Debunking the private equity industry’s messaging about its healthcare investments

Private equity’s role in the US healthcare sector is facing increased scrutiny from researchers, journalists, policymakers, and regulators, spurred by a growing body of evidence documenting its negative effects. Multiple state legislatures[1] and members of Congress[2] are introducing and debating legislation that would curtail some of the harmful business practices of private equity firms in healthcare. As a result, the private equity industry and its lobbyists are fighting for the industry to be seen as credible and reputable.

Over the last year, the primary private equity industry trade group, American Investment Council (AIC), has engaged in a digital campaign aimed at burnishing private equity’s reputation in healthcare.[3] In February 2024, it released a report, in partnership with PitchBook, in an attempt to argue that private equity is improving healthcare.[4] In June 2024, the AIC released a video and published a blog titled, “Proponents of Misinformed Inquiry into Health Care Consolidation Rely on False Narratives and Shoddy Research.”[5]

And in early July 2024, data provider PitchBook published an analyst note that argues that “In general, the role of PE investment within the broader US healthcare ecosystem has been vastly overstated.”[6] Healthcare industry news outlets have reported on this note without critically examining the data used to make such an argument.[7]

The Pitchbook report closely mirrors the misleading talking points that the American Investment Council has been using for months. AIC featured the Pitchbook report on its website shortly after its release.

PitchBook is a valuable resource for information on private investments and deals, including private equity investments. However, the data it aggregates is not immune to being spun to support narratives and claims that are misleading, or even worse, inaccurate.

In this blog post, we will fact-check and contextualize the major claims the private equity industry and others are making and/or amplifying in order to demonstrate how the private equity industry is spinning data to defend itself from legitimate, evidence-informed criticism.

Claim: “Private equity investment in health care providers is declining.”

Fact-check: This claim, published on an AIC website, cites PitchBook’s assertion that “PE investment in healthcare providers is neither new nor surging. Such investment grew as a proportion of overall PE activity between 2000 and 2018 but has declined proportionally since then.”[8] These claims are misleading for two reasons.

First, the PitchBook analyst note includes a footnote for this claim explaining that add-on deals have been excluded from this analysis.[9] Add-on acquisitions are when a private equity firm uses a platform company to roll-up multiple smaller companies. These types of deals have made up the majority of private equity-health services deals since 2018. Excluding add-on deals distorts the data to make it appear that private equity firms are not investing at the levels in which they actually are. A PitchBook search of US-based private equity healthcare services deals (buyouts, add-ons, and growth investments) for the time period January 1, 2018 to July 10, 2024, yielded 6,410 deals; 4,244 (66%) of which were add-on acquisitions.[10] To fail to include this number of deals in an analysis of private equity investment activity is disingenuous.

Second, the healthcare space includes multiple subsectors alongside providers, and there was overall increased deal activity by volume and deal value through 2021. PitchBook itself, alongside other consultant and analyst groups[11] in the industry, has documented increased PE deal activity in the U.S. healthcare sector through 2021.

Overall PE deal activity (in healthcare + all other industries) began to slow down in 2021 and new dealmaking is currently “sluggish.” The primary driver behind this trend is a high interest rate environment that makes it more challenging for firms to sell assets and buy assets because debt is now expensive and can be challenging to secure. Private equity firms still see substantial opportunity in the healthcare arena, including healthcare providers, and we can expect to see more deals as interest rates come down. Indeed, Pitchbook expects global private equity and other private fund assets under management to reach $20-$24 trillion by 2028 (from $14.7 trillion now).

The slowdown in dealmaking from record highs in 2020 and 2021 also masks the fact that despite current macroeconomic headwinds, many PE firms are still buying up healthcare services providers, as well as other types of healthcare companies. In January 2022, PitchBook reported that “Healthcare devices, supplies, and services—which include providers such as doctors and dentists—have continued to dominate overall PE deal activity. Other areas such as healthcare IT have also drawn significant PE interest.”[12]

PESP’s 2022 and 2023 Acquisitions reports, which both cited PitchBook data extensively, also show the same trends. The two categories with the highest number of deals in PESP’s 2023 report were outpatient care providers and dental care providers. There’s a high volume of deals, even if this volume is not as high as it was in the lower interest rate period leading up to 2022.

