Private Equity’s Footprint in Philadelphia Healthcare

Table of Contents

• Introduction
• Map of Philadelphia area companies owned by private equity
• Private equity in Philadelphia healthcare
  • Physical therapy
  • Behavioral health
  • Dental
  • Home health & hospice
  • Urgent care
  • Specialty
• Conclusion

Introduction

In recent years, concerns have grown about the impact of private equity investment on healthcare access, quality, and costs. However, the scope of private equity’s presence can be difficult to measure due to a lack of reliable public information about its investments. This report takes a snapshot of private equity’s geographic presence in Philadelphia-area healthcare using publicly available location data to identify approximately 900 private equity-owned healthcare provider locations in Philadelphia and the surrounding area.

Private equity has been active for many years in healthcare settings including hospitals, nursing homes, and home healthcare. More recently, private equity investment has expanded to high-margin specialties including gastroenterology, urology, cardiology, and others.[1] Over about the last 15 years, a significant share of urgent care clinics have also come under private equity ownership.[2]

Private equity has invested in parts of the healthcare sector through the serial acquisition of smaller medical businesses by larger platform companies. These add-on acquisitions, sometimes called “roll-ups,” are one of the fundamental strategies used by private equity firms seeking to grow their investments. Federal antitrust regulators – including the Federal Trade Commission and U.S. Department of Justice – have said that private equity roll-ups often unfairly reduce competition and can harm patients.[3]

The healthcare sector has seen significant involvement from private equity. In 2023, healthcare reached $60 billion in announced private equity deals globally, despite challenges including higher interest rates and inflationary pressures.[4] In the past decade, private equity investors have spent $1 trillion on healthcare acquisitions.[5]

Risks from private equity investment in healthcare
Patients seeking healthcare from a private equity-owned provider may be at higher risk of harm. A recent study published in JAMA found that adverse events at hospitals, such as patient falls and hospital-acquired infections, increased at hospitals following a private equity buyout.[6] Other research has found that when compared to nursing homes overall, the patient mortality rate is higher at facilities owned by private equity firms.[7]

Numerous studies have concluded that private equity has had a role in driving up healthcare costs for patients and payers.[8] For patients who cannot afford these growing costs, private equity-owned companies have created healthcare debt through medical credit cards, installment loans, and other payment products – this debt may later be collected by an aggressive debt collector owned by private equity.[9]

Due in part to private equity’s tendency to burden portfolio companies with debt, healthcare providers owned by private equity have increased bankruptcy risk. Bankruptcies can lead to layoffs and the disruption of critical healthcare services, which can burden other healthcare providers who must address gaps left by closures.[10] In the first half of 2024, nine private equity-owned healthcare companies filed for bankruptcy, and others defaulted on their debt but avoided bankruptcy court through distressed debt exchanges. Several other debt-burdened healthcare companies owned by private equity are at risk for bankruptcy.[11]

Methodology and limitations
The data here is generally sourced from information made available by private equity firms and their portfolio companies. Private equity firms typically are not required to disclose their holdings to the public, making it difficult to assess private equity’s presence in any select geographic area. For this reason, private equity is likely to have a larger presence in Philadelphia healthcare than is measured here.

An initial list of companies was prepared using a basic web search for healthcare providers in the Philadelphia area. Sources to confirm ownership include portfolio lists, press releases, trade publications, and other publicly available information. Data from PitchBook was used to identify some companies listed here, and private equity ownership status was confirmed using other sources that are publicly available. Location data comes directly from company website provider listings, which are meant to guide patients to services and generally do not include private equity ownership information.

The limited number of locations identified here should be sufficient to illustrate the concerning scale of private equity’s presence in and around one major U.S. city.

For a complete list of companies and sources referred to in this report, see Appendix B – List of Companies. Readers may not see a specific provider listed here but may find out by other means that the provider is actually private equity-owned.

Map of Philadelphia area companies owned by private equity

Private equity in Philadelphia healthcare

Philadelphia is notable for the impacts private equity has already made on the city, with residents currently dealing with the results. In recent years private equity has contributed to the closure of one major Philadelphia hospital and the financial decline of a hospital chain with multiple local sites.[12]

This report identifies approximately 900 private equity-owned healthcare provider locations in Philadelphia and the surrounding area. This includes healthcare from small-scale settings such as clinics and individual practices; to large-scale settings including hospitals and correctional institutions.

The most widespread healthcare services identified here include providers of physical therapy (271 locations), behavioral healthcare (98 locations), and dental care (86 locations). There were also 85 locations for home health and hospice providers, which include some central office sites for in-home care providers across broad geographic areas including entire counties.[13].

For complete location data, please see Appendix A – Philadelphia-area PE-owned Provider Locations.

The boundaries for this location data vaguely extend 50 miles each direction from Philadelphia, which serves as the geographic center of what this report is calling the Greater Philadelphia area.

Wilmington serves as the southern terminus in Delaware, and is also part of the western boundary, which runs northwards through the suburbs from Wilmington until Allentown. The northern boundary runs from Allentown eastward along the Delaware River and into South Jersey. Providers located on the South Jersey peninsula are generally included unless located along the Shore.

High activity around physical therapy

The largest share of our data is represented by physical therapy clinics, with at least six private equity-owned companies operating 271 locations in the Philadelphia area. This is also the highest company-location from our data, with an average of 45.2 clinics per company, suggesting there may be regional consolidation among physical therapy companies.

Private equity after nearly two decades has continued to invest in physical therapy clinics. The area remains attractive for private equity investors because it is expected to see continued growth and – despite several existing national platforms of scale – physical therapy is a fragmented industry which can be further consolidated.[21]

The number of physical therapy clinics has seen significant growth in recent years. In 2018, there were over 200,000 licensed physical therapists at 16,000 physical therapy clinics in the U.S., with no company exceeding 10% of market share.[22] Four years later in 2022, the estimated number of clinics had more than doubled to approximately 38,000.[23]

Physical therapy company Ivy Rehab had the highest number in our sample with 145 locations in the Philadelphia area, which represent a large portion of the company’s approximately 600 total locations.[24] In 2016,[25] Ivy Rehab was acquired by private equity firm Waud Capital Partners, which grew the company by more than tenfold by 2022.[26]

Athletico Physical Therapy – which also operates under the Pivot Physical Therapy brand – is a private equity-owned company with 18 locations in the Philadelphia area.[27] BDT Capital has owned Athletico since late 2016, when it bought the company from Harvest Partners, another private equity firm.[28]

Athletico has taken on considerable debt to fuel its growth, including $875 million in early 2022, which it used to refinance existing debt, add cash to its balance sheet, and fund the acquisition of Pivot Physical Therapy.[29] In late 2022, Moody’s Investors Service downgraded the company’s credit rating, citing its debt-funded growth strategy, among other factors.[30] A few months later, Moody’s again downgraded Athletico’s credit rating, due in part to its “aggressive growth strategy and very high financial leverage under private equity ownership.”[31]

Other private equity-owned chains with physical therapy locations in the Philadelphia area include Strive Physical Therapy,[32] owned by Partners Group, with 25 locations; Audax Group-owned Phoenix Physical Therapy,[33] which has 18 locations; and four locations for PT Solutions, a company owned by private equity firms General Atlantic and TowerBrook Capital Partners.[34]

