Changing Ownership of Health Care Entities in the U.S.

Day 1 | Thursday, September 4, 2025

Welcome and NIA Goals for the Discussion

Priscilla Novak introduced the motivation for the workshop and its alignment with NIH’s mission—specifically, NIA’s charge to “extend the healthy, active years of life” by supporting “genetic, biological, clinical, behavioral, social, and economic research on aging.” She reiterates that the central public health issue this workshop seeks to address is how to ensure the provision of high-quality healthcare that produces positive outcomes over time. Steering Committee member, Dr. Zirui Song, introduced the workshop by describing the content or themes for each panel.

• Priscilla Novak – National Institute on Aging
• Zirui Song – Harvard University

Panel 1: Getting Bigger — Horizontal and Vertical Provider Consolidation

Topic(s):

• The historical overview of provider ownership—from the solo family physician of the 1960s who knew everyone in town, to today’s large, integrated health systems that often serve as a region’s largest employer
• Horizontal consolidation, such as hospital-to-hospital mergers or the formation of large, for-profit nursing home chains
• Vertical consolidation, including hospitals acquiring physician practices or post-acute care providers
• Evidence on economic impacts (clinical impacts will be addressed in Panel 3 on Day 2)
• Care settings to be discussed include hospitals, health systems, nursing homes, and hospices

Presenters:

• Background
  • Martin "Marty" Gaynor – Carnegie Mellon University “Three (and ½) Points About Consolidation in Health Care Markets”
• Recent Findings:
  • Christopher Whaley – Brown University
    “Does Consolidation in the US Health Care System Impact Quality?”
  • Amy “Amelia” Bond – Cornell University
    “Vertical Integration Across Sectors: Primary Care in Health Systems and the Pharmaceutical Supply Chain”
  • Brady Post – Northeastern University
    “Vertical Integration of Hospitals and Cardiologists”
• Discussion Leader:
  • Meredith Rosenthal – Harvard University

Read panel summary

Panel 1 examined how consolidation in hospitals, physician practices, and the pharmaceutical supply chain is reshaping the U.S. healthcare system. Experts highlighted the rise of private equity, insurer-driven acquisitions, and the growing market dominance of a few large systems. While consolidation is often justified as improving efficiency and coordination, the evidence overwhelmingly shows that it raises costs without improving quality or access to care.

Speakers emphasized that consolidation consistently harms patients, particularly older adults and vulnerable populations. Research shows higher mortality rates, reduced medication adherence, and limited access to services such as obstetrics in rural areas following hospital mergers. Consolidation also depresses wages for healthcare workers and leads to job losses, creating ripple effects in the broader economy. In the pharmaceutical sector, vertical integration among insurers, pharmacy benefit managers, and pharmacies has increased patient steering and potential cost burdens, raising serious concerns about competition and equity.

The panel concluded that urgent policy action is needed. Strengthened antitrust enforcement should target both large-scale mergers and quieter forms of consolidation that occur through physician employment shifts. Transparency must be improved through expanded reporting of ownership and private equity arrangements. States are beginning to experiment with price caps and oversight in highly concentrated markets, and these approaches could provide models for broader reform. Payment models also require reassessment to ensure they do not inadvertently encourage consolidation without delivering quality gains. Ultimately, panelists called for a whole-of-government response, involving federal and state agencies, to address the monopoly power now shaping U.S. healthcare.

