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Does Private Equity Investment in Healthcare Benefit Patients? Evidence from Nursing Homes

Author

Listed:
  • Atul Gupta

    (University of Pennsylvania - Health Care Management)

  • Sabrina T Howell

    (New York University (NYU) - Leonard N. Stern School of Business; National Bureau of Economic Research (NBER))

  • Constantine Yannelis

    (University of Chicago)

  • Abhinav Gupta

    (New York University (NYU) - Department of Finance)

Abstract
The past two decades have seen a rapid increase in Private Equity (PE) investment in healthcare, a sector in which intensive government subsidy and market frictions could lead high-powered for-profit incentives to be misaligned with the social goal of affordable, quality care. This paper studies the effects of PE ownership on patient welfare at nursing homes. With administrative patient-level data, we use a within-facility differences-in-differences design to address non-random targeting of facilities. We use an instrumental variables strategy to control for the selection of patients into nursing homes. Our estimates show that PE ownership increases the short-term mortality of Medicare patients by 10%, implying 20,150 lives lost due to PE ownership over our twelve-year sample period. This is accompanied by declines in other measures of patient well-being, such as lower mobility, while taxpayer spending per patient episode increases by 11%. We observe operational changes that help to explain these effects, including declines in nursing staff and compliance with standards. Finally, we document a systematic shift in operating costs post-acquisition toward non-patient care items such as monitoring fees, interest, and lease payments.