Additionally, ATI Physical Therapy has at least 61 locations in the region. The company has been owned since 2016 by private equity firm Advent International, which took the company public in 2021 in a deal that merged ATI with a special-purpose acquisition company (SPAC) owned by asset manager Fortress Investment Group. As of July 2023, Advent International owns 55% of ATI Physical Therapy.[35]

Critics have suggested that SPACs are a shortcut around the traditional IPO process, allowing investors to take companies public before ready. In its first earnings report after going public, ATI reduced its earnings forecast from $119 million, to $60 to $70 million, blaming high attrition among therapists at its locations. Following the announcement – less than two months after the June 2021 SPAC merger – ATI shares fell more than 50 percent.[36]

In June 2023, ATI was notified by the New York Stock Exchange that it was at risk of losing its listing due to the company’s low stock price. In order to remain on the exchange, ATI was required to submit a plan explaining how it intends to come into compliance with listing standards.[37] As of August 2024, ATI had reduced its presence to 878 locations as part of an ongoing “footprint optimization initiative,” in which some of its approximately 900 clinics are divested or closed.[38]

Behavioral health’s relative fragmentation

Behavioral health clinics comprise the second-largest share from our sample of private equity-owned healthcare providers in the Philadelphia area. In total we identified 98 locations operated by 12 different companies, for an average of 8.2 locations per operator.

LifeStance Health operates the largest share of private equity-owned behavioral health clinics identified in the region. As of September 2024, LifeStance provides mental health services at approximately 550 locations across 33 U.S. states,[52] including 30 locations in the Philadelphia region.[53]

LifeStance was founded in 2015 by private equity firms Summit Partners and Silversmith Capital Partners as a platform to pursue an aggressive growth plan.[54] Private equity firm TPG became an additional company owner in 2020 as part of a deal to support the company’s continued expansion.[55] In 2021, LifeStance was valued at $7 billion in an initial public offering which left two-thirds of shares in the hands of Summit, Silversmith, and TPG.[56]

Private equity-owned Sevita operates at least 19 locations in the Philadelphia area, providing services including behavioral health, foster care, and home health. The company is owned by private equity firms Centerbridge Partners, Vistria Group, and Madison Dearborn.[57] Private equity firms Madison Dearborn, Vestar Capital, and Windrose Health Investors owned the company from 2001 until the company went public 2014 with Vestar retaining a majority stake. The company was taken private again by Centerbridge and Vistria in 2019.[58]

Sevita has received attention for providing inadequate care with sometimes fatal outcomes. According to an investigation by the U.S. Senate Committee on Finance, from 2005 until 2014 at least 86 children died while in the custody of Sevita (formerly known as the Mentor Network[59]).[60]

More recently, Sevita’s private equity owners have extracted hundreds of millions from the company. In the two years until February 2021, Centerbridge and Vistria extracted nearly half a billion dollars in debt-funded dividends from Sevita.[61]

For some private equity-backed companies, debt-funded dividends paid owners have been followed by credit downgrades.[62] The practice – which includes loading debt onto a company in order to give cash payouts to private equity owners – raises concerns for putting companies at increased risk of restructuring, bankruptcy, or harmful cost cutting to make interest and debt payments.[63]

Private equity has made substantial inroads acquiring U.S. behavioral health providers, and since 2018, has been involved in 60% of behavioral health acquisitions.[64] According to one recent study, private equity firms own 6% of mental health facilities and 7% of addiction treatment facilities nationwide.[65]

Private equity may be attracted to behavioral health services due to persistently high demand, as well as increased insurance coverage for behavioral health services.[66] In the last decade, the Affordable Care Act has contributed to increased access to behavioral health services.[67]

PESP has found multiple risks for behavioral health services acquired by private equity, including the potential for understaffing, reliance on untrained and unlicensed staff, pressure to provide unnecessary services, and abuse of federal funding programs at patient expense.[68]

Private equity firms have also acquired treatment centers for substance use disorder (SUD), including 12 Crossroads Treatment Center locations in the Philadelphia area. Crossroads has been owned by private equity firm Revelstoke Capital Partners since 2014.[69] It provides SUD treatment at more than 100 locations across nine U.S. states.[70]

Substance use treatment programs have received considerable private equity investment, which has brought federal scrutiny. According to STAT, in recent years private equity firms have acquired stakes in nearly a third of U.S. opioid treatment programs (OTPs).[71] In March 2024, six U.S. Senators signed letters sent to seven OTP chains, including Crossroads, as part of a bipartisan investigation into how private equity investment may impact access to and use of methadone for opioid use disorder (OUD).[72]

Dental care’s consolidators

Private equity’s presence in Philadelphia dental care includes at least 86 companies owned by six different companies, for an average of 14.3 locations for each dental care company included in this data.

The largest number of private equity-owned dental care locations in Philadelphia is operated by Dental Care Alliance, which is owned by Harvest Partners. [73]The company operates at least 25 dental care locations in the region.

From the six companies identified here, KKR-owned Heartland Dental had the fewest locations with six in the Philadelphia region. In 2023, the company claimed to be the largest dental support organization in the U.S., with more than 2,700 doctors in more than 1,700 offices across 38 states.[80] Heartland’s network includes 48 offices across Pennsylvania broadly.[81]

Aspen Dental is another large-scale dental company with locations in Philadelphia. As of March 2024, it claimed to be the largest group of branded dental offices in the world with more than 1,000 U.S. locations.[82] Aspen Dental has 15 locations in the Philadelphia area.[83]

Aspen Dental is owned by private equity firms Ares Management, Leonard Green & Partners, and American Securities.[84] The company has paid over $1.1 billion in debt-funded dividends to its private equity owners since 2012, including:

• $127 million in February 2012[85]
• $85 million in April 2018[86]
• $50 million in February 2020[87]
• $835 million in June 2021[88]

Moody’s downgraded the company’s credit rating outlook from stable to negative following the $835 million dividend in 2021.[89]

Aspen Dental has paid millions of dollars to settle allegations of deceptive marketing practices. Recently, in January 2023, the company paid $3.5 million to settle claims in Massachusetts that it cheated thousands of consumers through a series of bait-and-switch advertising campaigns.[90] It paid $1 million to settle similar charges in Massachusetts nearly a decade earlier.[91] Aspen has also paid to settle allegations including false advertising,[92] unlawful incentives, pressure on staff, and profit-sharing.[93]

Dental support organizations (DSOs) such as Aspen Dental, Heartland Dental, and Dental Care Alliance have become popular investments for private equity, providing dentists with administrative, nonclinical business services such as accounting and billing, human resources, compliance, information technology, marketing, and maintenance. The growth of larger DSOs has been fueled primarily by private equity. As of May 2023, 100 to 200 DSOs were backed by private equity.[94]

Private equity may be particularly interested in dental care – and especially profitable specialists – due to the industry’s continued growth. The dental care industry is also fragmented, which can be inviting for private equity-owned companies which seek to grow by consolidating existing practices.[95]

Understated extent of home health & hospice

Home health and hospice providers are well represented in the data here. In the Philadelphia area, we identified 15 companies with 85 locations. This represents potentially high presence in the Philadelphia region because individually identified locations can include central office sites for in-home care providers across broad geographic areas including entire counties.[96]

Private equity-owned companies AccentCare (Advent International[112]) and Senior Helpers (Waud Capital Partners[113]) have the highest number of locations in the region with each operating 10 sites.