Some specific areas of healthcare are seeing high volumes of deals even with high interest rates. Private equity has accounted for more than 60% of all behavioral health deals since 2018.[13] In the last ten years, 342 cardiology clinics were acquired by private equity, with more than 94% of the acquisitions occurring between 2021 and 2023.[14]

Claims: (1) “There “has not been a significant [private equity] acquisition of a US hospital” in over six years.” (AIC)[15] and (2) “Current PE deal activity in hospitals and skilled nursing facilities is near zero. There has not been a major PE investment in a US hospital or health system since 2018.” (PitchBook)[16]

Fact-check: This is misleading. There have been multiple private equity acquisitions of hospitals since 2018, including high-profile ones.

• In 2021, Apollo Global Management-owned Lifepoint Health acquired 61 Kindred hospitals which it spun into a new company, ScionHealth, along with 18 Lifepoint hospitals.[17]
• In January 2023, ScionHealth acquired Cornerstone Health Group adding 15 specialty hospitals and eight senior living locations with 3,000 employees.[18]
• In February 2023, Lifepoint acquired psychiatric hospital chain Springstone, adding 18 hospitals and 35 outpatient locations.[19] Apollo now owns approximately 220 hospitals through its two health systems – Lifepoint and Scion[20] – and is also an investor, via a loan made in 2022, in the real estate portfolio of eight Steward Health Care hospitals in Massachusetts.[21]
• In 2019, Pipeline Health (owned by Deerfield Management, Davidson Kempner Capital Management and Stanton Road Capital) acquired three safety net hospitals in Chicago, Illinois. Less than a year later, one of the hospitals closed, and it has still not reopened. Pipeline filed for Chapter 11 bankruptcy in October 2023.[22]
• In January 2024, venture capital firm General Catalyst announced plans to acquire nonprofit health system Summa Health in Ohio.[23]

PitchBook’s analysis excludes transactions like the ones listed above, since they are add-on acquisitions to already existing PE-owned hospital systems.[24] By excluding add-on acquisitions of hospitals, it distorts the data in way that makes it appear private equity firms are not investing in hospitals.

The assertion also obscures the number of hospitals that are currently owned by private equity firms: 460 hospitals in the US are owned by PE, which accounts for 8 percent of all private (non-government) hospitals and 22 percent of all proprietary for-profit hospitals (as documented by PESP’s original private equity hospital tracker).[25]

At private equity-owned hospitals, PESP, various unions, and other stakeholders have documented extensive issues. See our reports on Pipeline Health, Prospect Medical Holdings, Steward Health Care, and Apollo-owned hospitals (ScionHealth and Lifepoint) – all hospitals currently or formerly owned by private equity firms that follow/ed a typical private equity business model that uses extensive leverage and financial engineering (such as sale lease-backs and dividend recapitalizations), often resulting in understaffing, service cuts, closures, and other poor outcomes.

A recent peer-reviewed study demonstrated that private equity acquisition of

hospitals was associated with a 25.4 percent increase in hospital-acquired conditions, including falls and bloodstream infections.[26] A 2023 systematic review of the research on private equity ownership and its impacts on health outcomes, costs, and quality found that private equity ownership was associated with reduced nurse staffing levels.[27]

And finally, the PitchBook analyst looks at U.S. deals. But private equity firms are also buying up hospitals in the Global South as regulatory scrutiny heats up in the U.S.[28]

PE firms are also profiting from hospitals in ways that do not involve owning the hospital operations themselves. Many nonprofit and non PE-owned for-profit hospitals have contracts with private equity-owned physician staffing companies, radiology and imaging services, travel nursing companies and managed services providers, revenue cycle management companies, and other types of PE-owned contractors and vendors etc. Some PE-owned businesses are also entering into joint ventures (JVs) with nonprofit systems, such as Lifepoint’s JV with Ascension.

Even if investments in hospitals are slowing, that does not mean private equity acquisitions of hospitals do not need updated regulations. What has transpired with private equity-owned hospital systems in recent years could very well happen again without intervention from policymakers and regulators.In regards to short term nursing facilities, PE has indeed held off on making new investments, which is likely due to increased regulatory scrutiny following blockbuster research showing increased mortality rates at PE-owned nursing homes, as well as market saturation. However, PE firms are still investing in rehabilitation hospitals, senior living and assisted living facilities.