Panel 2: Getting Savvier — New Financial Participants in Provider Ownership

Topic(s):

• Emerging and alternative ownership models
• Private equity acquisitions, including of hospices
• Insurer acquisitions of physician practices (e.g., Optum)
• Retail chains entering provider ownership (e.g., CVS, Walmart), along with other new market entrants
• Health systems engaging in venture capital through hospital investment arms focused on early-stage innovation and commercialization—contributing to revenue volatility following the 2020 public health emergency
• Evidence on clinical and economic impacts, including the clinical consequences of cost-cutting measures
• The role of financial engineering in shaping ownership dynamics

Presenters:

• Background
  • Daniel Polsky – John Hopkins University “Getting Savvier – New Financial Participants in Provider Ownership”
• Recent findings/variety of cases (3 speakers, 15 minutes each):
  • Ashvin Gandhi – University of California Los Angeles
    “Provider ownership”
  • Nancy Beaulieu – Harvard University
    “Vertical Integration between Insurers and Providers”
  • Kosali Simon – Indiana University
    “The Push and Pull Forces Reshaping U.S. Healthcare Ownership & Implications for Patient Health”
• Discussion Leader:
  • Joseph Bruch – University of Chicago

Read panel summary

Panel 2 highlighted the growing complexity of healthcare ownership and the significant implications this has for affordability, access, and quality of care. Across physicians, hospitals, nursing homes, hospice, and home health, new financial participants such as private equity firms, real estate investment trusts, insurers, and management service organizations are playing an increasingly central role. These arrangements often create layered and opaque ownership structures that reduce accountability, blur regulatory boundaries, and complicate oversight.

Evidence shows that ownership changes can directly influence patient care, beyond the effects of market consolidation. While concerns such as reduced staffing, higher patient mortality, and cost-shifting practices are well-documented, there are also cases where standardized management under corporate ownership may improve certain outcomes. This variation underscores the need to move beyond documenting treatment effects and instead focus on understanding the mechanisms driving these outcomes—such as capital structure, management practices, and related-party financial transactions that obscure profitability.

Research on insurer–provider integration further suggests that ownership structures may enable practices like patient steering, preferential pricing, and regulatory circumvention. These raise questions about competition, consumer welfare, and the adequacy of current oversight tools.

Overall, the discussion emphasized that healthcare ownership is shaped by both external financial pressures and sector-specific incentives. While the influx of capital may fuel innovation and growth, it also increases risks such as declining quality of care, inequitable access, and new vulnerabilities like cybersecurity threats. A major gap in the field is the lack of comprehensive and transparent data, which limits the ability to evaluate outcomes and design effective policies. Future research must address these data constraints, disentangle the effects of corporatization, consolidation, and financialization, and develop frameworks for regulation that prioritize patient well-being alongside financial sustainability.

Day 2 | Friday, September 5, 2025

Reflection on Day 1

• Kriti Jain – National Institute on Aging
• Mark Aaron Unruh – Cornell University

Panel 3: Patient Experience and Outcomes

Topic(s):

• Explore existing literature on the impacts of consolidation and new types of ownership on patient outcomes in various domains (e.g., hospices, hospitals).

Presenters:

• Background (1 speaker, 15 minutes)
  • Lawrence Casalino – Weill Cornell Medicine “Patient Experience and Outcomes”
• Recent findings (3 speakers, 15 minutes each):
  • Rishi Wadhera – Harvard University “Private Equity Acquisition of Hospitals: Implications for Patient Care & Experience”
  • Zirui Song – Harvard University “Patient Experience and Outcomes”
  • Joan Teno – Brown University “For every Numerator, You need a Denominator: Key to Measurement for Studying Consolidation and Private Equity”
• Discussion Leader:
  • Debra Saliba – RAND

Read panel summary

Panel 3 examined the growing role of consolidation and changing ownership in healthcare, focusing on consequences for patient care, outcomes, and clinician well-being. Evidence presented showed that while PE brings capital and operational resources, acquisitions are strongly associated with higher prices, staffing reductions, and measurable declines in patient experience. National survey data revealed significant drops in overall hospital ratings, consumers recommending family members use a private equity owned hospital, and decreased staff responsiveness after PE acquisitions. Empirical studies also identified stroke patients experiencing more revisits and Black patients disproportionately transferred out of private equity acquired hospitals. These patterns suggest financial incentives may drive care decisions in ways that undermine equity and quality.

