Publications

@article{nokey,

title = {Changes in Payer Mix Associated With Private Equity Acquisition of Ophthalmology Practices},

author = {John E. Connolly and Matthew Guido and Anthony Girard and Robert Tyler Braun and Ezekiel J. Emanuel},

doi = {10.1001/jamanetworkopen.2025.12629},

year  = {2025},

date = {2025-05-28},

urldate = {2025-05-28},

journal = {JAMA Netw Open},

volume = {8},

number = {5},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Vertical Integration and the Transformation of American Medicine},

author = {Dhruv Khullar and Lawrence P. Casalino and Amelia M. Bond},

doi = {10.1056/NEJMp2313406},

year  = {2024},

date = {2024-03-14},

journal = {The New England Journal of Medicine},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Association of Private Equity Firm Acquisition of Ophthalmology Practices with Medicare Spending and Use of Ophthalmology Services},

author = {Robert Tyler Braun and Gary Joseph Lelli and Abhinav Pandey and Manyao Zhang and James P. Winebrake and Lawrence P. Casalino},

doi = {10.1016/j.ophtha.2023.09.029},

year  = {2023},

date = {2023-09-28},

journal = {American Academy of Opthalmology },

volume = {131},

issue = {3},

pages = {360-369},

abstract = {Purpose



Private equity (PE) firms increasingly are acquiring ophthalmology practices; little is known of their influence on care use and spending. We studied changes in use and Medicare spending after PE acquisition.



Design



Retrospective cohort study.



Participants



Seven hundred sixty-two clinicians in 123 practices acquired by PE between 2017 and 2018 and 34 807 clinicians in 20 549 never-acquired practices.



Methods



We analyzed Medicare fee-for-service claims (2012–2019) combined with a novel national database of PE acquisitions of ophthalmology practices using a difference-in-differences method within an event study framework to compare changes after a practice was acquired with changes in practices that were not acquired.



Main Outcome Measures



Numbers of beneficiaries seen; intravitreal injections and medications used for injections; and spending on ophthalmologist and optometrist services, ancillary services, and intravitreal injections.



Results



Comparing PE-acquired with nonacquired practices showed a 23.92% increase (n = 4.20 beneficiaries; 95% confidence interval [CI], 1.73–6.67) in beneficiaries seen per PE optometrist per quarter and no change for ophthalmologists, while spending per beneficiary increased 5.06% ($9.66; 95% CI, –2.82 to 22.14). Spending on clinician services decreased 1.62% (–$2.37; 95% CI, –5.78 to 1.04), with ophthalmologist services increasing 5.46% ($17.70; 95% CI, –2.73 to 38.15) and optometrists decreasing 4.60% (–$5.76; 95% CI, –9.17 to –2.34) per beneficiary per quarter. Ancillary services decreased 7.56% (–$2.19; 95% CI, 4.19 to –0.22). Intravitreal injection costs increased 25.0% ($20.02; 95% CI, –1.38 to 41.41) with the number increasing 5.10% (1.83; 95% CI, –0.1 to 3.80). There was a 74.09% increase (8.38 injections; 95% CI, 0.01–16.74) in ranibizumab and a 12.91% decrease (–3.40 injections; 95% CI, –6.86 to 0.07) in bevacizumab after acquisition. The event study showed consistent and often statistically significant increases in ranibizumab injections and decreases in bevacizumab injections after acquisition.



Conclusions

Although not all results reached statistical significance, this study suggested that PE acquisition of practices showed little or no overall effect on use or total spending, but increased the number of unique patients seen per optometrist and the use of expensive intravitreal injections.},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = { Physician Management Companies and Neonatology Prices, Utilization, and Clinical Outcomes},

author = {Jiani Yu and Robert Tyler Braun and Amelia M. Bond and Ambar M. La Forgia and Arindam RoyChoudhury and Manyao Zhang and Jin Kim and Lawrence P. Casalino},

doi = {https://doi.org/10.1542/peds.2022-057931},

year  = {2023},

date = {2023-04-01},

urldate = {2023-04-01},

journal = {Pediatrics},

volume = {151},

issue = {4},

abstract = {Background and objectives: Physician management companies (PMCs) acquire physician practices and contract with hospitals to provide physician management services. We evaluated the association between PMC-NICU affiliations and prices, spending, utilization, and clinical outcomes.