AccentCare has home health offices in locations in Blue Bell, Bristol, Colmar, Exton, and Gilbersville. It also provides services at Philadelphia Protestant Home and ChristianaCare Hospital in Delaware. The company provides hospice and palliative care in Delaware and Greater Philadelphia.[114]

Other companies with several offices in the region include Aveanna Healthcare (owned by Bain Capital and J.H. Whitney[115]) and Home Helpers Home Care (RiverGlade Capital[116]), which each have 9 locations; eight locations operated by Interim HealthCare (Wellspring Capital Management[117]); and seven locations each owned by Griswold Home Care (Pouschine Cook Capital Management[118]), Patriot Home Care (Madison Dearborn Partners[119]), and SYNERGY HomeCare (NexPhase Capital[120] and Ares Capital[121]).

In 2022, the home healthcare market in the U.S. was valued at approximately $140 billion. The market is expected to continue growing due to a population that prefers to age at home.[122] Private equity’s strong profit-driven business model can lower the quality of healthcare, increase costs, and reduce patient access, with lightly regulated industries like home healthcare and hospice at particular risk of issues including understaffing and service cuts.[123]

Multiple private equity-owned home health and hospice providers have paid billing fraud settlements in 2024. In May, the Department of Justice announced a $4.2 million settlement with Elara Caring to settle alleged False Claims Act violations which occurred over six years. In early August, it announced a $19.4 million settlement with Gentiva (formerly Kindred at Home). Later in August, Intrepid USA settled with Dallas-based Intrepid USA for $3.8 million.[124]

Urgent care companies’ local growth

Our data identifies 50 urgent care clinic locations in the Philadelphia area operated by three private equity-owned companies. As of March 2024, more than 2,300 U.S. urgent care centers are owned by private equity, amounting to approximately 17% of the national total.[125]

The largest number of urgent care centers in the U.S. is owned by Lorient Capital, which in March 2024 owned an estimated 402 locations through its platform companies American Family Care and Midwest Express Clinic.[126] Lorient bought American Family Care in March 2024 with plans to continue the company’s rapid expansion. The company operates more than 360 clinics,[127] including 30 sites in the Philadelphia region.

Local company Vybe Urgent Care has grown to 15 clinics as of August 2024, all of which are located in the Philadelphia area.[128] Private equity firm NewSpring Capital and Philadelphia College of Osteopathic Medicine (PCOM) provided Vybe with growth equity funding in 2018, intending to build out the local market.[129]

The urgent care industry is one of the fastest growing sectors in U.S. healthcare, according to one PESP report, which found private equity firms are continuing to exploit that growth by investing in and consolidating providers.[133]

Urgent care clinics may be used more frequently by low-income and underinsured Philadelphians. In February 2020, Vybe’s chief executive reported that more than half its patients did not have a primary care doctor.[134] In 2018 according to the Philadelphia Department of Public Health, 1 in 6 adult Philadelphians reported not having a primary care doctor, and tended to be younger, low-income, and underinsured.[135]

However, urgent care clinics are not a safety net. Many urgent care clinics do not accept Medicaid and can refuse to treat uninsured patients unless they pay a fee up front.[136] Demand may be in part driven by primary care physician shortages. NPR reported that some patients have used urgent care for primary care-type issues because it can be difficult to schedule an appointment with a primary care doctor.[137]

The urgent care business model is driven by volume, meaning clinicians are driven to treat many patients as quickly as possible in order to achieve higher profits, seeing up to 30 or 35 patients a day.[138] One estimate from 2022 puts the average charge for an urgent care visit at approximately $185.[139]

Specialty care

In order to avoid prohibitions against corporate ownership of physician practices, private equity-owned management companies – which focus on administrative services including insurance contracting and billing – often partner with physician-owned medical groups.[140]

Private equity-owned physician management companies have been associated with higher costs, increased utilization, and lowered staffing standards at their partner clinics:

• In 2022, a study in JAMA Internal Medicine found that prices paid to anesthesia practitioners increased after contracting with a physician management company – prices were substantially higher if the management company received private equity investment.[141]
• Another 2022 study in JAMA Health Forum, which looked at private equity-acquired dermatology, gastroenterology, and ophthalmology physician practices, found private equity acquisition was associated with increases in utilization as well as allowed amount and charges per claim.[142]
• In January 2023, Health Affairs published a study showing that physician practices acquired by private equity relied more on non-physician labor.[143]

One study published in Health Affairs in March 2024, which examined reported acquisitions of physician practices from 2012 to 2021, found that private equity firms’ market share exceeded 30% and 50% in some local markets.[144]

The study’s findings include data indicating that the areas around Philadelphia – including southern New Jersey, northern Delaware, southeastern Pennsylvania, and the Delaware Valley – private equity’s market share commonly exceeded 30% of physician practices.[145]

The data here includes one gastroenterology company, one company providing orthopedic care, and three eye care chains.

Gastroenterology
One company manages dozens of gastroenterology providers in the Philadelphia area. Private equity-owned U.S. Digestive Health has practices primarily within Pennsylvania, including 31 locations in the Philadelphia area.[154] As of August 2024, it claims to be one of the country’s largest gastroenterology practices, with 250 physicians across 37 offices, 23 ambulatory surgery centers, and 4 clinical research sites.[155]

Amulet Capital Partners formed the company in 2018 by merging management and administrative resources for three of Pennsylvania’s largest gastroenterology practices.[156] A recent study in Gastroenterology & Hepatology noted that private equity firms may find the fragmented market attractive due to potential returns from consolidation.[157]

Orthopedics
Private equity-owned Healthcare Outcomes Performance Company (HOPCo), which operates multiple brands, has at least 40 locations providing orthopedic care in the Philadelphia area. It has been owned by Linden Capital and Audax Private Equity since 2019.[158] In May 2022, HOPCo acquired Premier Orthopaedics and its more than 200 care providers in the region.[159] A few months later, HOPCo acquired Philadelphia Hand to Shoulder Center to become “one of the largest musculoskeletal platforms in the US,” with more than 50 locations and 265 providers.[160]

As of early 2023, at least 15 private equity-owned management companies had acquired orthopedic practices. Critics suggest private equity’s presence could lead to higher prices, longer work hours, reduced service delivery, and other concerning outcomes.[161] Orthopedics is highly fragmented, with high demand for its relatively low number of surgeons, which may attract more private equity investment aimed towards market consolidation.[162]

Vision care
Our data identifies three private equity-owned vision care brands operating 35 locations in the Philadelphia area, including:

• Capital Vision Services, which manages MyEyeDr., has been owned by Goldman Sachs since 2019, when it bought the company from private equity firm Altas Partners and Canadian pension fund Caisse de dépôt et placement du Québec.[163] The company has more than 500 vision care centers including 19 locations in the Philadelphia area.[164]
• ReFocus Eye Health, owned by private equity firm Zenyth Partners,[165] has more than 80 doctors across 30 U.S. practice locations and one ambulatory surgery center.[166] The company is focused in the Northeast, and it has 13 locations in Philadelphia and the surrounding region.[167]
• SightMD Pennsylvania has eight locations, including three in the Philadelphia area.[168] It has been owned by private equity firm Chicago Pacific Founders since 2018.[169]

An estimated 8% of U.S. ophthalmology practices were private equity-owned as of 2022. Private equity has invested in the offices of doctors who prescribe two of the most common macular degeneration eye drugs at high rates, according to KFF. These offices are likely to see a higher volume of patients and are thus likely to be more profitable.[170]

Conclusion

This report identifies approximately 900 private equity-owned healthcare provider locations in Philadelphia and the surrounding area using data generally made available by private equity firms and their portfolio companies.