Claims: (1) “Private equity is not the primary driver of an increase in employed (vs. private practice) physicians.” (AIC)[29] and (2) “The growth in physician employment is not primarily PE driven. More than half of all physicians, and more than 70% of all employed physicians, are employed by hospitals.” (PitchBook)[30]

Fact-check: The cited data does not disaggregate PE-owned hospitals from non-PE-owned hospitals, and we know that some PE-owned hospital systems have physician group business lines, such as Lifepoint. Furthermore, it obscures the fact that certain types of healthcare providers are dominated by PE in particular geographies. Last year, NYT reported that private equity owns more than half of specialists in certain U.S. markets, with higher prices in those respective markets.[31]

In AIC’s own February 2024 report, the trade group boasts of private equity’s role as a “catalyst” in helping multispecialty practices “expand and diversify.” The AIC report notes that :

“studies show that more physicians are working in large, multi-specialty clinics than ever. 27% of physicians now work in these clinics (up from 22% in 2012), and 18% work in practices with at least 50 other physicians (up from 12% in 2012). The American Medical Association found that ‘physicians are less likely to work in private practice than 10 years ago due to economic, administrative and regulatory burdens.’ More doctors are choosing to work under one roof with other physicians, and PE capital is a catalyst in helping those practices expand and diversify— especially into areas where more physicians are needed.”[32]

Claim: “PE investors currently shy away from out-of-network investment. While investors chased higher out-of-network rates in the past, they now avoid them assiduously in categories including acute-care physician staffing, SUD treatment, and EMT.”[33]

Fact-check: This is misleading. The report recognizes that the No Surprises Act, which went into effect in 2022, has limited the ability of private equity-backed physician staffing companies to use out-of-network billing (i.e. surprise billing). So a regulation curtailed this business practice, rather than PE firms deciding not to do it. It also neglects to mention the fact that PE-owned physician staffing companies spent tens of millions of dollars on a dark money campaign opposing legislation to reign in surprise billing.

Furthermore, private equity has indeed continued to chase out-of-network rates even after the No Surprises Act. The law established an independent dispute resolution (IDR) process to adjudicate disputes between insurers and providers over payment for affected out-of-network services. Four private equity-backed provider groups have accounted for a large and disproportionate share (approximately 74%) of cases in the IDR process.

Claim: “PE-backed providers represent less than 4% of the US healthcare provider ecosystem by revenue.”[34] 

Fact-check: This assertion is made based on an estimate that disaggregates revenue at hospitals versus “PE-backed healthcare providers.” However, multiple hospitals in the U.S. are owned by private equity for which this estimate does not account, and therefore the estimate is comparing apples to oranges. The analyst note also shows a graph that disaggregates annual healthcare provider spending by type, with the following three categories:  hospitals, PE-backed providers, and all other providers excluding PE-backed. It says the source for this table is CMS National Health Expenditures Data, even though CMS does not disaggregate spending data by ownership type.

The “less than four percent by revenue” estimate assumes the cumulative enterprise value (EV) of PE-backed provider companies in the US is an average 2.0x EV/revenue multiple. PE-owned providers are rarely required to report their revenues and other financial metrics, and therefore such an estimate is relying on incomplete and self-reported data from private equity firms.

It is true that there are many large, consolidated nonprofit and publicly traded health systems with substantial revenues, and PE’s primary areas of investment in the healthcare provider space are outpatient sector deals of smaller physician practices that they intend to roll-up/scale up.[35] However, with incomplete data and an data that does not take into account private equity-ownership of various hospital systems, the assertion that “PE-backed providers represent less than 4% of the US healthcare provider ecosystem by revenue” is likely a large underestimate.

One industry publication covering the analyst note amplified and distorted the assertion by writing, “Private equity-backed providers represent less than 4% of the US market: PitchBook.”[36]

This claim can easily be misunderstood to imply that PE-owned healthcare providers are inconsequential in our healthcare ecosystem, which is not the case. These investments are having an outsized impact on jobs, patients, and the face of the industry.