Methods: We linked commercial claims to PMC-NICU affiliations and conducted difference- in-differences analyses comparing changes in prices paid for physician services per critical or intensive care NICU day, length of the NICU stay, physician spending (total paid amount for physician services during stay), spending on hospital services (total paid amount for hospital services during stay), and clinical outcomes in PMC-affiliated versus non-PMC-affiliated NICUs. The study included 2858 infants admitted to 34 PMC-affiliated NICUs and 92 461 infants admitted to 2348 NICUs without an affiliation.



Results: PMC affiliation was associated with a differential increase in the mean price of the 5 most common types of critical and intensive care days in NICU admissions by $313 per day (95% confidence interval, $207-$419) for PMC-affiliated versus non- PMC-affiliated NICUs. This represents a 70.4% increase in prices, relative to the preaffiliation period PMC and non- PMC-affiliated NICU means. PMC-NICU affiliation was also associated with a differential increase in physician spending by $5161 per NICU stay (95% confidence interval, $3062-$7260), a 56.4% increase. There was no significant association between PMC-NICU affiliation and changes in length of stay, clinical outcomes, or hospital spending.



Conclusions: PMC affiliation was associated with large increases in prices and total spending for NICU services, but not with changes in length of stay or adverse clinical outcomes.},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Health Systems-The Present and the Future},

author = {Lawrence P. Casalino},

doi = {https://doi.org/10.1001/jama.2022.24141},

year  = {2023},

date = {2023-01-24},

urldate = {2023-01-24},

journal = {JAMA},

volume = {329},

issue = {4},

pages = {293-294},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = { US Generalist Physicians and Groups that Focused Practice in a Single Care Setting: 2014-2017},

author = {Kira L. Ryskina and Mark Aaron Unruh and Yuting Qian and Hye-Young Jung},

doi = {https://doi.org/10.1097/mlr.0000000000001778},

year  = {2022},

date = {2022-11-01},

urldate = {2022-11-01},

journal = {Medical Care },

volume = {60},

issue = {11},

pages = {831-838},

abstract = {Background: Some generalist physicians whose training prepared them for primary care practice increasingly practice in a facility (eg, hospitals, nursing homes); however, whether this trend was accompanied by a complimentary rise in generalist physicians who focused their practice on office-based care is unknown.



Objectives: Our objective in this study was to examine trends in the prevalence of generalist physicians and physician groups that practice in a single setting.



Research design: This was a retrospective cross-sectional study of generalist physicians trained in family medicine, internal medicine, or geriatrics. We used 2014-2017 billing data for Medicare fee-for-service beneficiaries to measure the proportion of all patient visits made by physicians in the following care settings: office, outpatient hospital department, inpatient hospital, and other sites.



Results: From 2014 to 2017, the proportion of generalist physicians who narrowed their practice to a single setting increased by 6.69% (from 62.80% to 67.00%, p for trend <0.001). In 2017, 4.63% of physician groups included more than 1 type of setting-based physicians.



Conclusions: Generalist physicians treating older adults increasingly narrowed their practice focus to a single type of health care setting. This trend was not accompanied by growth among physician groups that included different types of setting-based physicians. Further evaluation of the consequences of these trends on the fragmentation of primary care delivery across different health care settings and primary care outcomes is needed.},

keywords = {Corporatization and Consolidation, Medical Professionalism and Physician Well-being},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Association of Physician Management Companies and Private Equity Investment With Commercial Health Care Prices Paid to Anesthesia Practitioners},

author = {Ambar M. La Forgia and Amelia M. Bond and Robert Tyler Braun and Leah Z. Yao and Klaus Kjaer and Manyao Zhang and Lawrence P. Casalino},

doi = {https://doi.org/10.1001/jamainternmed.2022.0004},

year  = {2022},

date = {2022-04-01},

urldate = {2022-04-01},

journal = {JAMA Internal Medicine},

volume = {182},

issue = {4},

pages = {396-404},

abstract = {Importance: Physician management companies (PMCs), often backed by private equity (PE), are increasingly providing staffing and management services to health care facilities, yet little is known of their influence on prices.



Objective: To study changes in prices paid to practitioners (anesthesiologists and certified registered nurse anesthetists) before and after an outpatient facility contracted with a PMC.



Design, setting, and participants: This retrospective cohort study used difference-in-differences methods to compare price changes before and after a facility contracted with a PMC with facilities that did not and to compare differences between PMCs with and without PE investment. Commercial claims data (2012-2017) from 3 large national insurers in the Health Care Cost Institute database were combined with a novel data set of PMC facility contracts to identify prices paid to anesthesia practitioners in hospital outpatient departments and ambulatory surgery centers. The cohort included 2992 facilities that never contracted with a PMC and 672 facilities that contracted with a PMC between 2012 and 2017, collectively representing 2 255 933 anesthesia claims.