Suggested Citation

  • Atul Gupta & Sabrina T Howell & Constantine Yannelis & Abhinav Gupta, 2021. "Does Private Equity Investment in Healthcare Benefit Patients? Evidence from Nursing Homes," Working Papers 2021-20, Becker Friedman Institute for Research In Economics.
    • Handle: RePEc:bfi:wpaper:2021-20
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    1. David M. Cutler, 2011. "Where Are the Health Care Entrepreneurs? The Failure of Organizational Innovation in Health Care," NBER Chapters, in: Innovation Policy and the Economy, Volume 11, pages 1-28, National Bureau of Economic Research, Inc.
    2. David Card & Alessandra Fenizia & David Silver, 2023. "The Health Impacts of Hospital Delivery Practices," American Economic Journal: Economic Policy, American Economic Association, vol. 15(2), pages 42-81, May.
    3. Kate Ho & Robin S. Lee, 2019. "Equilibrium Provider Networks: Bargaining and Exclusion in Health Care Markets," American Economic Review, American Economic Association, vol. 109(2), pages 473-522, February.
    4. Nicholas Bloom & Raffaella Sadun & John Van Reenen, 2015. "Do Private Equity Owned Firms Have Better Management Practices?," American Economic Review, American Economic Association, vol. 105(5), pages 442-446, May.
    5. Cornelissen, Thomas & Dustmann, Christian & Raute, Anna & Schönberg, Uta, 2016. "From LATE to MTE: Alternative methods for the evaluation of policy interventions," Labour Economics, Elsevier, vol. 41(C), pages 47-60.
    6. Hill, Elaine L. & Slusky, David J.G. & Ginther, Donna K., 2019. "Reproductive health care in Catholic-owned hospitals," Journal of Health Economics, Elsevier, vol. 65(C), pages 48-62.
    7. James J. Heckman & Edward Vytlacil, 2005. "Structural Equations, Treatment Effects, and Econometric Policy Evaluation," Econometrica, Econometric Society, vol. 73(3), pages 669-738, May.
    8. Shai Bernstein & Josh Lerner & Filippo Mezzanotti, 2019. "Private Equity and Financial Fragility during the Crisis," The Review of Financial Studies, Society for Financial Studies, vol. 32(4), pages 1309-1373.
    9. Cesare Fracassi & Alessandro Previtero & Albert W. Sheen, 2020. "Barbarians at the Store? Private Equity, Products, and Consumers," NBER Working Papers 27435, National Bureau of Economic Research, Inc.
    10. David Grabowski & John Bowblis & Judith Lucas & Stephen Crystal, 2011. "Labor Prices and the Treatment of Nursing Home Residents with Dementia," International Journal of the Economics of Business, Taylor & Francis Journals, vol. 18(2), pages 273-292.
    11. Christian N. Brinch & Magne Mogstad & Matthew Wiswall, 2017. "Beyond LATE with a Discrete Instrument," Journal of Political Economy, University of Chicago Press, vol. 125(4), pages 985-1039.
    12. Alan M. Garber & Jonathan Skinner, 2008. "Is American Health Care Uniquely Inefficient?," Journal of Economic Perspectives, American Economic Association, vol. 22(4), pages 27-50, Fall.
    13. Van Nieuwerburgh, Stijn & Gupta, Arpit, 2019. "Valuing Private Equity Strip by Strip," CEPR Discussion Papers 14241, C.E.P.R. Discussion Papers.
    14. Leemore Dafny & Mark Duggan & Subramaniam Ramanarayanan, 2012. "Paying a Premium on Your Premium? Consolidation in the US Health Insurance Industry," American Economic Review, American Economic Association, vol. 102(2), pages 1161-1185, April.
    15. Jeffrey Clemens & Joshua D. Gottlieb, 2014. "Do Physicians' Financial Incentives Affect Medical Treatment and Patient Health?," American Economic Review, American Economic Association, vol. 104(4), pages 1320-1349, April.
    16. Pedro Carneiro & James J. Heckman & Edward J. Vytlacil, 2011. "Estimating Marginal Returns to Education," American Economic Review, American Economic Association, vol. 101(6), pages 2754-2781, October.
    17. Steven N. Kaplan & Antoinette Schoar, 2005. "Private Equity Performance: Returns, Persistence, and Capital Flows," Journal of Finance, American Finance Association, vol. 60(4), pages 1791-1823, August.
    18. Amitabh Chandra & Amy Finkelstein & Adam Sacarny & Chad Syverson, 2016. "Health Care Exceptionalism? Performance and Allocation in the US Health Care Sector," American Economic Review, American Economic Association, vol. 106(8), pages 2110-2144, August.
    19. Nicholas Bloom & Carol Propper & Stephan Seiler & John Van Reenen, 2015. "The Impact of Competition on Management Quality: Evidence from Public Hospitals," The Review of Economic Studies, Review of Economic Studies Ltd, vol. 82(2), pages 457-489.
    20. Vilsa Curto & Liran Einav & Jonathan Levin & Jay Bhattacharya, 2021. "Can Health Insurance Competition Work? Evidence from Medicare Advantage," Journal of Political Economy, University of Chicago Press, vol. 129(2), pages 570-606.
    21. Vilsa Curto & Liran Einav & Amy Finkelstein & Jonathan Levin & Jay Bhattacharya, 2019. "Health Care Spending and Utilization in Public and Private Medicare," American Economic Journal: Applied Economics, American Economic Association, vol. 11(2), pages 302-332, April.