For example, private equity-owned healthcare businesses accounted for 21 percent of all healthcare company bankruptcies in 2023 and another wave of PE-driven healthcare bankruptcies is expected in 2024 – almost all of the most distressed US healthcare companies are owned by private equity firms. This is because PE-owned healthcare businesses use debt in higher amounts and riskier ways than other types of healthcare businesses.[37]

That’s not to say that for-profit healthcare, more generally, is not rife with issues – financialization of healthcare is an ongoing problem across the board – but PE firms and their business model are an amplification of what happens when profit is put ahead of patient care, and these investments can be treated “as a divining rod that seeks various perverse incentives and market failures.”[38]

PitchBook claim: “The primary goals of inorganic growth (“roll-up”) strategies are multiple arbitrage and operational leverage, not market consolidation and price increases.”[39]

Fact-check: These may be strategies that private equity firms employ in roll-up transactions, but Pitchbook provides no citations to support its claims in this section. The primary goal of private equity firms and private equity deals is to make money for the PE firms and their investors.

Empirical research has found that PE-owned specialty practices often result in increased spending and utilization and sometimes higher prices. [40]Many PE deals involve add-on acquisitions of smaller companies that allow these deals to fall under the Hart-Scott-Rodino threshold for antitrust review. PE firms then use scale to increase revenues at the platform company making the add-on acquisitions, and then sell the scaled-up company down the road. These deals are certainly contributing to and have contributed to consolidation[41] (which can be accompanied by increased prices) in various subsectors, including emergency medicine, eye care, gastroenterology, anesthesiology, physical therapy, dental care, fertility clinics, methadone treatment centers, and air ambulances.

Claim: Private equity investors are not taking over healthcare, although the media and researchers are telling you otherwise.

Fact-check: This claim comes from an article written by a reporter at Fairness & Accuracy in Reporting (FAIR)[42] and was cited by the AIC.[43]The article makes important points about the larger issues in the US healthcare system and emphasizes how private equity firms are not the only problem, or even the biggest problem, in healthcare.[44]

This piece relies on a strawman argument, however, by suggesting that the journalists and researchers looking at private equity are ignoring and downplaying other issues and bad actors in US healthcare through their focus on private equity.

Accusing journalists that are looking closely at private equity-owned healthcare businesses and advocacy groups calling for better regulations of private equity as somehow ignoring larger issues in the for-profit healthcare system distorts the intentions and content of reporting and research focused on private equity.

PESP does not believe that private equity firms are the primary drivers of the failures of the US health system or for only private equity-owned healthcare companies to be regulated, and much of our policy recommendations would go above and beyond regulating private equity investments in healthcare to address broader financialization of healthcare issues that show up in nonprofit and for-profit business models alike.

Private equity business strategies are an amplification of the typical profit-seeking strategies seen in healthcare, and the financialization of healthcare in the United States is a multi-faceted issue that cannot be pinned on private equity alone.

However, it is important to point out that private equity does depart from other types of for-profit healthcare ownership in three key ways:

1. Lack of transparency: Private equity-owned companies are less regulated than publicly traded companies. They do not need to make the same disclosures to the Securities and Exchange Commission (SEC) or to their investors. As such, critical financial information about private equity investments often remains in the shadows.
2. Use of debt: Private equity investment strategies involve using much more debt than is typical in other types of investments. Firms use debt to buy companies in leveraged buyouts, and the company – not the PE firm and its investors – will be on the hook for the debt. Portfolio companies can also be directed by their PE owners to take on more debt during the ownership period in order to finance add-on acquisitions or pay dividends to investors.
3. The moral hazard of limited liability: A private equity firm can generate returns on an investment even if the company ends up in financial distress or bankruptcy. This is because private equity firms are not liable for the debt secured by their portfolio companies, and so they cannot lose more money than the amount they invested, which is often not much. In other words, private equity firms take on little risk but get to make outsized returns.[45]

For the reasons above, updated healthcare regulations must take these factors into account. Regulations that require increased transparency and financial disclosures, regulations on use of debt, and requirements for private equity firms and other investors to have more liability for their healthcare investments are all ways to put guardrails in place to protect patients and workers. These regulations should be bare minimums, and our policymakers and regulators can and should go much farther to protect patients from the increasing financialization of healthcare that is seen in both “nonprofit” and for-profit healthcare.