Exposures: Temporal variation in facility-level exposure to PMC contracts for anesthesia services.



Main outcomes and measures: Main outcomes were (1) allowed amounts and the unit price (allowed amounts standardized per unit of service) paid to anesthesia practitioners; and (2) the probability that a practitioner was out of network.



Results: From before to after the PMC contract period, allowed amounts increased by 16.5% (+$116.39; 95% CI, $76.11 to $156.67; P < .001), and the unit price increased by 18.7% (+$18.79; 95% CI, $12.73 to $24.84; P < .001) in PMC facilities relative to non-PMC facilities. Results did not show evidence that anesthesia practitioners were moved out of network (+2.25; 95% CI, -2.56 to 7.06; P < .36). In subsample analyses, PMCs without PE investment increased allowed amounts by 12.9% (+$89.88; 95% CI, $42.07 to $137.69; P < .001), while PE-backed PMCs (representing half of the PMCs in the sample) increased allowed amounts by 26.0% ($187.06; 95% CI, $133.59 to $240.52; P < .001). Similar price increases were observed for unit prices.



Conclusions and relevance: In this cohort study, prices paid to anesthesia practitioners increased after hospital outpatient departments and ambulatory surgery centers contracted with a PMC and were substantially higher if the PMC received PE investment. This research provides insights into the role of corporate ownership in health care relevant to policy makers, payers, practitioners, and patients.},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Association of Surprise-Billing Legislation with Prices Paid to In-Network and Out-of-Network Anesthesiologists in California, Florida, and New York: An Economic Analysis},

author = {Ambar M. La Forgia and Amelia M. Bond and Robert Tyler Braun and Klaus Kjaer and Manyao Zhang and Lawrence P. Casalino},

doi = {https://doi.org/10.1001/jamainternmed.2021.4564},

year  = {2021},

date = {2021-10-01},

urldate = {2021-10-01},

journal = {JAMA Internal Medicine},

volume = {181},

issue = {10},

pages = {1324-1331},

abstract = {Importance: Several states have passed surprise-billing legislation to protect patients from unanticipated out-of-network medical bills, yet little is known about how state laws influence out-of-network prices and whether spillovers exist to in-network prices.



Objective: To identify any changes in prices paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists before and after states passed surprise-billing legislation.



Design, setting, and participants: This retrospective economic analysis used difference-in-differences methods to compare price changes before and after the passage of legislation in California, Florida, and New York, which passed comprehensive surprise-billing legislation between January 1, 2014, and December 31, 2017, to 45 states that did not. Commercial claims data from the Health Care Cost Institute were used to identify prices paid to anesthesiologists in hospital outpatient departments and ambulatory surgery centers. The final analytic sample comprised 2 713 913 anesthesia claims across the 3 treated states and the 45 control states.



Exposures: Temporal and state-level variation in exposure to surprise-billing legislation.



Main outcomes and measures: The unit price (allowed amounts standardized per unit of service) paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists.



Results: This retrospective economic analysis of 2 713 913 anesthesia claims found that after surprise-billing laws were passed in 3 states, the unit price paid to out-of-network anesthesiologists at in-network facilities decreased significantly in 2 of them: California, -$12.71 (95% CI, -$25.70 to -$0.27; P = .05) and Florida, -$35.67 (95% CI, -$46.27 to -$25.07; P < .001). In New York, a decline in the overall out-of-network price was not statistically significant (-$7.91; 95% CI, -$17.48 to -$1.68; P = .10); however, by the fourth quarter of 2017, the decline was -$41.28 (95% CI, -$70.24 to -$12.33; P = .01). In-network prices decreased in California by -$10.68 (95% CI, -$12.70 to -$8.66; P < .001); in Florida, -$3.18 (95% CI, -$5.17 to -$1.19; P = .002); and in New York, -$8.05 (95% CI, -$11.46 to -$4.64; P < .001).



