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Figure.  Private Equity–Affiliated Obstetrics/Gynecology (OB/GYN) Offices in 2020
Private Equity–Affiliated Obstetrics/Gynecology (OB/GYN) Offices in 2020

We mapped 533 OB/GYN offices in 2020, excluding the 180 hospitals contracted with Ob Hospitalist Group and 439 offices without identifiable locations. No mapped offices were located in Alaska or Hawaii.

Table.  Women’s Health Organizations With Private Equity Affiliation From 2010 to 2019
Women’s Health Organizations With Private Equity Affiliation From 2010 to 2019
1.
Perlberg  H. How private equity is ruining American health care. Accessed June 15, 2020. https://www.bloomberg.com/news/features/2020-05-20/private-equity-is-ruining-health-care-covid-is-making-it-worse
2.
Gondi  S, Song  Z.  Potential implications of private equity investments in health care delivery.   JAMA. 2019;321(11):1047-1048. doi:10.1001/jama.2019.1077PubMedGoogle ScholarCrossref
3.
Eren Vural  I.  Financialisation in health care: an analysis of private equity fund investments in Turkey.   Soc Sci Med. 2017;187:276-286. doi:10.1016/j.socscimed.2017.06.008PubMedGoogle ScholarCrossref
4.
Zhu  JM, Hua  LM, Polsky  D.  Private equity acquisitions of physician medical groups across specialties, 2013-2016.   JAMA. 2020;323(7):663-665. doi:10.1001/jama.2019.21844PubMedGoogle ScholarCrossref
5.
Casalino  LP.  The Medicare Access and CHIP Reauthorization Act and the corporate transformation of American medicine.   Health Aff (Millwood). 2017;36(5):865-869. doi:10.1377/hlthaff.2016.1536PubMedGoogle ScholarCrossref
6.
Fontenot  K, Semega  J, Kollar  M. Income and poverty in the United States. Accessed April 12, 2020. https://www.census.gov/library/publications/2018/demo/p60-263.html
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    Research Letter
    August 24, 2020

    Expansion of Private Equity Involvement in Women’s Health Care

    Author Affiliations
    • 1Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, Massachusetts
    • 2Columbia University Mailman School of Public Health, Department of Sociomedical Sciences, New York, New York
    • 3Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
    • 4Department of Medicine, Massachusetts General Hospital, Boston
    • 5Department of the History of Science, Harvard University, Cambridge, Massachusetts
    • 6Committee on Degrees in Studies of Women, Gender, and Sexuality, Harvard University, Cambridge, Massachusetts
    JAMA Intern Med. 2020;180(11):1542-1545. doi:10.1001/jamainternmed.2020.3567

    An influx of private equity involvement in women’s health care has garnered attention and scrutiny.1 Over the past decade, private equity firms have increasingly invested in or acquired hospitals, physician practices, laboratories, and biomedical device companies. Private equity firms use capital from corporations or wealthy individuals to invest in and acquire organizations and generally sell their holdings within 3 to 7 years.2 Proponents argue that they produce economic value by increasing operational efficiency while maintaining or improving the quality of care. Critics fear that the need to quickly achieve high returns on investments may conflict with the quality and safety of care or exacerbate health inequities.3 Recent evidence shows growing acquisitions of physician groups across specialties between 2013 and 2016,4 which is aligned with larger trends in the corporatization of medicine.5 Despite the growth and geographic breadth of private equity involvement in health care, to our knowledge, relatively little empirical research exists, especially in women’s health.

    We document formerly non–private equity women’s health care companies, including physician networks, practices, and fertility clinics, that gained a private equity affiliation between 2010 and 2019. This evidence aims to inform discussions about the clinical and societal implications of private equity in women’s health.

    Methods

    Using market reports and multiple methods of verification, we identified organizations (ie, target companies) specializing in women’s health that transitioned from non–private equity to private equity–affiliated between 2010 and 2019. Affiliations included direct acquisitions, recapitalizations, and undisclosed financial partnerships, with targets providing clinical obstetrics/gynecology (OB/GYN) or fertility services. We describe the method of identifying affiliations and inclusion criteria in eTable in the Supplement. This study was exempt from institutional board review because it did not involve human participants nor was any of the publicly available data used directly or indirectly based on human participant information.

    We assessed whether OB/GYN offices are located in urban or rural areas by the zip code rural-urban commuting areas geographic taxonomy, version 3.10 (US Department of Agriculture). This mapping uses the 2010 Census work commuting data to classify zip codes from 1 (metropolitan) to 10 (rural) using the size and direction of primary commuting flows. We assessed average median household income using the zip codes for these offices.