Conclusion

Private equity’s recent campaign to shift the narrative about its investments in healthcare downplays and distorts data. If private equity firms succeed in shifting the narrative, we risk losing the momentum of this historic moment where legislators and regulators around the country are prepared to pass, and in some cases are passing, legislation that would better regulate the healthcare industry, including by protecting it from private equity’s most harmful business practices. It is important for stakeholders and policymakers alike to remain vigilant of how industry talking points are disseminated and amplified, and to critically examine claims being made about private equity and healthcare.

Resources

[1] Bugbee, Mary. “Big Step Forward for Illinois Healthcare Oversight.” Private Equity Stakeholder Project (blog), September 19, 2023. https://pestakeholder.org/news/big-step-forward-for-illinois-healthcare-oversight/; O’Grady, Eileen. “California Legislation Aims to Safeguard against Private Equity in Healthcare.” Private Equity Stakeholder Project, February 29, 2024. https://pestakeholder.org/news/california-legislation-aims-to-safeguard-against-private-equity-in-healthcare/; “Press Room – House Passes Major Health Care Legislation,” May 16, 2024. https://malegislature.gov/PressRoom/Detail?pressReleaseId=84.

[2] “Senators Warren, Markey Introduce the Corporate Crimes Against Health Care Act of 2024 | U.S. Senator Elizabeth Warren of Massachusetts.” Accessed July 17, 2024. https://www.warren.senate.gov/newsroom/press-releases/senators-warren-markey-introduce-the-corporate-crimes-against-health-care-act-of-2024.

[3] privateinvestmentworks.com. “New Report: Private Equity’s Role in U.S. Health Care ‘Has Been Vastly Overstated’ – Private Investment Works,” July 10, 2024. https://www.privateinvestmentworks.com/2024/07/10/new-report-private-equitys-role-in-u-s-health-care-has-been-vastly-overstated/; privateinvestmentworks.com. “Proponents of Misinformed Inquiry into Health Care Consolidation Rely on False Narratives and Shoddy Research – Private Investment Works,” June 7, 2024. https://www.privateinvestmentworks.com/2024/06/07/proponents-of-misinformed-inquiry-into-health-care-consolidation-rely-on-false-narratives-and-shoddy-research/; privateinvestmentworks.com. “Wrongly Blaming Private Equity for Challenges in the Massachusetts Health Care System Ignores the Truth – Private Investment Works,” April 2, 2024. https://www.privateinvestmentworks.com/2024/04/02/wrongly-blaming-private-equity-for-challenges-in-massachusetts-health-care-system-ignores-the-truth/.

[4] “New Report: Private Equity Is a Partner to Health Care Across America – Private Investment Works.” February 13, 2024, sec. Health Care. https://www.privateinvestmentworks.com/2024/02/13/new-report-private-equity-is-a-partner-to-health-care-across-america/.

[5] privateinvestmentworks.com. “Proponents of Misinformed Inquiry into Health Care Consolidation Rely on False Narratives and Shoddy Research – Private Investment Works,” June 7, 2024. https://www.privateinvestmentworks.com/2024/06/07/proponents-of-misinformed-inquiry-into-health-care-consolidation-rely-on-false-narratives-and-shoddy-research/.

[6] Springer, Rebecca. “Quantifying PE Investment in Healthcare Providers.” PitchBook, Inc., July 8, 2024. https://files.pitchbook.com/website/files/pdf/Q3_2024_PitchBook_Analyst_Note_Quantifying_PE_Investment_in_Healthcare_Providers.pdf.

[7] See: Ashley, Madeline. “PE’s Role in US Healthcare ‘Vastly Overstated’: Report.” Becker’s Hospital CFO Report, July 11, 2024. https://www.beckershospitalreview.com/finance/pes-role-in-us-healthcare-vastly-overstated-report.html; Olsen, Emily. “Private Equity-Backed Providers Represent Less than 4% of US Market: PitchBook.” Healthcare Dive, July 15, 2024. https://www.healthcaredive.com/news/private-equity-investment-healthcare-providers-pitchbook/720960/; Donlan, Andrew. “Why Private Equity’s Involvement In Home-Based Care Is Largely Overstated.” Home Health Care News, July 10, 2024. https://homehealthcarenews.com/2024/07/why-private-equitys-involvement-in-home-based-care-is-largely-overstated/.