Conclusions and relevance: This retrospective study found that prices paid to in-network and out-of-network anesthesiologists in hospital outpatient departments and ambulatory surgery centers decreased after the introduction of surprise-billing legislation, providing early insights into how prices may change under the federal No Surprises Act and in states that have recently passed their own legislation.},

keywords = {Corporatization and Consolidation, Payment Reform and Health Care Incentives},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Private Equity In Dermatology: Effect On Price, Utilization, And Spending},

author = {Robert Tyler Braun and Amelia M. Bond and Yuting Qian and Manyao Zhang and Lawrence P. Casalino},

doi = {https://doi.org/10.1377/hlthaff.2020.02062},

year  = {2021},

date = {2021-05-03},

urldate = {2021-05-03},

journal = {Health Affairs},

volume = {40},

issue = {5},

pages = {727-735},

abstract = {Private equity firms have increasingly acquired physician practices, and particularly dermatology practices. Analyzing commercial claims from the Health Care Cost Institute (2012–17), we used a difference-in-differences design within an event study framework to estimate the prevalence of private equity acquisitions and their impact on dermatologist prices, spending, utilization, and volume of patients. By 2017 one in eleven dermatologists practiced in a private equity–owned practice, and private equity–owned practices employed four advanced practitioners for every ten dermatologists compared with three for non–private equity practices. Private equity firms targeted their acquisitions at larger practices that saw more commercially insured patients compared with practices that were never acquired by private equity firms. The volume of patients per private equity dermatologist ranged from 4.7 percent to 17.0 percent higher than the volume per non–private equity dermatologist up to nine quarters after acquisition. At 1.5 years after acquisition, prices paid to private equity dermatologists for routine medical visits were 3–5 percent higher than those paid to non–private equity dermatologists. There was no significant consistent impact on dermatology spending or use of biopsies, lesion destruction, or Mohs surgery. Policy makers and dermatology practice leaders may want to track the rapidly evolving phenomenon of private equity acquisitions.},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Private Equity, Women's Health, and the Corporate Transformation of American Medicine},

author = {Lawrence P. Casalino},

doi = {https://doi.org/10.1001/jamainternmed.2020.3564},

year  = {2020},

date = {2020-11-01},

urldate = {2020-11-01},

journal = {JAMA Internal Medicine},

volume = {180},

issue = {11},

pages = {1545-1546},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {The Growth Of Private Equity Investment In Health Care: Perspectives From Ophthalmology},

author = {Eloise O'Donnell and Gary Joseph Lelli and Sami Bhidya and Lawrence P. Casalino},

doi = {https://doi.org/10.1377/hlthaff.2019.01419},

year  = {2020},

date = {2020-06-01},

urldate = {2020-06-01},

journal = {Health Affairs},

volume = {39},

issue = {6},

pages = {1026-1031},

abstract = {The growth of private equity investment in health care has dramatically changed the landscape of health care delivery over the past decade. Private equity firms are rapidly acquiring physician practices, with ophthalmology practices being one of the most frequently acquired types. We present perspectives from thirty-five semistructured interviews conducted with a wide range of knowledgeable people on private equity investment in physician practices, with a specific focus on ophthalmology. Acquisition by a private equity firm can be an attractive option for physicians, particularly older ones. However, interviewees had starkly conflicting perspectives on the likely impact of private equity acquisitions on the cost, quality, and use of medical care.},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Private Equity Investment in Behavioral Health Treatment Centers},

author = {Benjamin Brown and Eloise O'Donnell and Lawrence P. Casalino},

doi = {https://doi.org/10.1001/jamapsychiatry.2019.3880},

year  = {2020},

date = {2020-03-01},

urldate = {2020-03-01},

journal = {JAMA Psychiatry},

volume = {77},

issue = {3},

pages = {229-230},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Value-Based Purchasing and Physician Professionalism},

author = {Lawrence P. Casalino and Dhruv Khullar },

doi = {10.1001/jama.2019.14990},

year  = {2019},

date = {2019-09-20},

urldate = {2019-09-20},

journal = {JAMA},

volume = {322},

issue = {17},

pages = {1647-1648},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Private Equity Acquisition of Physician Practices},

author = {Lawrence P. Casalino and Rayhan Saiani and Sami Bhidya and Dhruv Khullar and Eloise O'Donnell},

doi = {https://doi.org/10.7326/l19-0256},

year  = {2019},

date = {2019-07-02},

urldate = {2019-07-02},

journal = {Annals of Internal Medicine},

volume = {171},

issue = {1},

pages = {78},

keywords = {Corporatization and Consolidation},

pubstate = {published},

tppubtype = {article}

}

@article{nokey,

title = {Can Small Physician Practices Survive? Sharing Services as a Path to Viability},

author = {Dhruv Khullar and Gregory C. Burke and Lawrence P. Casalino},

doi = {10.1001/jama.2017.21704},

year  = {2018},

date = {2018-04-03},

urldate = {2018-04-03},

journal = {JAMA},

volume = {319},

issue = {13},

pages = {1321–1322},

keywords = {Corporatization and Consolidation, Payment Reform and Health Care Incentives},

pubstate = {published},

tppubtype = {article}

}