) Of the practices listed on the Centers for Disease Control's 2018 Fertility Clinic Success Rates Report, 14.7% had a private equity affiliation. Of the 305,883 ART cycles performed in 2018, 29.3% (89,535) occurred at private equity-affiliated practices. Patients at private equity-affiliated practices were 6.75% (95% confidence interval [CI], -10.15%, -3.36%) less likely to initiate a cycle due to male factor infertility, and 10.60% (95% CI, 3.49, 17.76) more likely to use preimplantation genetic testing before embryo transfer. No statistically significant differences were found in success rates among women aged <35 years. The average median household income (standard error) in zip codes with private equity-affiliated practices compared with nonaffiliated practices was $83,610 ($35,990) and $72,161 ($32,314), respectively. CONCLUSION(S) A major portion of fertility practices in the United States are private equity-affiliated, and these practices perform an even greater portion of ART cycles in the United States each year. Fertility appears to be the medical specialty with the greatest market share owned by private equity. Our findings corroborate preliminary research, which forecasts the increasing involvement and consolidation by private equity in fertility. Future research should continue monitoring for differences in outcomes, financing, case mix, service use, and accessibility.
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Affiliation(s)
- Alexander Borsa
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York.
| | - Joseph Dov Bruch
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Brauer ER, Long EF, Petersen L, Ganz PA. Current practice patterns and gaps in guideline-concordant breast cancer survivorship care. J Cancer Surviv 2021; 17:906-915. [PMID: 34970715 PMCID: PMC9243187 DOI: 10.1007/s11764-021-01152-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/30/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Breast cancer-specific survivorship care guidelines for the more than 3.8 million survivors in the U.S. are available, but implementation in clinical practice remains challenging. We examined current practice patterns and factors associated with guideline-concordant survivorship care among oncologists. METHODS A national sample of medical oncologists, recruited using two databases, participated in a survey focused on practice patterns for breast cancer survivorship care. A "survivorship care composite score" was calculated for each respondent based on provision of services recommended in the survivorship guidelines. Descriptive statistics and multivariable linear regression analyses examined associations between physician and practice characteristics and composite scores. RESULTS The survey was completed by 217 medical oncologists, with an overall response rate of 17.9% and eligibility rate of 56.9% for those who responded. Oncologists reported high engagement in evaluation of disease recurrence (78%). Performed less frequently were the provision of survivorship care plans (46%), assessment of psychosocial long-term and late effects (34%), and screening for subsequent cancers (34%). Lack of survivorship care training (p = 0.038) and not routinely informing patients about potential late effects (p = 0.003) were significantly associated with poorer survivorship care composite scores. CONCLUSIONS Despite the availability of disease-specific survivorship care guidelines, adherence to their recommendations in clinical practice is suboptimal. Survey results identified key gaps in survivorship care for breast cancer survivors, particularly related to subsequent primary cancers and psychosocial long-term and late effects. IMPLICATIONS FOR CANCER SURVIVORS Improving the delivery of comprehensive survivorship care for the growing population of breast cancer survivors is a high priority. Disease-specific clinical guidelines for cancer survivorship provide valuable recommendations, but innovative strategies are needed to integrate them into the care of long-term breast cancer survivors.
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Affiliation(s)
- Eden R. Brauer
- School of Nursing, University of California, Los Angeles (UCLA)
| | - Elisa F. Long
- Anderson School of Management, University of California, Los Angeles (UCLA)
| | - Laura Petersen
- Cancer Prevention and Control Research, University of California, Los Angeles (UCLA)
| | - Patricia A. Ganz
- David Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles (UCLA)
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Cerullo M, Yang KK, Roberts J, McDevitt RC, Offodile AC. Private Equity Acquisition And Responsiveness To Service-Line Profitability At Short-Term Acute Care Hospitals. Health Aff (Millwood) 2021; 40:1697-1705. [PMID: 34724425 DOI: 10.1377/hlthaff.2021.00541] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
As private equity firms continue to increase their ownership stake in various health care sectors in the US, questions arise about potential impacts on the organization and delivery of care. Using a difference-in-differences approach, we investigated changes in service-line provision in private equity-acquired hospitals. Relative to nonacquired hospitals, private equity acquisition was associated with a higher probability of adding specific profitable hospital-based services (interventional cardiac catheterization, hemodialysis, and labor and delivery), profitable technologies (robotic surgery and digital mammography), and freestanding or satellite emergency departments. Moreover, private equity acquisition was associated with an increased probability of providing services that were previously categorized as unprofitable but that have more recently become areas of financial opportunity (for example, mental health services). Finally, private equity-acquired hospitals were less likely to add or continue services that have unreliable revenue streams or that may face competition from nonprofit hospitals (for example, outpatient psychiatry), although fewer shifts were noted among unprofitable services. This may reflect a prevailing shift by acute care hospitals toward outpatient settings for appropriate procedures and synergies with existing holdings by private equity firms.