The footprint measured here is an undercount, as private equity firms generally are not required to disclose their holdings to the public, which makes it difficult to assess private equity’s presence in any select geographic area.

Private equity-backed urology practices, for example, control nearly 40% of the market in the Philadelphia region according to a recent study in Health Affairs, but only the largest private equity-owned company’s 26 locations are included here.[171]

Only one women’s healthcare company has been identified here – Partners Group-owned Axia Women’s Health[172] – with more than 50 locations in the region.[173]

Private equity has already made a substantial impact negative on Philadelphians’ access to healthcare, including the closure of one hospital and the financial ruin of others. Increased private equity investment is likely to bring increased risks and debt for patients and providers alike.

Hahnemann University Hospital served Philadelphia and the surrounding communities for more than 170 years before announcing its closure in 2019 – in connection with the Chapter 11 bankruptcy filing of its private equity-owned parent company.[174] The closure of Hahnemann’s 496-bed facility was a major loss for Philadelphia and was the first ever closure of a major urban hospital in the U.S.[175]

Hospital system Crozer Health, part of national health system Prospect Medical Holdings, includes Philadelphia-area hospitals Crozer-Chester Medical Center, Taylor Hospital; Delaware County Memorial Hospital, Springfield Hospital.[176]

Prospect was formerly owned by private equity firm Leonard Green & Partners, which over the course of a decade extracted hundreds of millions in dividends and fees by loading up Prospect with debt – even when Prospect sometimes could not pay for medical supplies.[177]

In 2021, Leonard Green sold its stake in Prospect leaving the health system in considerable debt.[178] Since then, Prospect has struggled to maintain the Crozer locations and has laid off hundreds of healthcare workers. In August 2024, Prospect signed a letter of intent to sell the hospitals to a real estate company.[179]

Healthcare companies owned by private equity also operate in settings which are more difficult to observe. Two private equity-owned companies provide healthcare services in prisons and jails around Philadelphia.

Wellpath – owned by H.I.G. Capital[180] – is contracted to provide healthcare at Pennsylvania Department of Corrections facilities,[181]  which includes locations in Chester[182] and Collegeville.[183] YesCare (formerly Corizon Health) has been private equity-owned for at least 16 years[184] and contracts with Philadelphia’s Department of Prisons to provide healthcare services at the city jail.[185]

Regulatory developments and policy recommendations
Recent proposals to regulate private equity investment in healthcare have been introduced at various levels of government.

At the federal level, two pieces of legislation – the Health Over Wealth Act[186] and the Corporate Crimes Against Health Care Act[187] – have been introduced aiming to provide more oversight of private equity investment in healthcare.

State legislation was successfully passed in Indiana broadening merger review authority held by the state attorney general.^[188] California recently passed legislation requiring the state attorney general to approve private equity acquisitions of healthcare companies with more than $25 in revenue.[189]

Meanwhile, in the Pennsylvania legislature, three bills are being considered which would impose notification requirements for healthcare facilities, systems, or providers engaging in certain healthcare transactions.^[190] The bills are a modest step towards addressing the issues which stem from private equity in Pennsylvania healthcare – Pennsylvania lawmakers should approve the proposals and seek to build on them through a broad range of accountability and transparency measures.

Federal oversight bodies have recently given some attention to private equity roll-ups of healthcare providers, including the strategy’s tendency to create market consolidation. Private equity firms have been able to gain control of a significant share of physician practice specialties in some U.S. markets by steadily acquiring existing medical practices over a period of time.[191]

In 2024, two federal investigations have been launched investigating private equity tactics.

In March, the Federal Trade Commission, Department of Justice (DOJ) Antitrust Division, and U.S. Department of Health and Human Services (HHS) jointly launched a public inquiry into private equity firms and other corporate owners which are increasingly involved in healthcare system transactions.[192]

In May, the FTC and DOJ Antitrust Division jointly launched a public inquiry on serial acquisitions and roll-up strategies used by corporate actors, including private equity firms, across a wide array of markets and industries. The inquiry is meant to complement the parallel inquiry on healthcare system transactions.[193]

In June, 11 attorneys general submitted a comment letter in response to the FTC, DOJ, and HHS inquiry on healthcare transactions. The letter advocated for enforcement and regulatory action where federal and state governments can collaborate, and it laid out possible action to address the detrimental effects of private equity healthcare transactions, including roll-up acquisitions.[194]

In addition to stronger oversight of private equity roll-ups, PESP recommends policymakers pass measures which broaden healthcare provider merger and acquisition review; require full transparency of licensed hospital operators and other healthcare facilities, as well as their investors; and place limits on financial tactics used to enrich private equity investors at the expense of providers and patients – among other measures needed to address potential harms stemming from private equity investment in healthcare.

Appendices

Selection of other private equity-owned companies in Philadelphia
The following companies are included in the Philadelphia location data, but are not discussed or included in the report:

Appendix A– Philadelphia-area PE-owned Provider Locations

Appendix B– List of Companies

Resources

[1] David Blumenthal. “Private Equity’s Role in Health Care.” Commonwealth Fund, November 17, 2023. https://doi.org/10.26099/3kcn-8j78.

[2] Alan Ayers. “Private Equity Ownership in Urgent Care By Number of Centers, 2024.” Journal of Urgent Care Medicine, March 31, 2024. https://www.jucm.com/private-equity-ownership-in-urgent-care-by-number-of-centers-2024/.

[3] Chris Cumming. “Private Equity Puts Brakes on Healthcare Roll-Ups After Government Scrutiny.” Wall Street Journal, June 4, 2024. https://www.wsj.com/articles/private-equity-puts-brakes-on-healthcare-roll-ups-after-government-scrutiny-6fc64f5a.

[4] Nirad Jain and Kara Murphy. “Healthcare Holds Its Own amid a Tepid Deal Market, Reaching $60 Billion in Announced Deal Value.” Bain & Company, January 3, 2024. https://www.bain.com/about/media-center/press-releases/2023/healthcare-holds-its-own-amid-a-tepid-deal-market-reaching-$60-billion-in-announced-deal-value/.

[5] David Blumenthal. “Private Equity’s Role in Health Care.” Commonwealth Fund, November 17, 2023. https://doi.org/10.26099/3kcn-8j78.

[6] Sneha Kannan, 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.

[7] Atul Gupta, Sabrina T. Howell, Constantine Yannelis, and Abhinav Gupta. “How Patients Fare When Private Equity Funds Acquire Nursing Homes.” NBER, April 1, 2021. https://www.nber.org/digest/202104/how-patients-fare-when-private-equity-funds-acquire-nursing-homes.