    Results

    We found 24 target companies that gained private equity affiliation between 2010 and 2019 (Table). Acquisitions accelerated over the period studied, with 17 occurring between 2017 and 2019. In total, we found 605 offices and 2019 clinicians (ie, physicians, nurse practitioners, nurse midwives, and physician assistants) at the time of affiliation. As of 2020, we identified 1340 offices and 3989 clinicians.

    We found 17 target companies that were OB/GYN practices or networks and 7 target companies that provided fertility services. We located and mapped 533 (39.8%) of the 1340 offices of the 17 OB/GYN target companies in 2020. We excluded 180 hospitals contracted with the Ob Hospitalist Group (13.4%) and 439 offices (32.8%) without identifiable locations (Figure). Of the 533 offices, 240 (45.0%) were located in the Northeast, 229 (43.0%) in the South, 29 (5.5%) in the West, and 34 (6.4%) in the Midwest. Using the zip codes of these offices, we found that the average median (SE) household income was $76 107 ($1470) and the rural-urban commuting area score was 1.19 (0.04), which corresponds to a highly metropolitan area. Overall, 520 (97.6%) of these offices accepted Medicare and 453 (85.0%) accepted at least 1 form of Medicaid. Private insurance was accepted at all of these offices.

    Discussion

    There has been a substantial increase in private equity affiliations in women’s health care since 2017. Private equity–affiliated OB/GYN offices are located in urban locations, with an average 2017 median household income 24% higher than the 2017 national average of $61 372.6 They generally accept Medicare, Medicaid, and private insurance. Several private equity firms have affiliations with multiple target companies, suggesting that these firms may have growing influence in women’s health.

    Our analysis does not represent the totality of private equity investment in the women’s health sector. Target companies affiliated with private equity before 2010 whose affiliation was not publicly reported or who did not primarily provide OB/GYN or fertility services were excluded.

    How the incentives of private equity firms interact with the clinical mission of women’s health is a critical area of inquiry. Future debate about private equity in women’s health will likely be shaped by the associations between economic incentives and quality of care, elective or cosmetic procedures, and access to reproductive health services, especially among low-income, LGBTQIA, and other disadvantaged populations.

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    Article Information

    Accepted for Publication: June 18, 2020.

    Corresponding Author: Joseph Dov Bruch, BA, Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences, 677 Huntington Ave, Boston, MA 02115 (jbruch@g.harvard.edu).

    Published Online: August 24, 2020. doi:10.1001/jamainternmed.2020.3567

    Conflict of Interest Disclosures: Dr Song reported receiving grants from the National Institutes of Health and the Laura and John Arnold Foundation; receiving personal fees from the Research Triangle Institute for work on risk adjustment, from the International Foundation of Employee Benefit Plans for a lecture outside of this work, and for providing expert testimony outside of this work. No other disclosures were reported.

    Funding: This study was supported by the Office of the Director, National Institutes of Health (grant DP5-OD024564 to Dr Song).

    Role of the Funder/Sponsor: The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Perlberg  H. How private equity is ruining American health care. Accessed June 15, 2020. https://www.bloomberg.com/news/features/2020-05-20/private-equity-is-ruining-health-care-covid-is-making-it-worse
    2.
    Gondi  S, Song  Z.  Potential implications of private equity investments in health care delivery.   JAMA. 2019;321(11):1047-1048. doi:10.1001/jama.2019.1077PubMedGoogle ScholarCrossref
    3.
    Eren Vural  I.  Financialisation in health care: an analysis of private equity fund investments in Turkey.   Soc Sci Med. 2017;187:276-286. doi:10.1016/j.socscimed.2017.06.008PubMedGoogle ScholarCrossref
    4.
    Zhu  JM, Hua  LM, Polsky  D.  Private equity acquisitions of physician medical groups across specialties, 2013-2016.   JAMA. 2020;323(7):663-665. doi:10.1001/jama.2019.21844PubMedGoogle ScholarCrossref
    5.
    Casalino  LP.  The Medicare Access and CHIP Reauthorization Act and the corporate transformation of American medicine.   Health Aff (Millwood). 2017;36(5):865-869. doi:10.1377/hlthaff.2016.1536PubMedGoogle ScholarCrossref
    6.
    Fontenot  K, Semega  J, Kollar  M. Income and poverty in the United States. Accessed April 12, 2020. https://www.census.gov/library/publications/2018/demo/p60-263.html
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