Private equity staffs 27% of US emergency departments

Private equity-owned companies staff at least 27% of US emergency departments

Over the last decade, hospitals have begun to contract with private companies to staff and operate their emergency departments. Many of those companies are owned by private equity. In Staffing by private equity-owned companies represents cost and quality of care issues for patients.

Below is a table of the 15 largest emergency room staffing companies.

To estimate the number of emergency departments staffed by private equity-backed companies, we used the number of departments staffed by TeamHealth, US Acute Care Solutions, SCP Health, Emergency Care Partners, and Sound Physicians for a total of 1,199. We used PESP’s hospital tracker to identify all hospitals with emergency services for a total of 4,416. Assuming that each hospital only uses one physician staffing company for its emergency department, we can determine that at least 27% of emergency departments use a private equity-backed staffing company.

three largest emergency room staffing companies are private equity-backed. The emergency medicine market is highly concentrated and has seen significant activity in the last decade.

Quality of care issues

In a 2021 article for MedPage, an emergency physician in Michigan described changes in her hospital after the emergency department’s staffing group was bought by TeamHealth. According to the doctor, the article explained, “the acquisition of EMS by TeamHealth (which was ultimately bought by Blackstone in 2016) has brought steady declines in the number of physicians on staff in the emergency department (ED), coupled with significant cuts to doctors’ compensation and resources.”

The article in MedPagedescribed Li’s experience with the private equity takeover of emergency department staffing: “After the 2014 transition, Li said the hospital and TeamHealth, increasingly driven by metrics, became primarily concerned with patient satisfaction scores and the ED’s “left without being seen” (LWBS) numbers.” The company and hospital used physician assistants to conduct medical screenings in order to improve scores of how quickly patients are seen, thereby decreasing their “left without being seen” metric. Meanwhile, patients waited hours to see a doctor.

Some staffing shortages can be attributed to business decisions. American Physician Partners, a private equity-backed staffing company that ceased operations in 2023, described employing fewer doctors as a cost-saving measure intended to increase earnings in a presentation to lenders.

Physician labor is typically the highest expense for emergency departments, so some departments replace doctors with “mid-level practitioners” such as nurse practitioners and physician assistants. While mid-level practitioners can perform many of the same duties as doctors, critics of the staffing strategy of using providers with less training say that it may result in “leaving patients vulnerable to misdiagnoses, higher medical bills, and inadequate care.”

In a 2025 MedPage article, Vicky Norton, MD, then-president-elect of the American Academy of Emergency Medicine explained, “To maximize profits in emergency departments, Norton said, private equity firms understaff facilities, cut pay and benefits for physicians and other healthcare professionals – even as they have to see more patients with fewer resources – and increase what patients are charged by multiples. That increase in profits goes to shareholders, not doctors, she said.” Norton continued, saying that understaffing and pressure to see more patients can lead to burnout, and that can affect patients, too. She said, “They’re going into situations where the physicians and non-physicians working there are not happy and can’t provide quality of care.” Additionally, physicians working for private equity-backed companies may not speak out about issues at their facilities out of fear of being fired on short notice without an opportunity to contest claims against them.

In April 2024, Senator Gary Peters of Michigan and then-chair of the Homeland Security and Governmental Affairs Committee raised concerns about staffing levels, wait times, and patient safety and the ability of emergency departments staffed by private equity-backed companies to provide care in the event of a major emergency. The senator noted that, while the issues outlined “are not limited to private equity, they are exacerbated by the private equity business model, which hinges on leveraged debt, little equity, and the need to obtain outsized returns within a limited time.”

Surprise billing

Before legislation banning them, surprise medical bills from ambulance services and emergency room visits could be devastating for patients. Researchers Eileen Appelbaum and Rosemary Batt described how, before the No Surprises Act, patients could find themselves with an enormous, unexpected bill: “Patients who go to the ER believe that their insurance will cover the costs for ER services in the hospital that accepts their insurance; but they often later find that the ER doctors bill them directly because, in fact, the hospital has outsourced the ER to a physician staffing company that is not covered by their insurance.”

At a conference in 2023, Appelbaum argued that surprise billing was a business strategy, not an accident, for at least one private equity-backed provider: “The secret sauce was basically having doctors out-of-network, and then delivering surprise medical bills to families who had shown up at an emergency room, loading them up with medical debt.”

In the summer of 2019, the No Surprises Act was introduced in Congress with the goal of protecting consumers from surprise medical bills from out-of-network providers. Quickly, the original bill was with a polarizing arbitration provision supported by many doctors and hospitals, but deeply unpopular with the insurance industry.

Around this time, a shadowy group called Doctor Patient Unity was running ads and sending mailers in multiple states, targeting politicians up for re-election and suggesting that government “rate setting” posed a risk to patient care and would benefit insurers. Later that month, TheNew York Times that private equity-backed companies Envision and TeamHealth, both major emergency room staffing companies, both private equity-backed at the time, were the primary funders behind the dark money group and detailed their extensive campaign. By September 2019, the campaign had already totaled over $28 million in spending, and by April 2020, ProPublicareported that it had spent $57 million.

The No Surprises Act passed in late 2020 and included an independent dispute resolution (IDR) process. The IDR process serves to resolve certain out-of-network payment disputes between providers, facilities, and health plans and it requires the health, treasury, and labor departments to release data on the IRD process. That data reveals that private equity-backed providers have consistently dominated the list of companies bringing cases to the IDR process, both in general claims and for air ambulance companies. The data released for the first half of 2023 revealed that private equity-backed emergency department staffing companies topped the list of companies with the highest number of disputes. TeamHealth initiated the highest number of disputes, accounting for 30% of all disputes in the first half of 2023. SCP Health initiated the second highest number of disputes accounting for 20%.