[8] Haizhen Lin, Elizabeth L. Munnich, Michael R. Richards, Christopher M. Whaley, and Xiaoxi Zhao. “Private Equity and Healthcare Firm Behavior: Evidence from Ambulatory Surgery Centers.” Journal of Health Economics 91 (September 1, 2023): 102801. https://doi.org/10.1016/j.jhealeco.2023.102801; Richard M. Scheffler, Laura Alexander, Brent D. Fulton, Daniel R. Arnold, and Ola A. Abdelhadi. “Monetizing Medicine: Private Equity and Competition in Physician Practice Markets.” American Antitrust Institute, Petris Center on Health Care Markets, Washington Center for Equitable Growth, July 10, 2023. https://www.antitrustinstitute.org/wp-content/uploads/2023/07/AAI-UCB-EG_Private-Equity-I-Physician-Practice-Report_FINAL.pdf; Alexander Borsa, 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; Yashaswini Singh, 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; Ambar La Forgia, Amelia M. Bond, Robert Tyler Braun, Leah Z. Yao, Klaus Kjaer, Manyao Zhang, and Lawrence P. Casalino. “Association of Physician Management Companies and Private Equity Investment With Commercial Health Care Prices Paid to Anesthesia Practitioners.” JAMA Internal Medicine 182, no. 4 (April 2022): 396–404. https://doi.org/10.1001/jamainternmed.2022.0004.

[9] Michael Fenne. “Private Equity’s Revenue Cycle: Creating and Collecting U.S. Medical Debt.” Private Equity Stakeholder Project PESP, September 12, 2024. https://pestakeholder.org/reports/private-equitys-revenue-cycle-creating-and-collecting-u-s-medical-debt/.

[10] O’Grady, Eileen. “Private Equity Healthcare Bankruptcies Are on the Rise.” Private Equity Stakeholder Project, April 17, 2024. https://pestakeholder.org/reports/private-equity-healthcare-bankruptcies-are-on-the-rise/.

[11] Eileen O’Grady. “Private Equity Healthcare Bankruptcies Show No Signs of Slowing.” Private Equity Stakeholder Project PESP, August 1, 2024. https://pestakeholder.org/news/private-equity-healthcare-bankruptcies-show-no-signs-of-slowing/.

[12] Lauren Coleman-Lochner and Steven Church. “Private Equity Is No Longer a Reliable Last Resort for Troubled Hospitals.” Bloomberg, September 12, 2023. https://www.bloomberg.com/news/articles/2023-09-12/troubled-pennsylvania-hospital-reveals-failure-of-private-equity-deals.

[13] See, e.g., Aging With Comfort. “Frequently Asked Questions (FAQ).” Accessed September 26, 2024. https://agingwithcomfort.com/faq/ (serving Philadelphia, Bucks, Montgomery, Delaware, and Chester Counties); Senior Helpers of Chestnut Hill. “Home Care Services In Philadelphia, PA.” Accessed September 11, 2024. https://www.seniorhelpers.com/pa/philadelphia-chestnut-hill/ (serving Philadelphia, Montgomery, and Delaware Counties); and SYNERGY HomeCare of Chester County. “Home.” Accessed September 11, 2024. https://synergyhomecare.com/pa-chester-county-19335/ (Chester County).

[14] Waud Capital Partners. “Waud Capital Partners Closes Continuation Fund for Ivy Rehab Physical Therapy,” October 4, 2022. https://www.waudcapital.com/en/media/waud-capital-partners-closes-continuation-fund-for-ivy-rehab-physical-therapy/.

[15] Katherine Davis. “ATI Physical Therapy at Risk of Losing NYSE Listing.” Crain’s Chicago Business, July 6, 2023. https://www.chicagobusiness.com/health-care/ati-physical-therapy-risk-losing-nyse-listing.

[16] Partners Group. “Partners Group Invests in Confluent Health, a Leading US Provider of Physical Therapy Services,” May 30, 2019. https://www.partnersgroup.com/en/news-and-views/press-releases/investment-news/detail?news_id=dbf22e8a-9a6c-4c53-af7d-8aca4d8c9e52; Michael Schoeck. “Partners Group Evaluates Buyout Interest for PT Clinic Operator Confluent Health, Sources Say.” Content. PE Hub, July 17, 2024. https://www.pehub.com/partners-group-evaluates-buyout-interest-for-pt-clinic-operator-confluent-health-sources-say/.

[17] Jones Day. “Athletico Physical Therapy Sold to BDT Capital | Experience,” December 2016. https://www.jonesday.com/en/practices/experience/2016/12/athletico-physical-therapy-sold-to-bdt-capital; Tyler Udland. “Athletico Physical Therapy Completes $875M Term Loan at Tight End of Talk; Terms.” S&P Global Market Intelligence, February 3, 2022. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/athletico-physical-therapy-completes-875m-term-loan-at-tight-end-of-talk-terms-68731419.

[18] Phoenix Physical Therapy. “Phoenix Physical Therapy and Health Services, Inc. Enters into New Management Partnership with Audax Private Equity,” December 18, 2018. https://phoenixphysicaltherapy.com/phoenix-rehabilitation-and-health-services-inc-enters-into-new-management-partnership-with-audax-private-equity/; Audax Private Equity. “Phoenix Rehabilitation.” Accessed September 4, 2024. https://www.audaxprivateequity.com/portfolio/phoenix-rehabilitation-and-health-services-inc.

[19] Sarah Pringle. “General Atlantic Snaps up PT Solutions at $1.2 Billion Valuation.” Axios, January 7, 2022. https://www.axios.com/2022/01/07/ga-buys-pt-solutions-1-billion-valuation.

[20] TowerBrook. “PT Solutions.” Accessed September 13, 2024. https://www.towerbrook.com/us/portfolio/pt-solutions/.

[21] Andy Dixon, Cheairs Porter, and Geoff Smith. “Sector Spotlight: Physical Therapy.” Harris Williams, October 10, 2022. https://www.harriswilliams.com/our-insights/hcls-sector-spotlight-physical-therapy.

[22] Provident Perspective. “The Evolving M&A Landscape in the Physical Therapy Sector,” Q2 2018. https://www.providenthp.com/wp-content/uploads/2018/07/Physical-Therapy-Whitepaper_FINAL.pdf, 2.

[23] Harris Williams. “Physical Therapy Market Overview.” Q2 2022. https://assets.ctfassets.net/xpbu77rkft4z/1Vb2V910Qp2bPjsdcQOCgK/8b80150e7823c5fd2507a47f607f90d6/hw_pt_market_overview_q2_2022.pdf.

[24] Ivy Rehab. “Find a Physical Therapist Clinic near Me: Appointments Available.” Accessed August 19, 2024. https://www.ivyrehab.com/locations/.

[25] Waud Capital Partners. “Ivy Rehab.” Accessed August 19, 2024. https://www.waudcapital.com/en/portfolio/ivy-rehab/.

[26] Waud Capital Partners. “Waud Capital Partners Closes Continuation Fund for Ivy Rehab Physical Therapy,” October 4, 2022. https://www.waudcapital.com/en/media/waud-capital-partners-closes-continuation-fund-for-ivy-rehab-physical-therapy/.

[27] Pivot Physical Therapy. “Locations.” Accessed March 15, 2023. https://www.pivotphysicaltherapy.com/locations/.

[28] Jones Day. “Athletico Physical Therapy Sold to BDT Capital | Experience,” December 2016. https://www.jonesday.com/en/practices/experience/2016/12/athletico-physical-therapy-sold-to-bdt-capital.

[29] Jonathan Hemingway. “Athletico Physical Therapy Launches $875 Million Term Loan B.” S&P Global Market Intelligence, January 20, 2022. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/athletico-physical-therapy-launches-875-million-term-loan-b-68504436.