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Affiliation(s)
- Marcelo Cerullo
- Marcelo Cerullo is a resident in the General Surgery Residency Program, Duke University Hospital, in Durham, North Carolina
| | - Kelly Kaili Yang
- Kelly Kaili Yang is a graduate student in the Department of Economics, Duke University, in Durham, North Carolina
| | - James Roberts
- James Roberts is a professor in and chair of the Department of Economics, Duke University, and a research associate with the National Bureau of Economic Research
| | - Ryan C McDevitt
- Ryan C. McDevitt is a professor in the Fuqua School of Business, Duke University
| | - Anaeze C Offodile
- Anaeze C. Offodile II is an assistant professor in the Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, in Austin, Texas, and a nonresident fellow in Domestic Health Policy at the Baker Institute for Public Policy, Rice University, in Houston, Texas. He is the current Gilbert Omenn Fellow of the National Academy of Medicine
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Boysen PG, Cox K, Hearns G. A Dirge for Academic Medicine: Combined Effects of the COVID-19 Pandemic and Private Equity Acquisitions. MISSOURI MEDICINE 2021; 118:523-528. [PMID: 34924616 PMCID: PMC8672944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Philip G Boysen
- Professor and Vice Chair, Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Katherine Cox
- Assistant Professor and Program Director, Department of Anesthesiology
| | - Gary Hearns
- Professor and Chair, Department of Anesthesiology; both are at Tulane University School of Medicine, New Orleans, Louisiana
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Berry LL, Letchuman S, Ramani N, Barach P. The High Stakes of Outsourcing in Health Care. Mayo Clin Proc 2021; 96:2879-2890. [PMID: 34412855 DOI: 10.1016/j.mayocp.2021.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/13/2021] [Accepted: 07/06/2021] [Indexed: 11/16/2022]
Abstract
Outsourcing in health care has become increasingly common as health system administrators seek to enhance profitability and efficiency while maintaining clinical excellence. When clinical services are outsourced, however, the outsourcing organization relinquishes control over its most important service value: high-quality patient care. Farming out work to an external service provider can have many unintended results, including inconsistencies in standards of care; harmful medical errors; declines in patient and employee satisfaction; and damage to clinicians' morale and income, and to the health organization's culture, reputation, and long-term financial performance. Research on outsourcing in the areas of emergency medicine, radiology, laboratory services, and environmental services provides concerning evidence of potentially large downsides when outsourcing is driven by short-term cost concerns or is planned without diligently considering all of the ramifications of not keeping key clinical and nonclinical services in-house. To better equip health system leaders for decision-making about outsourcing, we examine this body of literature, identify common pitfalls of outsourcing in specific clinical and nonclinical health services and scenarios, explore alternatives to outsourcing, and consider how outsourcing (when necessary) can be done in a strategic manner that does not compromise the values of the organization and its commitment to patients.
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Affiliation(s)
- Leonard L Berry
- Mays Business School, Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Boston, MA.
| | | | - Nandini Ramani
- Mays Business School, Texas A&M University, College Station, TX
| | - Paul Barach
- Wayne State University School of Medicine, MI; Jefferson College of Population Health, Philadelphia, PA; Interdisciplinary Research Institute for Health Law and Science, Sigmund Freud University, Vienna, Austria
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Private Equity and Its Emergence in Orthopaedics. J Am Acad Orthop Surg 2021; 29:e1005-e1012. [PMID: 34288894 DOI: 10.5435/jaaos-d-21-00058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/18/2021] [Indexed: 02/01/2023] Open
Abstract
Private equity (PE) is increasing its role in healthcare financing and may be a source of strategic funding for orthopaedic practice groups. With acquisitions in other medical specialties such as dermatology and ophthalmology, PE works to increase operating efficiency and cut costs. Orthopaedic practices' access to revenue through ancillary services and ambulatory surgery centers, coupled with a growing, aging cohort, make them an attractive candidate for PE acquisition. However, careful consideration is warranted before surgeons enter these partnerships to ensure patient safety, and the quality of care is not compromised because PE works to increase the return on their investment.