Private equity is also involved in the dispute process from the arbiter side. As of October 2025, at least a third of the certified IDR entities that contract with the Centers for Medicare & Medicaid Services to adjudicate disputes are private equity-backed, and PESP research found that two of the arbiters share private equity investors with providers initiating disputes.

Though the No Surprises Act has reduced surprise bills for patients, it has led to ballooning health system costs that may be passed on to patients in the form of higher premiums. Private equity-backed companies remain key players in the costly IDR process, as providers that successfully extract high payments from payers through their high volume use of the IDR process and as certified IDR entities that receive fees to arbitrate disputes.

Notable private equity-backed emergency department staffing companies

TeamHealth
TeamHealth is by far the largest emergency department staffing company, providing physicians for nearly double the number of emergency departments as the next largest staffing company. TeamHealth was acquired by Blackstone Capital Partners VII in a public-private leveraged buyout in 2017.

A September 2019 investigation by The New York Times found that TeamHealth was one of the two largest financial backers of Doctor Patient Unity, the group that poured millions of dollars into opposing legislation to ban surprise billing.

US Acute Care Solutions
US Acute Care Solutions is the second largest emergency department staffing company. It is backed by Ascension Health, TowerBrook Capital Partners, and Apollo Global Management.

Ascension and TowerBrook have partnered multiple times to acquire healthcare companies, such as Compassus, Regent Surgical, and R1 Revenue Cycle Management. One of TowerBrook’s largest investors reported that the company leverages its relationship with the large nonprofit healthcare company, Ascension, “to provide the firm with a competitive advantage in sourcing healthcare investments.” See PESP’s report on private equity and nonprofit joint ventures to read more about Ascension-TowerBrook investments.

In addition to US Acute Care Solutions, Apollo also backs the hospital chains Lifepoint Health and ScionHealth. ScionHealth was formed through a series of transactions with Lifepoint Health. ScionHealth has struggled with substantial debt and closed three hospitals in 2025. In June 2026, Lifepoint announced that it had completed the acquisition of eight of ScionHealth’s community hospitals. Lifepoint and Apollo have relied heavily on joint ventures with nonprofit health systems to expand their hospital footprint, as report on private equity and nonprofit joint ventures.

Sound Physicians
Sound Physicians offers staffing for emergency medicine, critical care, anesthesia, and telemedicine, as well as practice management. Sound Physicians was acquired by a group of investors led by Summit Partners in 2018 for $2.15 billion. Sound Physicians has faced formal complaints from doctors in Washington who allege that the interim director of hospitalist services hospitalist employed by the company at PeaceHealth St. Joseph Medical Center was influencing patient care without an active Washington state medical license.

On July 2, 2026, Bloomberg that Barclays had withdrawn a $960 million financing offer to Sound Physicians from the debt capital markets due to insufficient investor demand. While Barclays is expected to revise the financing terms and relaunch the loan at a later date, the original deal was one of the few leveraged loans to be pulled so far in 2026.

Envision Physician Services
While Envision claims it is no longer private equity-backed, its history serves as a meaningful case study in the role of private equity ownership of staffing companies. PESP covered Envision’s role in surprise billing in 2022.

Eileen Appelbaum argued that surprise billing was Envision’s “secret sauce.” After private equity firm KKR acquired Envision, it adopted aggressive billing tactics, driven by pressure to pay back debts. Along with TeamHealth, Envision was one of the largest financial backers of Doctor Patient Unity, which spent millions opposing the No Surprises Act.

Even before the No Surprises Act passed, creditors could see that Envision would struggle to pay its debts if it was unable to use surprise billing as part of its business model. Envision filed for Chapter 11 bankruptcy in May 2023, citing debt, slowing patient volumes, legal battles with insurers, and the “flawed” implementation of the No Surprises Act as reasons for its financial decline. Ahead of the bankruptcy filing, KKR moved Envision’s profitable assets – its ambulatory surgical centers – to a new investment vehicle to protect them from creditors, leaving the remainder of the company to pay back billions of dollars in debt without a clear profitmaking strategy.

Envision exited bankruptcy in November 2023, splitting into AmSurg, a profitable ambulatory surgical center business, and Envision Physician Services, a struggling physician staffing company. Bankruptcy wiped out the initial $3.5 billion equity investment of KKR and its private equity investors and their stake in the physician staffing company was wiped out. KKR and its investors still owned a 20% stake in AmSurg, but the company’s creditors bought out KKR’s remaining shares. The Wall Street Journal the loss as “among the steepest write-downs the private equity firm has swallowed in recent years.”

More oversight needed

Private equity-backed companies profit at nearly all stages of emergency medicine, from staffing agencies for emergency departments to the arbitration process following disagreements about payment for care. Through Medicaid and Medicare, government agencies are the largest payers for health care and well-functioning emergency room departments are critical to maintaining public health and safety in all kinds of disasters. Given the quality of care issues and concerns around ballooning costs associated with the No Surprises Act, more oversight is needed for private equity-backed emergency room staffing to ensure that patients are receiving quality care without enormous costs.

[1] ApolloMD was formed by investments its founders and leaders made through ValorBridge Partners