[30] “Moody’s downgrades Athletico’s CFR to B3; outlook revised to negative,” Moody’s Investor Service, November 4, 2022. https://www.moodys.com/research/Moodys-downgrades-Athleticos-CFR-to-B3-outlook-revised-to-negative-Rating-Action–PR_471060.

[31] “Moody’s downgrades Athletico’s CFR to Caa1; outlook is stable,” Moody’s Investor Service, March 24, 2023. https://www.moodys.com/research/Moodys-downgrades-Athleticos-CFR-to-Caa1-outlook-is-stable-Rating-Action–PR_475192.

[32] Strive Physical Therapy. “Site Info.” Accessed September 4, 2024. https://strivephysicaltherapy.com/site-info/; Partners Group. “Partners Group Invests in Confluent Health, a Leading US Provider of Physical Therapy Services,” May 30, 2019. https://www.partnersgroup.com/en/news-and-views/press-releases/investment-news/detail?news_id=dbf22e8a-9a6c-4c53-af7d-8aca4d8c9e52; Michael Schoeck. “Partners Group Evaluates Buyout Interest for PT Clinic Operator Confluent Health, Sources Say.” Content. PE Hub, July 17, 2024. https://www.pehub.com/partners-group-evaluates-buyout-interest-for-pt-clinic-operator-confluent-health-sources-say/.

[33] Audax Private Equity. “Phoenix Rehabilitation.” Accessed September 4, 2024. https://www.audaxprivateequity.com/portfolio/phoenix-rehabilitation-and-health-services-inc.

[34] Sarah Pringle. “General Atlantic Snaps up PT Solutions at $1.2 Billion Valuation.” Axios, January 7, 2022. https://www.axios.com/2022/01/07/ga-buys-pt-solutions-1-billion-valuation.

[35] Advent International. “Advent International-Backed ATI Physical Therapy Set to Go Public through Business Combination with Fortress Value Acquisition Corp. II,” February 22, 2021. https://www.adventinternational.com/advent-international-backed-ati-physical-therapy-set-to-go-public-through-business-combination-with-fortress-value-acquisition-corp-ii/; Katherine Davis. “ATI Physical Therapy at Risk of Losing NYSE Listing.” Crain’s Chicago Business, July 6, 2023. https://www.chicagobusiness.com/health-care/ati-physical-therapy-risk-losing-nyse-listing.

[36] Joe Cahill. “ATI Flubs Revenue Forecast, Highlighting Perils of SPACs.” Crain’s Chicago Business, August 11, 2021. https://www.chicagobusiness.com/joe-cahill-business/ati-flubs-revenue-forecast-highlighting-perils-spacs.

[37] Katherine Davis. “ATI Physical Therapy at Risk of Losing NYSE Listing.” Crain’s Chicago Business, July 6, 2023. https://www.chicagobusiness.com/health-care/ati-physical-therapy-risk-losing-nyse-listing.

[38] ATI Physical Therapy. “ATI Physical Therapy Reports Second Quarter 2024 Results.” PR Newswire, August 5, 2024. https://www.prnewswire.com/news-releases/ati-physical-therapy-reports-second-quarter-2024-results-302213867.html; ATI Physical Therapy. “What To Look For In A Physical Therapist,” September 5, 2023. https://www.atipt.com/blog/what-to-look-for-in-a-physical-therapist.

[39] Business Wire. “LifeStance Health Partners with TPG, Summit Partners, and Silversmith to Expand Behavioral Health Access,” April 16, 2020. https://www.businesswire.com/news/home/20200416005666/en/LifeStance-Health-Partners-with-TPG-Summit-Partners-and-Silversmith-to-Expand-Behavioral-Health-Access.

[40] Centerbridge Partners. “Centerbridge Partners Strategies.” Accessed September 13, 2024. https://www.centerbridge.com/our-strategies/.

[41] The Vistria Group. “Portfolio.” Accessed September 13, 2024. https://vistria.com/portfolio/.

[42] Revelstoke Capital Partners. “Revelstoke Capital Partners and CDPQ Announce Significant Investment in Crossroads Treatment Centers.” Cision PR Newswire, January 11, 2022. https://www.prnewswire.com/news-releases/revelstoke-capital-partners-and-cdpq-announce-significant-investment-in-crossroads-treatment-centers-301457764.html.

[43] NeurAbilities Healthcare. “Press Release: Council Capital Partners With CNNH,” October 26, 2018. https://neurabilities.com/press-release-council-capital-partners-with-cnnh/; John R. Fischer. “Council Capital Invests in Medical Management Consultant OccMD.” Content. PE Hub, April 30, 2024. https://www.pehub.com/council-capital-invests-in-medical-management-consultant-occmd/.

[44] Linden Capital Partners. “Pinnacle Treatment Centers.” Accessed September 13, 2024. https://www.linden.com/portfolio/investments/current/pinnacle-treatment-centers/.

[45] PR Newswire. “Centra Capital, LLC Purchases CM Counsel, Leading Philadelphia Outpatient Behavioral Health Group,” January 26, 2021. https://www.prnewswire.com/news-releases/centra-capital-llc-purchases-cm-counsel-leading-philadelphia-outpatient-behavioral-health-group-301214238.html.

[46] Cressey & Company. “Partnerships.” Accessed September 13, 2024. https://www.cresseyco.com/partnerships?search=&cat=all.

[47] Business Wire. “Blue Wolf Capital Acquires RHA Health Services,” August 5, 2019. https://www.businesswire.com/news/home/20190805005207/en/Blue-Wolf-Capital-Acquires-RHA-Health-Services; Opalesque. “Blue Wolf Capital Reorganizes,” January 11, 2022. https://www.opalesque.com/industry-updates/6643/blue-wolf-capital-reorganizes.html;

[48] Nautic. “All Investments.” Accessed September 13, 2024. https://nautic.com/all-investments-by-name/.

[49] PR Newswire. “Halifax Partners with ChanceLight Behavioral Health, Therapy & Education,” May 15, 2018. https://www.prnewswire.com/news-releases/halifax-partners-with-chancelight-behavioral-health-therapy–education-300648353.html; The Halifax Group. “ChanceLight Behavioral Health, Therapy, & Education.” Accessed September 26, 2024. https://thehalifaxgroup.com/companies/chancelight-behavioral-health-and-therapy-hw/;

[50] Webster Equity Partners. “BayMark.” Accessed September 13, 2023. https://websterequitypartners.com/portfolio/baymark/.

[51] Sarah Pringle. “Carlyle Buys Nautic’s Odyssey Behavioral in $200 Mln Deal.” Content. PE Hub, December 19, 2018. https://www.pehub.com/carlyle-buys-nautics-odyssey-behavioral-in-200-mln-deal/; Deborah Balshem, Rebecca Wenzel, and Bhavna Kaul. “Carlyle-Backed Odyssey Behavioral Hires Banker for Sale, Sources Say.” ION Analytics, July 19, 2024. https://ionanalytics.com/insights/mergermarket/carlyle-backed-odyssey-behavioral-hires-banker-for-sale-sources-say/.

[52] Lifestance Health. “Online Therapy & Psychiatry Appointments.” Accessed August 19, 2024. https://lifestance.com/.

[53] Lifestance Health. “Mental Health Care Locations in Pennsylvania: Psychiatrists & Therapists.” Accessed August 19, 2024. https://lifestance.com/location/state/pennsylvania/.