[8] Springer, Rebecca. “Quantifying PE Investment in Healthcare Providers.” PitchBook, Inc., July 8, 2024. https://files.pitchbook.com/website/files/pdf/Q3_2024_PitchBook_Analyst_Note_Quantifying_PE_Investment_in_Healthcare_Providers.pdf.

[9] See pg. 4 of Springer, Rebecca. “Quantifying PE Investment in Healthcare Providers.” PitchBook, Inc., July 8, 2024. https://files.pitchbook.com/website/files/pdf/Q3_2024_PitchBook_Analyst_Note_Quantifying_PE_Investment_in_Healthcare_Providers.pdf.

[10] Source: PitchBook deals search conducted on July 16, 2024.

[11] Jain, Nirad, Kara Murphy, Franz-Robert Klingan, Dmitry Podpolny, and Vikram Kapur. “Healthcare Private Equity Market 2021: The Year in Review.” Bain, March 16, 2022, sec. Report. https://www.bain.com/insights/year-in-review-global-healthcare-private-equity-and-ma-report-2022/

[12] Prete, Ryan. “PE Healthcare Investments Mature in an Uncertain Year for Health.” PitchBook (blog), January 14, 2022. https://pitchbook.com/news/articles/us-pe-healthcare-investments-2021-charts.

[13] See pg. 3 of “Behavioral Healh Mergers & Acquisitions – Year in Review: 2023.” The Braff Group, March 2024. https://thebraffgroup.com/wp-content/uploads/2024/03/BH-Year-End-Report-2023.pdf.

[14] Wallace, Claire. “342 Cardiology Clinics Acquired by Private Equity in 10 Years.” Becker’s ASC Review, July 1, 2024. https://www.beckersasc.com/cardiology/342-cardiology-clinics-acquired-by-private-equity-in-10-years.html.

[15] privateinvestmentworks.com. “New Report: Private Equity’s Role in U.S. Health Care ‘Has Been Vastly Overstated’ – Private Investment Works,” July 10, 2024. https://www.privateinvestmentworks.com/2024/07/10/new-report-private-equitys-role-in-u-s-health-care-has-been-vastly-overstated/.

[16] Springer, Rebecca. “Quantifying PE Investment in Healthcare Providers.” PitchBook, Inc., July 8, 2024. https://files.pitchbook.com/website/files/pdf/Q3_2024_PitchBook_Analyst_Note_Quantifying_PE_Investment_in_Healthcare_Providers.pdf.

[17] Lifepoint Health. “LifePoint Health Completes Kindred Healthcare Transaction,” December 23, 2021. https://lifepointhealth.net/news/lifepoint-health-completes-kindred-healthcare-transaction; Kacik, Alec. “LifePoint Health and Kindred Healthcare Close Deal, Form New Company.” Modern Healthcare, December 22, 2021, sec. Mergers & Acquisitions. https://www.modernhealthcare.com/mergers-acquisitions/lifepoint-health-and-kindred-healthcare-close-deal-form-new-company.

[18] ScionHealth. “ScionHealth Completes Acquisition of Cornerstone Healthcare Group,” January 23, 2023. https://www.prnewswire.com/news-releases/scionhealth-completes-acquisition-of-cornerstone-healthcare-group-301728275.html.

[19] Lovett, Laura. “LifePoint Secures Foothold in Behavioral Health, Finalizes Deal for US Behavioral Partners.” Behavioral Health Business, February 8, 2023. https://bhbusiness.com/2023/02/08/lifepoint-secures-foothold-in-behavioral-health-finalizes-deal-for-us-behavioral-partners/.