    22. Andrei Shleifer & Lawrence H. Summers, 1988. "Breach of Trust in Hostile Takeovers," NBER Chapters, in: Corporate Takeovers: Causes and Consequences, pages 33-68, National Bureau of Economic Research, Inc.
    23. Zack Cooper & Fiona Scott Morton & Nathan Shekita, 2020. "Surprise! Out-of-Network Billing for Emergency Care in the United States," Journal of Political Economy, University of Chicago Press, vol. 128(9), pages 3626-3677.
    24. Janet Currie & David Slusky, 2020. "Does the Marginal Hospitalization Save Lives? The Case of Respiratory Admissions for the Elderly," NBER Working Papers 26618, National Bureau of Economic Research, Inc.
    25. Oliver Hart & Andrei Shleifer & Robert W. Vishny, 1997. "The Proper Scope of Government: Theory and an Application to Prisons," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 112(4), pages 1127-1161.
    26. Viral V. Acharya & Oliver F. Gottschalg & Moritz Hahn & Conor Kehoe, 2013. "Corporate Governance and Value Creation: Evidence from Private Equity," The Review of Financial Studies, Society for Financial Studies, vol. 26(2), pages 368-402.
    27. Anna, Petrenko, 2016. "Мaркування готової продукції як складова частина інформаційного забезпечення маркетингової діяльності підприємств овочепродуктового підкомплексу," Agricultural and Resource Economics: International Scientific E-Journal, Agricultural and Resource Economics: International Scientific E-Journal, vol. 2(1), March.
    28. James J. Heckman & Sergio Urzua & Edward Vytlacil, 2006. "Understanding Instrumental Variables in Models with Essential Heterogeneity," The Review of Economics and Statistics, MIT Press, vol. 88(3), pages 389-432, August.
    29. Mark McClellan & Douglas Staiger, 1999. "The Quality of Health Care Providers," NBER Working Papers 7327, National Bureau of Economic Research, Inc.
    30. Pelech, Daria, 2018. "Paying more for less? Insurer competition and health plan generosity in the Medicare Advantage program," Journal of Health Economics, Elsevier, vol. 61(C), pages 77-92.
    31. Eileen Appelbaum & Rosemary Batt, 2020. "Private Equity Buyouts in Healthcare: Who Wins, Who Loses?," Working Papers Series 118, Institute for New Economic Thinking.
    32. Kaplan, Steven, 1989. "The effects of management buyouts on operating performance and value," Journal of Financial Economics, Elsevier, vol. 24(2), pages 217-254.
    33. Grabowski, David C. & Hirth, Richard A., 2003. "Competitive spillovers across non-profit and for-profit nursing homes," Journal of Health Economics, Elsevier, vol. 22(1), pages 1-22, January.
    34. David M. Cutler, 2011. "Where Are the Health Care Entrepreneurs? The Failure of Organizational Innovation in Health Care," Innovation Policy and the Economy, University of Chicago Press, vol. 11(1), pages 1-28.
    35. Phalippou, Ludovic & Rauch, Christian & Umber, Marc, 2018. "Private equity portfolio company fees," Journal of Financial Economics, Elsevier, vol. 129(3), pages 559-585.
    36. Liran Einav & Amy Finkelstein & Heidi Williams, 2016. "Paying on the Margin for Medical Care: Evidence from Breast Cancer Treatments," American Economic Journal: Economic Policy, American Economic Association, vol. 8(1), pages 52-79, February.
    37. Mark G. Duggan, 2000. "Hospital Ownership and Public Medical Spending," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 115(4), pages 1343-1373.
    38. Sean Shenghsiu Huang & John R. Bowblis, 2019. "Private equity ownership and nursing home quality: an instrumental variables approach," International Journal of Health Economics and Management, Springer, vol. 19(3), pages 273-299, December.
    39. Patricia K. Tong, 2011. "The effects of California minimum nurse staffing laws on nurse labor and patient mortality in skilled nursing facilities," Health Economics, John Wiley & Sons, Ltd., vol. 20(7), pages 802-816, July.
    40. Paul J Eliason & Benjamin Heebsh & Ryan C McDevitt & James W Roberts, 2020. "How Acquisitions Affect Firm Behavior and Performance: Evidence from the Dialysis Industry," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 135(1), pages 221-267.
    41. Gompers, Paul & Kaplan, Steven N. & Mukharlyamov, Vladimir, 2016. "What do private equity firms say they do?," Journal of Financial Economics, Elsevier, vol. 121(3), pages 449-476.
    42. Steven J. Davis & John Haltiwanger & Kyle Handley & Ron Jarmin & Josh Lerner & Javier Miranda, 2014. "Private Equity, Jobs, and Productivity," American Economic Review, American Economic Association, vol. 104(12), pages 3956-3990, December.
    43. Martin B. Hackmann, 2019. "Incentivizing Better Quality of Care: The Role of Medicaid and Competition in the Nursing Home Industry," American Economic Review, American Economic Association, vol. 109(5), pages 1684-1716, May.
    44. Haizhen Lin, 2014. "Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach," Working Papers 2014-01, Indiana University, Kelley School of Business, Department of Business Economics and Public Policy.
    45. Lin, Haizhen, 2014. "Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach," Journal of Health Economics, Elsevier, vol. 37(C), pages 13-24.