[54] Summit Partners. “LifeStance Health Enters the Behavioral Healthcare Arena in Partnership With Summit Partners and Silversmith Capital Partners.” GlobeNewswire, December 3, 2015. https://www.globenewswire.com/en/news-release/2015/12/03/1120638/0/en/LifeStance-Health-Enters-the-Behavioral-Healthcare-Arena-in-Partnership-With-Summit-Partners-and-Silversmith-Capital-Partners.html.

[55] Darren M. Black. “LifeStance Health Announces Partnership to Expand Behavioral Health Access.” Summit Partners, April 16, 2020. https://www.summitpartners.com/news/lifestance-health-announces-partnership-to-expand-behavioral-health-access.

[56] Heather Landi. “Mental Health Provider LifeStance Health Valued at More than $7B as Stock Jumps Following IPO.” Fierce Healthcare, June 15, 2021. https://www.fiercehealthcare.com/tech/lifestance-health-valued-at-more-than-7b-as-stock-jumps-following-ipo.

[57] Chris Larson. “Madison Dearborn to Buy 25% of Sevita at Roughly $3B Valuation.” Behavioral Health Business, January 20, 2022. https://bhbusiness.com/2022/01/20/madison-dearborn-to-buy-25-of-sevita-at-roughly-3b-valuation/.

[58] Eileen O’Grady. “The Kids Are Not Alright: How Private Equity Profits Off of Behavioral Health Services for Vulnerable and At-Risk Youth,” p.10. Private Equity Stakeholder Project PESP, February 2022. https://pestakeholder.org/wp-content/uploads/2022/02/PESP_Youth_BH_Report_2022.pdf.

[59] Sevita. “The MENTOR Network Is Becoming Sevita,” September 23, 2021. https://sevitahealth.com/news-article/the-mentor-network-is-becoming-sevita/.

[60] Aaron Roston and Jeremy Singer-Vine, “Senate Finds 86 Children Died In Care Of Giant For-Profit Foster Care Firm, Citing BuzzFeed News,” Buzzfeed News, October 18, 2017. https://www.buzzfeednews.com/article/aramroston/senate-finds-86-children-died-in-care-of-giant-for-profit

[61] Moody’s Investors Service. “Moody’s Downgrades National MENTOR Holdings, Inc.’s First Lien Credit Facilities to B2 from B1; B2 CFR Affirmed; Outlook Is Stable | Rating Action,” January 27, 2020. https://www.moodys.com/research/Moodys-downgrades-National-MENTOR-Holdings-Incs-first-lien-credit-facilities-Rating-Action–PR_417670; Moody’s Investors Service. “Moody’s Affirms National Mentor’s B2 CFR; Outlook to Negative | Rating Action,” February 9, 2021. https://www.moodys.com/research/Moodys-affirms-National-Mentors-B2-CFR-outlook-to-negative-Rating-Action–PR_439884.

[62] Chris Cumming. “For Some Companies, Debt Downgrades Followed Payouts to Private-Equity Owners.” Wall Street Journal, June 11, 2023. https://www.wsj.com/articles/for-some-companies-debt-downgrades-followed-payouts-to-private-equity-owners-e9cde86.

[63] Eileen O’Grady. “Private Equity Firms Reaped Billions of Dollars in Debt-Funded Dividends from Healthcare Companies in 2021.” Private Equity Stakeholder Project PESP, January 5, 2022. https://pestakeholder.org/news/private-equity-firms-reaped-billions-of-dollars-in-debt-funded-dividends-from-healthcare-companies-in-2021/.

[64] Morgan Gonzales. “IOPs, PHPs Were Bright Spots Amid 2023’s Behavioral Health M&A Slowdown.” Behavioral Health Business, March 19, 2024. https://bhbusiness.com/2024/03/19/iops-phps-were-bright-spots-amid-2023s-behavioral-health-ma-slowdown/;

Jane M. Zhu, Emmanuel Greenberg, Marissa King, and Susan Busch. “Geographic Penetration of Private Equity Ownership in Outpatient and Residential Behavioral Health.” JAMA Psychiatry 81, no. 7 (July 1, 2024): 732–35. https://doi.org/10.1001/jamapsychiatry.2024.0825.

[65] Angie Basiouny. “Why Are Private Equity Firms Buying Mental Health Clinics?” Knowledge at Wharton, July 15, 2024. https://knowledge.wharton.upenn.edu/article/why-are-private-equity-firms-buying-mental-health-clinics/.

[66] Network of Care. “Private Equity Moves into Care in Northwest: Investment Firms Buying Mental Health, Substance Use Clinics – Columbian, 5/22/2024 Washington, D.C., District Of Columbia,” May 22, 2024. https://washington.dc.networkofcare.org/mh/news-article-detail.aspx?id=152581.

[67] Jesse C. Baumgartner, Gabriella N. Aboulafia, and Audrey McIntosh, “The ACA at 10: How Has It Impacted Mental Health Care?” The Commonwealth Fund, April 3, 2020. https://www.commonwealthfund.org/blog/2020/aca-10-how-has-it-impacted-mental-health-care

[68] Eileen O’Grady. “Understaffed, Unlicensed, and Untrained: Behavioral Health Under Private Equity.” Private Equity Stakeholder Project PESP, September 28, 2020. https://pestakeholder.org/reports/understaffed-unlicensed-and-untrained-behavioral-health-under-private-equity/.

[69] Revelstoke Capital Partners. “Revelstoke Invests in Crossroads Treatment Centers,” December 23, 2014. https://www.revelstokecapital.com/news/revelstoke-capital-partners-completes-investment-in-crossroads-treatment-centers/.

[70] Crossroads Treatment Centers. “Why Crossroads.” Accessed August 19, 2024. https://www.crossroadstreatmentcenters.com/why-crossroads/.

[71] Lev Facher. “The Methadone Clinic Monopoly: Opioid Treatment Chains Backed by Private Equity Are Fighting Calls for Reform.” STAT, March 19, 2024. https://www.statnews.com/2024/03/19/methadone-clinics-opioid-addiction-private-equity/.

[72] U.S. Senator Ed Markey of Massachusetts. “Senator Markey Leads Colleagues in Bipartisan Investigation into the Role of Private Equity in Restricting Access to Methadone Treatment for Opioid Use Disorder,” March 13, 2024. https://www.markey.senate.gov/news/press-releases/senator-markey-leads-colleagues-in-bipartisan-investigation-into-the-role-of-private-equity-in-restricting-access-to-methadone-treatment-for-opioid-use-disorder.

[73] Harvest Partners. “DCA.” Accessed September 13, 2024. https://harvestpartners.com/portfolio/dental-care-alliance/.

[74] Harvest Partners. “DCA.” Accessed September 13, 2024. https://harvestpartners.com/portfolio/dental-care-alliance/.

[75] TriSpan. “ProSmile.” Accessed September 13, 2024. https://www.trispanllp.com/portfolio/pg-dental-holdings-llc/.

[76] Leonard Green & Partners. “Ares Management & Leonard Green Increase Ownership In Aspen Dental Management, Inc.,” June 13, 2017. https://www.leonardgreen.com/ares-management-leonard-green-increase-ownership-in-aspen-dental-management-inc/; Jonathan Hemingway. “Aspen Dental Management Launches $1.2B Incremental Term Loan for M&A.” S&P Global Market Intelligence, December 2, 2020. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/aspen-dental-management-launches-1-2b-incremental-term-loan-for-m-a-61535168.

