Associations of U.S. hospital closure (2007-2018) with area socioeconomic disadvantage and racial/ethnic composition.

PURPOSE: To examine whether hospital closure is associated with high levels of area socioeconomic disadvantage and racial/ethnic minority composition. METHODS: Pooled cross-sectional analysis (2007-2018) of 6467 U.S. hospitals from the American Hospital Association's Annual Survey, comparing hospital population characteristics of closed hospitals to all remaining open hospitals. We used multilevel mixed-effects logistic regression models to assess closure as a function of population characteristics, including area deprivation index ([ADI], a composite measure of socioeconomic disadvantage), racial/ethnic composition, and rural classification, nesting hospitals within hospital service areas (HSAs) and hospital referral regions. Secondary analyses examined public or private hospital type. RESULTS: Overall, 326 (5.0%) of 6467 U.S. hospitals closed during the study period. In multivariable models, hospitals in HSAs with a higher burden of socioeconomic disadvantage (per 10% above median ADI ZIP codes, AOR 1.05; 95% CI, 1.01-1.09) and Black Non-Hispanic composition (highest quartile, AOR 4.03; 95% CI, 2.62-6.21) had higher odds of closure. We did not observe disparities in closure by Hispanic/Latino composition or rurality. Disparities persisted for Black Non-Hispanic communities, even among HSAs with the lowest burden of disadvantage. CONCLUSIONS: Disproportionate hospital closure in communities with higher socioeconomic disadvantage and Black racial composition raises concerns about unequal loss of healthcare resources in the U.S.

Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition.

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.

Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review.

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.

Workforce Composition In Private Equity-Acquired Versus Non-Private Equity-Acquired Physician Practices.

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.

Comparison of the Financial and Operational Characteristics of For-Profit and Nonprofit Hospitals Receiving Federal Graduate Medical Education Payments, 2011-2020.

This study compares graduate medical education (GME) payments between nonprofit and for-profit hospitals between 2011 and 2020 to assess how hospitals value GME.

Association of Private Equity Acquisition of Physician Practices With Changes in Health Care Spending and Utilization.

Importance: Private equity acquisitions of physician practices in the US have been increasing rapidly; however, the implications for health care delivery and spending are unclear. Objective: To examine changes in prices and utilization associated with private equity acquisitions of physician practices across multiple specialties. Design, Settings, and Participants: This was a difference-in-differences event study of US physician practices specialized in dermatology, gastroenterology, and ophthalmology that were acquired by private equity firms from 2016 to 2020. Within each specialty, each private equity-acquired (PE-acquired) practice was matched with as many as 5 control practices based on the preacquisition number of unique patients, encounters, risk score, share of services billed out-of-network, and spending. The PE-acquired practices were compared with matched controls through year 2 after acquisition, using a difference-in-differences event study. Data analyses were performed from March 2021 to February 2022. Exposures: Private equity acquisition of physician practices. Main Outcomes and Measures: Measures of spending and utilization, including the charge and price (amount paid) per claim, new and unique patients, and total encounters. Results: Compared with the 2874 control practices, the 578 PE-acquired physician practices exhibited an average increase of $71 (+20.2%) charged per claim (95% CI, 13.1%-27.3%; P < .001) and $23 (+11.0%) in the allowed amount per claim (95% CI, 5.6%-16.5%; P < .001). The PE-acquired practices increased their numbers of unique patients seen by 25.8% (95% CI, 15.8%-35.6%; P < .001) compared with control practices, driven by a 37.9% increase in visits by new patients (95% CI, 25.6%-50.2%; P < .001). In aggregate, their volume of encounters increased by 16.3% (95% CI, 1.0%-32.0%; P = .04) compared with the control group, with a 9.4% increase in the share of office visits for established patients that were billed as longer than 30 minutes (95% CI, 1.7%-17.0%; P = .02). No statistically significant changes in patient risk scores were found between PE-acquired practices and controls. Within specialties, we found modest differences along selected outcomes. Conclusions and Relevance: In this difference-in-differences study, private equity acquisition of physician practices in dermatology, gastroenterology, and ophthalmology were associated with differential increases in allowed amount and charges per claim, volume of encounters, and new patients seen, as well as some changes in billing and coding.

Private Equity Acquisitions Of Ambulatory Surgical Centers Were Not Associated With Quality, Cost, Or Volume Changes.

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.

Trends in Real Estate Investment Trust Ownership of US Health Care Properties.

This cross-sectional study examines the prevalence and characteristics of real estate investment trust-owned health care properties in the US health care sector.

Prevalence and performance of private equity-affiliated fertility practices in the United States.

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.