[20] See pg. 3 of Private Equity Stakeholder Project. “Apollo’s Stranglehold on Hospitals Harms Patients and Healthcare Workers.” Private Equity Stakeholder Project, American Federation of Teachers, International Association of Machinists and Aerospace Workers, January 11, 2024. https://pestakeholder.org/wp-content/uploads/2024/01/PESP__Report_Apollo_Lifepoint_2024.pdf.

[21] Pg. 17 of Bugbee, Mary. “The Pillaging of Steward Health Care: How a Private Equity Firm and Hospital Landlord Contributed to Steward’s Bankruptcy.” Private Equity Stakeholder Project, June 26, 2024. https://pestakeholder.org/reports/the-pillaging-of-steward-health-care/.

[22] Pgs. 2-3 of Bugbee, Mary. “How Private Equity Raided Safety Net Hospitals: Volume 2- Pipeline Health,” July 18, 2023. https://pestakeholder.org/reports/how-private-equity-raided-safety-net-hospitals-pipeline-health/.

[23] Muoio, Dave. “General Catalyst to Acquire Nonprofit System Summa Health.” FierceHealthcare, January 17, 2024. https://www.fiercehealthcare.com/providers/general-catalysts-new-health-system-company-acquire-summa-health.

[24] See pg. 6 of Springer, Rebecca. “Quantifying PE Investment in Healthcare Providers.” PitchBook, Inc., July 8, 2024. https://files.pitchbook.com/website/files/pdf/Q3_2024_PitchBook_Analyst_Note_Quantifying_PE_Investment_in_Healthcare_Providers.pdf.

[25] Private Equity Stakeholder Project. “PESP Private Equity Hospital Tracker.” Accessed April 8, 2024. https://pestakeholder.org/private-equity-hospital-tracker/.

[26] Kannan, Sneha, Joseph Dov Bruch, and Zirui Song. “Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition.” JAMA 330, no. 24 (December 26, 2023): 2365–75. https://doi.org/10.1001/jama.2023.23147.

[27] Borsa, Alexander, Geronimo Bejarano, Moriah Ellen, and Joseph Dov Bruch. “Evaluating Trends in Private Equity Ownership and Impacts on Health Outcomes, Costs, and Quality: Systematic Review.” BMJ 382 (July 19, 2023): e075244. https://doi.org/10.1136/bmj-2023-075244.

[28] Bugbee, Mary. “Private Equity Is Buying up Hospitals in Low- and Middle-Income Countries with the Help of Development Finance Institutions.” Private Equity Stakeholder Project (blog), May 21, 2024. https://pestakeholder.org/news/private-equity-is-buying-up-hospitals-in-low-and-middle-income-countries-with-the-help-of-development-finance-institutions/.

[29] privateinvestmentworks.com. “New Report: Private Equity’s Role in U.S. Health Care ‘Has Been Vastly Overstated’ – Private Investment Works,” July 10, 2024. https://www.privateinvestmentworks.com/2024/07/10/new-report-private-equitys-role-in-u-s-health-care-has-been-vastly-overstated/.

[30] See pg. 4 of Springer, Rebecca. “Quantifying PE Investment in Healthcare Providers.” PitchBook, Inc., July 8, 2024. https://files.pitchbook.com/website/files/pdf/Q3_2024_PitchBook_Analyst_Note_Quantifying_PE_Investment_in_Healthcare_Providers.pdf.

[31] Abelson, Reed, and Margot Sanger-Katz. “Who Employs Your Doctor? Increasingly, a Private Equity Firm.” The New York Times, July 10, 2023, sec. The Upshot. https://www.nytimes.com/2023/07/10/upshot/private-equity-doctors-offices.html.

[32] Pg. 5 of “A Partner to Health Care: How Private Equity Complements and Strengthens the Health Care Industry.” American Investment Council, February 2024. https://www.investmentcouncil.org/wp-content/uploads/2024/01/AIC-2023-Health-Care-Report.pdf.

[33] Pg. 8 of Springer, Rebecca. “Quantifying PE Investment in Healthcare Providers.” PitchBook, Inc., July 8, 2024. https://files.pitchbook.com/website/files/pdf/Q3_2024_PitchBook_Analyst_Note_Quantifying_PE_Investment_in_Healthcare_Providers.pdf.