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38
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Price DW, Davis DA, Filerman GL. "Systems-Integrated CME": The Implementation and Outcomes Imperative for Continuing Medical Education in the Learning Health Care Enterprise. NAM Perspect 2021; 2021:202110a. [PMID: 34901778 PMCID: PMC8654469 DOI: 10.31478/202110a] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- David W Price
- University of Colorado Anschutz School of Medicine and the American Board of Family Medicine
| | - David A Davis
- AXDEV Group, University of Toronto and Mohammed Bin Rashid University of Medicine & the Health Sciences
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Crowley R, Atiq O, Hilden D. Financial Profit in Medicine: A Position Paper From the American College of Physicians. Ann Intern Med 2021; 174:1447-1449. [PMID: 34487452 DOI: 10.7326/m21-1178] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.
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Affiliation(s)
- Ryan Crowley
- American College of Physicians, Washington, DC (R.C.)
| | - Omar Atiq
- University of Arkansas for Medical Sciences, Little Rock, Arkansas (O.A.)
| | - David Hilden
- Hennepin Healthcare, Minneapolis, Minnesota (D.H.)
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Affiliation(s)
- Joan M. Teno
- School of Medicine, Oregon Health & Science University, Portland
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41
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Newton DC, Arthur ME, Berman AE. Private equity in anesthesiology - Indicators for future evaluation. J Clin Anesth 2021; 75:110447. [PMID: 34252730 DOI: 10.1016/j.jclinane.2021.110447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Affiliation(s)
- David C Newton
- Medical College of Georgia, Augusta, GA 30912, United States of America.
| | - Mary E Arthur
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta, GA 30912, United States of America
| | - Adam E Berman
- Division of Cardiology, Division of Health Economics and Modeling, Medical College of Georgia, Augusta, GA 30912, United States of America
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Braun RT, Bond AM, Qian Y, Zhang M, Casalino LP. Private Equity In Dermatology: Effect On Price, Utilization, And Spending. Health Aff (Millwood) 2021; 40:727-735. [PMID: 33939519 DOI: 10.1377/hlthaff.2020.02062] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Private equity firms have increasingly acquired physician practices, and particularly dermatology practices. Analyzing commercial claims from the Health Care Cost Institute (2012-17), we used a difference-in-differences design within an event study framework to estimate the prevalence of private equity acquisitions and their impact on dermatologist prices, spending, utilization, and volume of patients. By 2017 one in eleven dermatologists practiced in a private equity-owned practice, and private equity-owned practices employed four advanced practitioners for every ten dermatologists compared with three for non-private equity practices. Private equity firms targeted their acquisitions at larger practices that saw more commercially insured patients compared with practices that were never acquired by private equity firms. The volume of patients per private equity dermatologist ranged from 4.7 percent to 17.0 percent higher than the volume per non-private equity dermatologist up to nine quarters after acquisition. At 1.5 years after acquisition, prices paid to private equity dermatologists for routine medical visits were 3-5 percent higher than those paid to non-private equity dermatologists. There was no significant consistent impact on dermatology spending or use of biopsies, lesion destruction, or Mohs surgery. Policy makers and dermatology practice leaders may want to track the rapidly evolving phenomenon of private equity acquisitions.
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Affiliation(s)
- Robert Tyler Braun
- Robert Tyler Braun is an instructor in population health sciences in the Department of Population Health Sciences, Weill Cornell Medicine, in New York, New York
| | - Amelia M Bond
- Amelia M. Bond is an assistant professor of population health sciences in the Department of Population Health Sciences, Weill Cornell Medicine
| | - Yuting Qian
- Yuting Qian is a research coordinator in the Department of Population Health Sciences, Weill Cornell Medicine
| | - Manyao Zhang
- Manyao Zhang is a data analyst in the Department of Population Health Sciences, Weill Cornell Medicine
| | - Lawrence P Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor and chief of the Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medicine
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DeCamp M, Snyder Sulmasy L. Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices: A Policy Paper From the American College of Physicians. Ann Intern Med 2021; 174:844-851. [PMID: 33721520 DOI: 10.7326/m20-7093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The environment in which physicians practice and patients receive care continues to change. Increasing employment of physicians, changing practice models, new regulatory requirements, and market dynamics all affect medical practice; some changes may also place greater emphasis on the business of medicine. Fundamental ethical principles and professional values about the patient-physician relationship, the primacy of patient welfare over self-interest, and the role of medicine as a moral community and learned profession need to be applied to the changing environment, and physicians must consider the effect the practice environment has on their ethical and professional responsibilities. Recognizing that all health care delivery arrangements come with advantages, disadvantages, and salient questions for ethics and professionalism, this American College of Physicians policy paper examines the ethical implications of issues that are particularly relevant today, including incentives in the shift to value-based care, physician contract clauses that affect care, private equity ownership, clinical priority setting, and physician leadership. Physicians should take the lead in helping to ensure that relationships and practices are structured to explicitly recognize and support the commitments of the physician and the profession of medicine to patients and patient care.