Mortality Before and After Border Wall Construction Along the US-Mexico Border, 1990-2017.

Objectives. To evaluate changes in mortality in US counties along the US-Mexico border in which there was substantial new border wall construction after the Secure Fence Act of 2006 relative to border counties in which there was no such border wall construction. Methods. Using complete 1990 to 2017 mortality microdata and a quasi-experimental difference-in-differences design, we evaluated changes in overall (all-cause) mortality, mortality from drug overdose, and mortality from homicide in the 10 counties with substantial new border wall construction and 11 counties with no such construction. We fit a linear model, adjusting for population characteristics and county and year fixed effects, with Bonferroni adjustments for multiple comparisons. Sensitivity analyses included the addition of adjacent inland counties and modifications to the statistical model. Results. Relative to counties without substantial new border wall construction, counties in which a substantial amount of new border wall was constructed exhibited a nonsignificant 0.02-percentage-point increase (95% confidence interval [CI] = -0.06, 0.10; P > .99) in overall mortality after construction. Border wall construction was not associated with changes in either deaths from overdose or deaths from homicide. Conclusions. Wall construction along the US-Mexico border after the Secure Fence Act of 2006 was not associated with discernible changes in mortality.

Changes in Hospital Income, Use, and Quality Associated With Private Equity Acquisition.

Importance: Rigorous evidence describing the relationship between private equity acquisition and changes in hospital spending and quality is currently lacking. Objective: To examine changes in hospital income, use, and quality measures that may be associated with private equity acquisition. Design, Setting, and Participants: This cohort study identified 204 hospitals acquired by private equity firms from 2005 to 2017 and 532 matched hospitals not acquired by private equity. Using a difference-in-differences design, this study evaluated changes in net income, charges, charge to cost ratios, case mix index (a measure of reported illness burden), share of discharges for patients with Medicare or Medicaid coverage, discharges per year, and aggregate hospital quality measures associated with private equity acquisition through 3 years after acquisition, adjusted for case mix, hospital beds, calendar year, and adjustment for multiple hypothesis testing. In subgroup analyses, changes in outcomes for private equity-owned Hospital Corporation of America (HCA) hospitals and non-HCA hospitals relative to matched controls were assessed. Primary Outcomes and Measures: Eight hospital income and use measures and 3 aggregate hospital quality measures were examined. Results: Relative to 532 control hospitals, the 204 private equity-acquired hospitals showed a mean increase of $2 302 391 (95% CI, $956 660-$3 648 123; P = .009) in annual net income, an increase of $407 (95% CI, $296-$518; P < .001) in total charge per inpatient day, an increase of 0.61 (95% CI, 0.48-0.73; P < .001) in emergency department charge to cost ratio, an increase of 0.31 (95% CI, 0.26-0.37; P < .001) in total charge to cost ratio, an increase of 0.02 (95% CI, 0.01-0.02; P = .007) in case mix index, and a decrease of 0.96% (95% CI, 0.46%-1.45%; P = .002) in share of Medicare discharges. Medicaid's share of discharges (-0.16%; 95% CI, -0.86% to 0.53%; P > .99) and total hospital discharges (98; 95% CI, -54 to 250; P > .99) did not change differentially in a statistically significant manner. The aggregate quality score for acute myocardial infarction increased by 3.3% (95% CI, 1.6%-5.0%; P = .002), and the aggregate score for pneumonia increased by 2.9% (95% CI, 1.8%-3.9%; P < .001) in private equity-acquired hospitals relative to controls. The aggregate score for heart failure (1.3%; 95% CI, -0.2% to 2.7%; P = .92) did not differentially change in a statistically significant manner. In subgroup analyses, HCA hospitals showed similar findings to the entire sample. Among non-HCA hospitals, the only statistically significant relative changes were the increase in the emergency department charge to cost ratio (0.30; 95% CI, 0.12-0.48; P = .02) and the decrease in Medicare's share (-1.15%; 95% CI, -1.88% to -0.43%; P = .02). Non-HCA hospitals showed a decrease in the aggregate heart failure score (-3.3%; 95% CI, -5.3% to -1.3%; P = .01) and no statistically significant changes in the aggregate score for acute myocardial infarction (2.4%; 95% CI, -0.7% to 5.4%; P > .99) or pneumonia (0.2%; 95% CI, -1.4% to 1.7%; P > .99). Conclusions and Relevance: Hospitals acquired by private equity were associated with larger increases in net income, charges, charge to cost ratios, and case mix index as well as with improvement in some quality measures after acquisition relative to nonacquired controls. Heterogeneity in some findings was observed between HCA and non-HCA hospitals.