[77] The Smilist. “The Smilist Affiliates with Simply Beautiful Smiles Offices and Expands to Maryland.” PR Newswire, July 9, 2024. https://www.prnewswire.com/news-releases/the-smilist-affiliates-with-simply-beautiful-smiles-offices-and-expands-to-maryland-302191193.html.

[78] Harvest Partners. “Affordable Care.” Accessed September 13, 2024. https://harvestpartners.com/portfolio/affordable-care/.

[79] Ontario Teachers’ Pension Plan. “KKR to Acquire Majority Interest in Heartland Dental,” March 7, 2018. https://www.otpp.com/en-ca/about-us/news-and-insights/2018/kkr-to-acquire-majority-interest-in-heartland-dental/; PR Newswire. “Heartland Dental Celebrates Record New Construction, Affiliation Growth, and Technology Enhancements in 2023,” January 31, 2024. https://www.prnewswire.com/news-releases/heartland-dental-celebrates-record-new-construction-affiliation-growth-and-technology-enhancements-in-2023-302048651.html.

[80] Heartland Dental. “Heartland Dental Celebrates Record Growth Year in 2022,” February 1, 2023. https://blog.heartland.com/heartland-dental-2022-growth.

[81] Heartland Dental. “Supported Doctor Benefits.” Accessed March 16, 2023. https://heartland.com/affiliate-with-us.

[82] Aspen Dental Newsroom. “Aspen Dental and International Medical Relief Provide Free Dental Services to Patients in Ecuador,” March 20, 2024. https://aspendental.mediaroom.com/world-oral-health-day-2024.

[83] AspenDental. “Office Listings.” Accessed September 15, 2024. https://www.aspendental.com/dentist/.

[84] Leonard Green & Partners. “Ares Management & Leonard Green Increase Ownership In Aspen Dental Management, Inc.,” June 13, 2017. https://www.leonardgreen.com/ares-management-leonard-green-increase-ownership-in-aspen-dental-management-inc/.

[85] Moody’s. “Moody’s Rates Aspen Dental’s Amended Credit Facility B2; CFR Affirmed at B2 | Rating Action,” February 17, 2012. https://www.moodys.com/research/Moodys-rates-Aspen-Dentals-Rating-Action–PR_237938.

[86] Moody’s. “Moody’s Affirms ADMI’s B2 CFR, Assigns B2 to the Proposed Credit Facility | Rating Action,” April 2, 2018. https://www.moodys.com/research/Moodys-affirms-ADMIs-B2-CFR-Rating-Action–PR_381690.

[87] Jonathan Hemingway. “Aspen Dental Management Launches $1.2B Incremental Term Loan for M&A.” S&P Global Market Intelligence, December 2, 2020. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/aspen-dental-management-launches-1-2b-incremental-term-loan-for-m-a-61535168.

[88] Moody’s. “Moody’s Affirms ADMI Corp.’s B2 Corporate Family Rating, Outlook Changed to Negative | Rating Action,” June 11, 2021. https://www.moodys.com/research/Moodys-affirms-ADMI-Corps-B2-Rating-Action–PR_447749.

[89] Moody’s. “Moody’s Affirms ADMI Corp.’s B2 Corporate Family Rating, Outlook Changed to Negative | Rating Action,” June 11, 2021. https://www.moodys.com/research/Moodys-affirms-ADMI-Corps-B2-Rating-Action–PR_447749.

[90] Office of the Massachusetts Attorney General. “Attorney General’s Office Reaches $3.5 Million Settlement With Aspen Dental Over Claims of Deceptive Advertising,” January 5, 2023. https://www.mass.gov/news/attorney-generals-office-reaches-35-million-settlement-with-aspen-dental-over-claims-of-deceptive-advertising.

[91] Jack Newsham. “Aspen Dental to Pay $1 Million to Settle Fraud Allegations – The Boston Globe.” Boston Globe, December 22, 2014. https://www.bostonglobe.com/business/2014/12/22/aspen-dental-pay-million-settle-coakley-allegations/doXudUfuYJGwCJnfYxUKWO/story.html.

[92] Emily Moore. “Aspen Dental Management to Pay Settlement amid False Advertising Claims.” Legal Newsline, November 13, 2015. https://legalnewsline.com/stories/510647952-aspen-dental-management-to-pay-settlement-amid-false-advertising-claims.

[93] NBC News. “Some Doctors Say a Focus on Profits Is Hurting Health Care in U.S. ERs,” March 28, 2022. https://www.nbcnews.com/health/health-care/doctor-fired-er-warns-effect-profit-firms-us-health-care-rcna19975.

[94] McGuireWoods. “Pushing Upmarket: Consolidation of DSOs and Secondary Private Equity Sales,” May 5, 2023. https://www.mcguirewoods.com/client-resources/alerts/2023/5/consolidation-dsos-secondary-private-equity-sales/.

[95] McGuireWoods. “Pushing Upmarket: Consolidation of DSOs and Secondary Private Equity Sales,” May 5, 2023. https://www.mcguirewoods.com/client-resources/alerts/2023/5/consolidation-dsos-secondary-private-equity-sales/.

[96] See, e.g., Aging With Comfort. “Frequently Asked Questions (FAQ).” Accessed September 26, 2024. https://agingwithcomfort.com/faq/ (serving Philadelphia, Bucks, Montgomery, Delaware, and Chester Counties); Senior Helpers of Chestnut Hill. “Home Care Services In Philadelphia, PA.” Accessed September 11, 2024. https://www.seniorhelpers.com/pa/philadelphia-chestnut-hill/ (serving Philadelphia, Montgomery, and Delaware Counties); and SYNERGY HomeCare of Chester County. “Home.” Accessed September 11, 2024. https://synergyhomecare.com/pa-chester-county-19335/ (Chester County).

[97] Andrea Ramsey. “Advent International Acquires AccentCare.” Advent International, May 16, 2019. https://www.adventinternational.com/advent-international-acquires-accentcare/; Advent International. “Investments.” Accessed September 26, 2024. https://www.adventinternational.com/investments/.

[98] Dave Muoio. “Advocate Health Sells Home Care Franchise to PE Firm,” March 25, 2024. https://www.fiercehealthcare.com/providers/advocate-health-sells-home-care-franchise-senior-helpers-pe-firm-waud-capital.

[99] Bain Capital Private Equity. “Portfolio.” Accessed September 13, 2024. https://www.baincapitalprivateequity.com/portfolio.

[100] Yahoo Finance. “Aveanna Healthcare Holdings Inc. (AVAH) Stock Major Holders.” Accessed September 17, 2024. https://finance.yahoo.com/quote/AVAH/holders/.

[101] RiverGlade Capital. “RiverGlade Capital Announces New Partnership with Home Helpers,” April 8, 2021. https://rivergladecapital.com/riverglade-capital-announces-new-partnership-with-home-helpers/.

[102] Andrew Donlan. “Wellspring Capital Management Acquires Interim HealthCare Parent Company Caring Brands International.” Home Health Care News, October 25, 2021. https://homehealthcarenews.com/2021/10/wellspring-capital-management-acquires-interim-healthcare-parent-company-caring-brands-international/.

[103] Pouschine Cook Capital Management. “Investments.” Accessed September 13, 2024. https://pouschinecook.com/investments/.

[104] BDO Capital Partners. “Transactions.” Accessed September 13, 2024. https://bdocap.com/transactions.

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