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Affiliation(s)
- Matthew DeCamp
- University of Colorado Anschutz Medical Campus, Aurora, Colorado (M.D.)
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Hahn U, Baulig C, Brzoska P. [Structures of Outpatient Medical Care: Germany and Other Decentrally Organized Healthcare Systems]. DAS GESUNDHEITSWESEN 2021; 83:337-344. [PMID: 33765686 PMCID: PMC8116118 DOI: 10.1055/a-1390-3935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hintergrund
Das Bild vertragsärztlicher Versorgung ist arztbezogen; wenig beachtet wird der (potentielle) Einfluss von Versorgungsorganisationen (VO) und deren Merkmalen auf das Versorgungsgeschehen.
Ziel
Beschreibung der organisationsbezogenen Angebotsstrukturen nach Rechtsformen, Abgleich mit denen anderer dezentral organisierter Gesundheitssysteme und Diskussion, ob sich entlang der Rechtsform Effekte für verschiedene Dimensionen des Versorgungsgeschehens zeigen lassen.
Material und Methoden
Die Häufigkeiten von Einzelpraxis, Gemeinschaftspraxis und Medizinischen Versorgungszentren (MVZ) für haus- und fachärztliche Versorgungsbereiche, die durchschnittliche ärztliche Teamstärke und der Anteil der VO mit interdisziplinärer Aufstellung werden auf Basis von Sekundärdatenquellen (überwiegend Kassenärztliche Bundesvereinigung) im Zeitablauf beschrieben.
Ergebnisse
Die Angebotsstrukturen sind durch hohe Fragmentierung (2018:>80 000 VO) mit hohem Anteil von Kleinstorganisationen (über alle VO 73% Einzelpraxen), niedriger durchschnittlicher Teamstärke (über alle VO 1,7 Ärzte) und geringem Anteil mit interdisziplinärer Aufstellung (17% aller Gemeinschaftspraxen und MVZ) bei geringer Konzentrationsdynamik in der haus- und fachärztlichen Versorgung geprägt.
Schlussfolgerungen
Die Kleinteiligkeit der deutschen Angebotsstrukturen ist ausgeprägter bzw. persistierender als die in anderen dezentralen Gesundheitssystemen. Rechtsformen und Durchschnittswerte erfassen die Heterogenität der VO-Morphologien nur unzureichend. Wünschenswert, z. B. für eine gezielte Versorgungssteuerung, wäre eine breitere Datenbasis zu mehr organisationsbezogenen Merkmalen.
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Affiliation(s)
- Ursula Hahn
- Lehrstuhl für Medizinische Biometrie und Epidemiologie, Universität Witten/Herdecke Fakultät für Gesundheit, Witten, Deutschland.,OcuNet GmbH & Co. KG, Düsseldorf, Deutschland
| | - Christine Baulig
- Lehrstuhl für Medizinische Biometrie und Epidemiologie, Universität Witten/Herdecke Fakultät für Gesundheit, Witten, Deutschland
| | - Patrick Brzoska
- Lehrstuhl für Versorgungsforschung, Universität Witten/Herdecke Fakultät für Gesundheit, Witten, Deutschland
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Affiliation(s)
- Jane M Zhu
- From the Division of General Internal Medicine, Oregon Health and Science University, Portland (J.M.Z.); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, the Johns Hopkins Carey Business School, and the Hopkins Business of Health Initiative, Johns Hopkins University, Baltimore (D.P.)
| | - Daniel Polsky
- From the Division of General Internal Medicine, Oregon Health and Science University, Portland (J.M.Z.); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, the Johns Hopkins Carey Business School, and the Hopkins Business of Health Initiative, Johns Hopkins University, Baltimore (D.P.)
