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COSTS RISE, QUALITY FALLS AFTER NURSING HOME ACQUISITIONS: REVIEW
Kimberly Marselas
@KimMarselas
July 21, 2023
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As acquisitions in US seniors housing and senior care continue at record levels,
a new paper in an international medical journal finds such transactions
typically bring about a rise in costs and a drop off in quality.
Public health and epidemiology researchers from five universities in three
countries reviewed dozens of studies on private equity ownership and found that
an escalation in private equity takeovers across healthcare settings has led to
higher costs for patients and payers. Several studies also found more ensuing
harmful health outcome impacts than beneficial ones, they reported in BMJ on
Wednesday.
Of the 55 international studies reviewed, the most in any one setting occurred
in nursing homes, where researchers noted an association between PE ownership
and a decrease in nurse staffing or a shift to lower nursing skill mix, which
they said “could be pursued as a means of keeping operating costs low.”
Among 27 studies that measured quality of care, a dozen reported worse quality
scores associated with private equity ownership, nine showed mixed results, and
three reported neutral results after acquisition.
“No consistently beneficial impacts of PE ownership were identified,” wrote the
authors, led by Joseph Dov Bruch, an assistant professor at the University of
Chicago.
The extensive review came in the same week as investment bank Ziegler’s
mid-year, not-for-profit mergers and acquisition update for senior living and
care, which reported continued “record-level activity.”
“Since 2015, roughly 46% of not-for-profit changes have been not-for-profits
being acquired by buyers from the private sector,” Ziegler reported. “This
pattern has been most notable among freestanding nursing homes. Only roughly 10%
of not-for-profit nursing homes that look for a new sponsor/owner end up going
to another not-for-profit.”
Driving the trend
Pressures driving nursing homes to merge or sell, often with no nonprofit
offers, include staffing, the complexities of the skilled nursing marketplace,
CEO turnover, and for some, significant expenses.
Those conditions can leave facilities vulnerable to private equity takeover in
the right markets. The BMJ review found that acquisitions and consolidation are
most notable in the fragmented Northeast and the South.
In total, 12 previous private equity studies identified some sort of harmful
impact of PE ownership on nursing homes, while seven studies identified
beneficial impacts. Privately held nursing homes, and PE-backed facilities, have
been a recurring target of the Biden administration.
According to a related BMJ editorial, the Medicare Payment Advisory Commission
recently estimated that private equity firms own 11% of US skilled nursing
facilities and 4% of US hospitals. The American Health Care Association,
however, has put such SNF ownership at less than 5%, with about 12% of
facilities owned by a real estate investment trust.
Some proponents of private equity investment have argued that firms use their
managerial expertise to “implement operational and financial changes and improve
the acquired company’s value after an acquisition,” the study said.
But the authors said such changes are “often reflected in greater costs to
patients and payers. The fact that no consistently positive effects of PE in
healthcare were identified also provides an evidentiary basis to remain cautious
about claims that PE ownership is a self-evident benefit to healthcare
provision.”
“Unlike non-profit and government operators of healthcare institutions, private
equity investors’ business plans are laser focused on selling investments at a
large profit after three to seven years,” noted an accompanying BMJ editorial.
“Critics of this short term orientation have focused most of their criticism on
the financial implications for patients and healthcare employees.”
The editorial noted that new private owners often sell off real estate, leaving
operators with burdensome lease structures, now a common practice in skilled
nursing. In other sectors, such as safety net hospitals, that “led after just a
few years to considerable redundancies [layoffs], service cuts and even
closures.”
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