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Owner Incentives and Performance in Healthcare: Private Equity Investment in Nursing Homes

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  • Atul Gupta
  • Sabrina T. Howell
  • Constantine Yannelis
  • Abhinav Gupta
Abstract
Amid an aging population and a growing role for private equity (PE) in elder care, this paper studies how PE ownership affects U.S. nursing homes using patient-level Medicare data. We show that PE ownership leads to lower-risk patients and increases mortality. After instrumenting for the patient-nursing home match, we recover a local average treatment effect on mortality of 11%. Declines in measures of patient well-being, nurse staffing, and compliance with care standards help to explain the mortality effect. Overall, we conclude that PE has nuanced effects, with adverse outcomes for a subset of patients.

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  • Atul Gupta & Sabrina T. Howell & Constantine Yannelis & Abhinav Gupta, 2021. "Owner Incentives and Performance in Healthcare: Private Equity Investment in Nursing Homes," NBER Working Papers 28474, National Bureau of Economic Research, Inc.
    • Handle: RePEc:nbr:nberwo:28474
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    1. 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.
    2. Bruce Ian Carlin & David T. Robinson, 2012. "What Does Financial Literacy Training Teach Us?," The Journal of Economic Education, Taylor & Francis Journals, vol. 43(3), pages 235-247, July.
    3. Propper, Carol & Kunz, Johannes & Staub, Kevin & Winkelmann, Rainer, 2020. "Assessing the Quality of Public Services: Does Hospital Competition Crowd Out the For-Profit Quality Gap?," CEPR Discussion Papers 15045, C.E.P.R. Discussion Papers.
    4. 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.
    5. 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.
    6. 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.
    7. Robinson, David T. & Sensoy, Berk A., 2016. "Cyclicality, performance measurement, and cash flow liquidity in private equity," Journal of Financial Economics, Elsevier, vol. 122(3), pages 521-543.
    8. 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.
    9. 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.
    10. Charlie Eaton & Sabrina T Howell & Constantine Yannelis & Francesca Cornelli, 2020. "When Investor Incentives and Consumer Interests Diverge: Private Equity in Higher Education," The Review of Financial Studies, Society for Financial Studies, vol. 33(9), pages 4024-4060.
    11. 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.
    12. 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.
    13. Cory S. Capps & Dennis W. Carlton & Guy David, 2020. "Antitrust Treatment Of Nonprofits: Should Hospitals Receive Special Care?," Economic Inquiry, Western Economic Association International, vol. 58(3), pages 1183-1199, July.
    14. 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.
    15. Callaway, Brantly & Sant’Anna, Pedro H.C., 2021. "Difference-in-Differences with multiple time periods," Journal of Econometrics, Elsevier, vol. 225(2), pages 200-230.
    16. Arpit Gupta & Stijn Van Nieuwerburgh, 2021. "Valuing Private Equity Investments Strip by Strip," Journal of Finance, American Finance Association, vol. 76(6), pages 3255-3307, December.
    17. 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.
    18. Rahman, Momotazur & Norton, Edward C. & Grabowski, David C., 2016. "Do hospital-owned skilled nursing facilities provide better post-acute care quality?," Journal of Health Economics, Elsevier, vol. 50(C), pages 36-46.
    19. Manuel Adelino & Katharina Lewellen & Anant Sundaram, 2015. "Investment Decisions of Nonprofit Firms: Evidence from Hospitals," Journal of Finance, American Finance Association, vol. 70(4), pages 1583-1628, August.
    20. 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.
    21. Mark McClellan & Douglas Staiger, 1999. "The Quality of Health Care Providers," NBER Working Papers 7327, National Bureau of Economic Research, Inc.
    22. 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.
    23. Robert S. Harris & Tim Jenkinson & Steven N. Kaplan, 2014. "Private Equity Performance: What Do We Know?," Journal of Finance, American Finance Association, vol. 69(5), pages 1851-1882, October.
    24. 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.
    25. 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.
    26. Kaplan, Steven N & Weisbach, Michael S, 1992. "The Success of Acquisitions: Evidence from Divestitures," Journal of Finance, American Finance Association, vol. 47(1), pages 107-138, March.
    27. 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.
    28. Sun, Liyang & Abraham, Sarah, 2021. "Estimating dynamic treatment effects in event studies with heterogeneous treatment effects," Journal of Econometrics, Elsevier, vol. 225(2), pages 175-199.
    29. Yael V. Hochberg & Joshua D. Rauh, 2013. "Local Overweighting and Underperformance: Evidence from Limited Partner Private Equity Investments," The Review of Financial Studies, Society for Financial Studies, vol. 26(2), pages 403-451.
    30. Cornell, Portia Y. & Grabowski, David C. & Norton, Edward C. & Rahman, Momotazur, 2019. "Do report cards predict future quality? The case of skilled nursing facilities," Journal of Health Economics, Elsevier, vol. 66(C), pages 208-221.
    31. 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.
    32. Steven N. Kaplan & Per Stromberg, 2009. "Leveraged Buyouts and Private Equity," Journal of Economic Perspectives, American Economic Association, vol. 23(1), pages 121-146, Winter.
    33. James J. Heckman & Edward Vytlacil, 2005. "Structural Equations, Treatment Effects, and Econometric Policy Evaluation," Econometrica, Econometric Society, vol. 73(3), pages 669-738, May.
    34. Kaplan, Steven, 1989. "The effects of management buyouts on operating performance and value," Journal of Financial Economics, Elsevier, vol. 24(2), pages 217-254.
    35. 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.
    36. Susan Rose-Ackerman, 1996. "Altruism, Nonprofits, and Economic Theory," Journal of Economic Literature, American Economic Association, vol. 34(2), pages 701-728, June.
    37. 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.
    38. Shourun Guo & Edith S. Hotchkiss & Weihong Song, 2011. "Do Buyouts (Still) Create Value?," Journal of Finance, American Finance Association, vol. 66(2), pages 479-517, April.
    39. Gabriel Picone & Shin-Yi Chou & Frank Sloan, 2002. "Are For-Profit Hospital Conversions Harmful to Patients and to Medicare?," RAND Journal of Economics, The RAND Corporation, vol. 33(3), pages 507-523, Autumn.
    40. 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.
    41. 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.
    42. Paul J. Eliason & Paul L. E. Grieco & Ryan C. McDevitt & James W. Roberts, 2018. "Strategic Patient Discharge: The Case of Long-Term Care Hospitals," American Economic Review, American Economic Association, vol. 108(11), pages 3232-3265, November.
    43. Joshua Angrist & Victor Lavy & Analia Schlosser, 2010. "Multiple Experiments for the Causal Link between the Quantity and Quality of Children," Journal of Labor Economics, University of Chicago Press, vol. 28(4), pages 773-824, October.
    44. 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.
    45. Korteweg, Arthur & Sorensen, Morten, 2017. "Skill and luck in private equity performance," Journal of Financial Economics, Elsevier, vol. 124(3), pages 535-562.
    46. Benjamin U Friedrich & Martin B Hackmann, 2021. "The Returns to Nursing: Evidence from a Parental-Leave Program [Access to Cardiac Rehabilitation and the Role of Language Barriers in the Provision of Cardiac Rehabilitation to Migrants]," The Review of Economic Studies, Review of Economic Studies Ltd, vol. 88(5), pages 2308-2343.
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    Cited by:

    1. 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.
    2. 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.
    3. 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.
    4. 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.).
    5. 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.
    6. 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.
    7. 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.
    8. Rebucci, Alessandro & Bai, Ge & Jiménez, Daniel & Phan, Phillip & , & Sun, Xian, 2021. "The Financial Fragility of For-profit Hospitals: Evidence from the COVID-19 Pandemic," CEPR Discussion Papers 16650, C.E.P.R. Discussion Papers.
    9. Shubhranshu Shekhar & Jetson Leder-Luis & Leman Akoglu, 2023. "Unsupervised Machine Learning for Explainable Health Care Fraud Detection," NBER Working Papers 30946, National Bureau of Economic Research, Inc.
    10. 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.
    11. 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.).
    12. Mathias Dewatripont & Jean Tirole, 2022. "The Morality of Markets," Working Papers ECARES 2022-35, ULB -- Universite Libre de Bruxelles.
    13. Michael Alexeev & Ivan Dedyukhin & Leonid Polishchuk, 2024. "Ownership, Asymmetric Information, and Quality of Care for the Elderly: Evidence from US Nursing Homes During the COVID-19 Pandemic," CAEPR Working Papers 2024-006 Classification-, Center for Applied Economics and Policy Research, Department of Economics, Indiana University Bloomington.
    14. 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.
    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.

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    More about this item

    JEL classification:

    • G3 - Financial Economics - - Corporate Finance and Governance
    • G32 - Financial Economics - - Corporate Finance and Governance - - - Financing Policy; Financial Risk and Risk Management; Capital and Ownership Structure; Value of Firms; Goodwill
    • G34 - Financial Economics - - Corporate Finance and Governance - - - Mergers; Acquisitions; Restructuring; Corporate Governance
    • G38 - Financial Economics - - Corporate Finance and Governance - - - Government Policy and Regulation
    • I1 - Health, Education, and Welfare - - Health
    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health

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