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Kirsh GM, Kapoor DA. Private Equity and Urology: An Emerging Model for Independent Practice. Urol Clin North Am 2021; 48:233-244. [PMID: 33795057 DOI: 10.1016/j.ucl.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Independent urology practices are under increasing competitive pressure in a changing marketplace. By providing access to capital and business management expertise, private equity can help practices consolidate and scale to unlock new growth opportunities, navigate an increasingly complex regulatory environment, and institute best practice across a network, while retaining physician ownership and an opportunity for equity appreciation. This article examines the role of private equity in urology and the potential benefits of private equity investment. It also looks at what firms look for in investment partners, how to prepare for private equity investment, and how private equity investments are structured.
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Affiliation(s)
- Gary M Kirsh
- The Urology Group Cincinnati, Solaris Health Holdings, 2000 Joseph E. Sanker Boulevard, Cincinnati, OH 45212, USA.
| | - Deepak A Kapoor
- Integrated Medical Professionals, Solaris Health Holdings, LLC, The Icahn School of Medicine at Mount Sinai, 340 Broadhollow Road, Farmingdale, NY 11735, USA
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47
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Affiliation(s)
- Carrie Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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48
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Satiani B, Zigrang TA, Bailey-Wheaton JL. Should surgeons consider partnering with private equity investors? Am J Surg 2020; 222:453-458. [PMID: 33358374 DOI: 10.1016/j.amjsurg.2020.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/08/2020] [Accepted: 12/16/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Bhagwan Satiani
- The Division of Vascular Diseases & Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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Maurer KA, Blue L, Orzol S, Morrison Hensleigh N, Peikes D. Measuring physician practice site characteristics: A comparison of data from SK&A and a practice site survey. Health Serv Res 2020; 56:334-340. [PMID: 33197041 DOI: 10.1111/1475-6773.13601] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate the comparability of commercially available practice site data from SK&A with survey data to understand the implications of using SK&A data for health services research. DATA SOURCES Responses to the Comprehensive Primary Care Plus (CPC+) Practice Survey and SK&A data. STUDY DESIGN Comparison of CPC + Practice Survey responses to SK&A information for 2698 primary care practice sites. DATA COLLECTION CPC + Practice Survey data collected through a web-only survey from April through September 2017, and SK&A data purchased in November 2016. PRINCIPAL FINDINGS Information was similar across data sources, although some discrepancies were common. For example, 56% of practice sites had differences in the reported number of practitioners, and larger sites tended to have larger differences. Among practice sites with 1 practitioner in the survey, only 1.3% had a difference of 3 or more practitioners between the data sources, whereas 63% of practice sites with 11 or more practitioners had a difference of 3 or more practitioners. CONCLUSIONS Discrepancies between data sources could reflect differences of interpretation when defining practice site characteristics, changes over time in those characteristics, or data errors in either SK&A or the survey. Researchers using SK&A data should consider possible ramifications for their studies.
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Affiliation(s)
| | - Laura Blue
- Mathematica Policy Research Inc, Washington, District of Colombia, USA
| | - Sean Orzol
- Mathematica Policy Research Inc, Ann Arbor, Michigan, USA
| | | | - Deborah Peikes
- Mathematica Policy Research Inc, Princeton, New Jersey, USA
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50
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Private Equity Investments in Women's Health and Obstetrics and Gynecology Practices. Obstet Gynecol 2020; 136:1217-1220. [PMID: 33156192 DOI: 10.1097/aog.0000000000004151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Private equity has evolved into a major force in health care, with deal values and volumes rising year-over-year as these firms purchase hospital systems and physician groups. Historically, these investors have played an outsized role in highly reimbursed specialties such as dermatology and anesthesia. Private equity is relatively new to women's health; when it has invested in this sector, it has typically done so in fertility services. In recent years, however, private equity firms have ventured into general obstetrics and gynecology, drawn by its promise of steady returns, its fragmented landscape, and the potential to integrate related laboratory, ultrasound, and fertility services into obstetric care. Obstetrics and gynecology practices may soon face the prospect of acquisition by private equity firms offering professional management, centralized back-office functions, streamlined customer service, and the capital needed to reach a broader patient base. However, physicians may have concerns about the tradeoffs that accompany private equity acquisitions. Private equity-owned practices have been known to increase the use of lucrative services, deploy advanced practice professionals in place of physicians, and circumvent conflict-of-interest laws, potentially distorting clinical care and driving up costs for consumers. Furthermore, firms generally aim to exit their investment within a 3- to 7-year timeframe, and short-term growth plans may leave physician-owners with uncertain long-term management. As private equity makes headway into women's health, physicians and policymakers must pay closer attention to how this activity can change practice patterns and transform local health care markets while also demanding transparency in the process.
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