Beyond patient perceptions, clinical quality and safety metrics also worsened in PE-acquired hospitals. Hospital-acquired complications such as infections, falls, and surgical site problems rose by about 25%, with much of this linked to staffing and salary cuts in emergency departments and intensive care units. Hospice and end-of-life care were highlighted as particularly vulnerable: PE-owned and vertically integrated systems often reduced skilled nursing visits, prioritized more profitable long-stay dementia patients, and have weak federal and state oversight of hospice licensing, benefit design, and inspections, leading to poorer family experiences and higher risks of inadequate symptom management at the end of life.

Speakers emphasized that these changes affect not only patients but also the healthcare workforce. Larger, profit-driven organizations were described as contributing to 'widgetization,' where clinicians feel like interchangeable parts, undermining intrinsic motivation and discouraging new physicians from pursuing patient-facing careers. The panel called for urgent action, including greater ownership transparency, new person-centered outcome measures, stronger regulatory oversight, and research on previously unmeasured aspects of quality. Together, these steps are needed to balance financial forces with what the speakers defined as the core mission of healthcare—delivering high-quality, equitable, and compassionate care.

Panel 4: Implications and Societal Responses

Topic(s):

• Synthesize prior discussions to outline where further health services research is needed and what information policymakers—broadly defined (e.g., including employers)—should contemplate
• Address the full range of actors involved, from the private to the public sector
• Examine how healthcare providers are responding, such as unionizing or leaving traditional practices to form independent practices that do not accept insurance
• Explore how policymakers are responding, including actions by federal and state governments and employers directing employees to non-traditional or small practices
• Consider implications for the healthcare workforce, including physician turnover, provider stress, and broader workforce effects

Presenters:

• Background
  • Erin Fuse Brown – Brown University “Workshop on Changing Ownership of Healthcare Entities in the U.S.”
• Recent findings:
  • Mark Aaron Unruh – Cornell University “Changes in Nursing Home Ownership and Quality: Private Equity and Real Estate Investment Trust Investments”
  • Yashaswini Singh – Brown University “Changing Ownership of Physician Practices: Trends, Evidence, and Workforce Implications”
  • Maureen Hensley-Quinn – National Academy for State Health Policy (NASHP) “Changing Ownership of Healthcare Entities in the U. S.”
• Discussion Leader:
  • Jane Zhu – Oregon Health and Science University

Read panel summary

Panel 4 examined the societal implications of growing consolidation and financialization in U.S. healthcare, particularly the role of private equity (PE), real estate investment trusts (REITs), and corporate ownership. Panelists emphasized that while these investments can bring capital and efficiency, they often raise costs, reduce affordability, and disrupt workforce stability. Evidence shows increased prices, reduced access through closures or bankruptcies, and declines in care quality, especially in nursing homes and physician practices. Policymakers are particularly concerned about the erosion of physician autonomy, growing turnover, and workforce instability linked to profit-driven business models.

Research presented on nursing homes highlighted that PE and REIT ownership correlates with higher mortality, reduced registered nurse staffing, worse deficiency scores, and higher Medicare spending. Similarly, studies of physician practices showed that PE acquisitions drive price increases, prioritize profitable services, and reduce provision of less lucrative but essential care. These trends also shift clinical staffing toward advanced practice providers, while restrictive noncompete agreements limit physician mobility. Counter-movements such as concierge care and physician unionization were discussed as responses to perceived loss of autonomy, though they raise equity concerns.

Speakers focused on policy responses at both federal and state levels. Recommended approaches include greater ownership transparency, stronger antitrust enforcement, oversight of smaller or hidden transactions, reforms to corporate practice of medicine laws, and closing payment loopholes that enable revenue-maximizing but low-value care. States like Oregon and Massachusetts were highlighted as innovators in transaction oversight and transparency laws. Panelists agreed that corporatization is unlikely to reverse on its own; sustained policy interventions, coupled with improved data infrastructure, are necessary to safeguard patient outcomes, workforce stability, and healthcare affordability.