[34] Springer, Rebecca. “Quantifying PE Investment in Healthcare Providers.” PitchBook, Inc., July 8, 2024. https://files.pitchbook.com/website/files/pdf/Q3_2024_PitchBook_Analyst_Note_Quantifying_PE_Investment_in_Healthcare_Providers.pdf.

[35] Bugbee, Mary, Eileen O’Grady, and Michael Fenne. “Private Equity in U.S. Healthcare: Trends in 2023 Deal Activity.” Private Equity Stakeholder Project, March 6, 2024. https://pestakeholder.org/private-equity-healthcare-2023-trends/.

[36] Olsen, Emily. “Private Equity-Backed Providers Represent Less than 4% of US Market: PitchBook.” Healthcare Dive, July 15, 2024. https://www.healthcaredive.com/news/private-equity-investment-healthcare-providers-pitchbook/720960/.

[37] O’Grady, Eileen. “Private Equity Healthcare Bankruptcies Are on the Rise.” Private Equity Stakeholder Project, January 2024. https://pestakeholder.org/private-equity-healthcare-bankruptcies-are-on-the-rise/.

[38] See pg. 16 of Fuse Brown, Erin, Loren Adler, Erin Duffy, Paul B. Ginsburg, Mark Hall, and Samuel Valdez. “Private Equity Investment As A Divining Rod For Market Failure: Policy Responses To Harmful Physician Practice Acquisitions.” USC-Brookings Schaeffer Initiative for Health Policy, October 2021. https://www.brookings.edu/wp-content/uploads/2021/10/Private-Equity-Investment-As-A-Divining-Rod-For-Market-Failure-14.pdf.

[39] Pgs. 6-7 of Springer, Rebecca. “Quantifying PE Investment in Healthcare Providers.” PitchBook, Inc., July 8, 2024. https://files.pitchbook.com/website/files/pdf/Q3_2024_PitchBook_Analyst_Note_Quantifying_PE_Investment_in_Healthcare_Providers.pdf.

[40] Singh, Yashaswini, Zirui Song, Daniel Polsky, Joseph D. Bruch, and Jane M. Zhu. “Association of Private Equity Acquisition of Physician Practices With Changes in Health Care Spending and Utilization.” JAMA Health Forum 3, no. 9 (September 2, 2022): e222886. https://doi.org/10.1001/jamahealthforum.2022.2886.

[41] Adler, Loren, Conrad Milhaupt, and Samuel Valdez. “Measuring Private Equity Penetration and Consolidation in Emergency Medicine and Anesthesiology.” Health Affairs Scholar 1, no. 1 (July 1, 2023): qxad008. https://doi.org/10.1093/haschl/qxad008.

[42] Canham-Clyne, John. “Private Equity ‘Takeover’ Is Not Driving Healthcare Crisis.” FAIR, January 16, 2024, sec. Blog. https://fair.org/home/private-equity-takeover-is-not-driving-healthcare-crisis/.

[43] privateinvestmentworks.com. “New Report: Private Equity’s Role in U.S. Health Care ‘Has Been Vastly Overstated’ – Private Investment Works,” July 10, 2024. https://www.privateinvestmentworks.com/2024/07/10/new-report-private-equitys-role-in-u-s-health-care-has-been-vastly-overstated/.

[44] Canham-Clyne, John. “Private Equity ‘Takeover’ Is Not Driving Healthcare Crisis.” FAIR, January 16, 2024, sec. Blog. https://fair.org/home/private-equity-takeover-is-not-driving-healthcare-crisis/.

[45] E. Appelbaum and R. Batt, “How Private Equity Firms Are Designed to Earn Big While Risking Little of Their Own,” LSE Business Review (blog), January 23, 2017, blogs.lse.ac.uk/businessreview/2017/01/23/how-private-equity-firms-are-designed-to-earn-big-while-risking-little-of-their-own; A. Gupta and S. Howell, “The Role of Private Equity in the U.S. Economy, and Whether and How Favorable Tax Policies for the Sector Need to Be Reformed,” Washington Center for Equitable Growth, September 14, 2023, equitablegrowth.org/the-role-of-private-equity-in-the-u-s-economy-and-whether-and-how-favorable-tax-policies-for-the-sector-need-to-be-reformed.