    46. Skinner, Jonathan, 2011. "Causes and Consequences of Regional Variations in Health Care," Handbook of Health Economics, in: Mark V. Pauly & Thomas G. Mcguire & Pedro P. Barros (ed.), Handbook of Health Economics, volume 2, chapter 0, pages 45-93, Elsevier.
    47. Shai Bernstein & Albert Sheen, 2016. "The Operational Consequences of Private Equity Buyouts: Evidence from the Restaurant Industry," The Review of Financial Studies, Society for Financial Studies, vol. 29(9), pages 2387-2418.
    48. Cawley, John & Grabowski, David C. & Hirth, Richard A., 2006. "Factor substitution in nursing homes," Journal of Health Economics, Elsevier, vol. 25(2), pages 234-247, March.
    49. Anirban Basu & James J. Heckman & Salvador Navarro-Lozano & Sergio Urzua, 2007. "Use of instrumental variables in the presence of heterogeneity and self-selection: An application in breast cancer patients," Health, Econometrics and Data Group (HEDG) Working Papers 07/07, HEDG, c/o Department of Economics, University of York.
    50. Grabowski, David C. & Feng, Zhanlian & Hirth, Richard & Rahman, Momotazur & Mor, Vincent, 2013. "Effect of nursing home ownership on the quality of post-acute care: An instrumental variables approach," Journal of Health Economics, Elsevier, vol. 32(1), pages 12-21.
    51. Ljungqvist, Alexander & Bircan, Cagatay & Biesinger, Markus, 2020. "Value Creation in Private Equity," CEPR Discussion Papers 14676, C.E.P.R. Discussion Papers.
    52. Alan M. Garber & Jonathan Skinner, 2008. "Is American Health Care Uniquely Inefficient?," NBER Working Papers 14257, National Bureau of Economic Research, Inc.
    53. Andrew Metrick, 2010. "The Economics of Private Equity Funds," The Review of Financial Studies, Society for Financial Studies, vol. 23(6), pages 2303-2341, June.
    54. Werner, Rachel M. & Norton, Edward C. & Konetzka, R. Tamara & Polsky, Daniel, 2012. "Do consumers respond to publicly reported quality information? Evidence from nursing homes," Journal of Health Economics, Elsevier, vol. 31(1), pages 50-61.
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    3. Martin B. Hackmann & R. Vincent Pohl & Nicolas R. Ziebarth, 2024. "Patient versus Provider Incentives in Long-Term Care," American Economic Journal: Applied Economics, American Economic Association, vol. 16(3), pages 178-218, July.
    4. Bar, M.; & Bakx, P.; & Wouterse, B.; & van Doorslaer, Eddy.;, 2022. "Estimating the health value added by nursing homes," Health, Econometrics and Data Group (HEDG) Working Papers 22/12, HEDG, c/o Department of Economics, University of York.
    5. Sharjil M. Haque, 2023. "Does Private Equity Over-Lever Portfolio Companies?," Finance and Economics Discussion Series 2023-009, Board of Governors of the Federal Reserve System (U.S.).
    6. Johannes S. Kunz & Carol Propper & Kevin E. Staub & Rainer Winkelmann, 2024. "Assessing the quality of public services: For‐profits, chains, and concentration in the hospital market," Health Economics, John Wiley & Sons, Ltd., vol. 33(9), pages 2162-2181, September.
    7. Lo, Andrew W. & Thakor, Richard T., 2023. "Financial intermediation and the funding of biomedical innovation: A review," Journal of Financial Intermediation, Elsevier, vol. 54(C).
    8. Mathias Dewatripont & Jean Tirole, 2022. "The Morality of Markets," Working Papers ECARES 2022-35, ULB -- Universite Libre de Bruxelles.
    9. Jonathan Gruber & David H. Howard & Jetson Leder-Luis & Theodore L. Caputi, 2023. "Dying or Lying? For-Profit Hospices and End of Life Care," NBER Working Papers 31035, National Bureau of Economic Research, Inc.
    10. Bär, Marlies & Bakx, Pieter & Wouterse, Bram & van Doorslaer, Eddy, 2022. "Estimating the health value added by nursing homes," Journal of Economic Behavior & Organization, Elsevier, vol. 203(C), pages 1-23.
    11. Raja, Chandni, 2023. "How do hospitals respond to input regulation? Evidence from the California nurse staffing mandate," Journal of Health Economics, Elsevier, vol. 92(C).
    12. Liran Einav & Amy Finkelstein & Neale Mahoney, 2022. "Producing Health: Measuring Value Added of Nursing Homes," NBER Working Papers 30228, National Bureau of Economic Research, Inc.
    13. Sharjil M. Haque & Anya V. Kleymenova, 2023. "Private Equity and Debt Contract Enforcement: Evidence from Covenant Violations," Finance and Economics Discussion Series 2023-018, Board of Governors of the Federal Reserve System (U.S.).
    14. Tim N. Nolte & Felix Miedaner & Sandra Sülz, 2022. "Physicians’ Perspectives Regarding Private Equity Transactions in Outpatient Health Care—A Scoping Review and Qualitative Analysis," IJERPH, MDPI, vol. 19(23), pages 1-13, November.
    15. Dörte Heger & Annika Herr & Anne Mensen, 2022. "Paying for the view? How nursing home prices affect certified staffing ratios," Health Economics, John Wiley & Sons, Ltd., vol. 31(8), pages 1618-1632, August.
    16. Cesare Fracassi & Alessandro Previtero & Albert Sheen, 2022. "Barbarians at the Store? Private Equity, Products, and Consumers," Journal of Finance, American Finance Association, vol. 77(3), pages 1439-1488, June.

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