Private Equity Oversight Gaps Threaten Patient Safety, ACP Warns

Private equity (PE) investment in health care has increased substantially over the last few years, rising from $41.5 billion in 2010 to $119.9 billion in 2019.¹ However, federal oversight mechanisms remain poorly equipped to track or curb the trend, according to a new position paper from the American College of Physicians (ACP). The paper, published in Annals of Internal Medicine, calls on Congress and state and federal regulators to close transparency gaps, strengthen antitrust enforcement, and protect physicians' clinical autonomy from investor-driven pressure.

What the Clinical Evidence Shows

The ACP's policy framework arrives against a backdrop of accumulating outcomes data that positions PE ownership as a measurable patient safety concern, not merely a financial or structural one.

A December 2023 study in JAMA examined more than 1 million Medicare hospitalizations at 51 PE-acquired hospitals and 259 matched control facilities over an 11-year period.² The findings show that PE-owned hospitals saw a 25% increase in hospital-acquired conditions after acquisition compared with non-PE peers, driven by a 27% jump in patient falls and a 38% rise in central line-associated bloodstream infections despite PE facilities placing 16% fewer central lines than before acquisition, relative to control hospitals. In-hospital mortality showed a slight decline, but researchers attributed that largely to selection effects as PE-owned hospitals were admitting younger, healthier Medicare patients and transferring sicker ones, particularly those with sepsis, to other acute-care facilities at higher rates. That decline disappeared entirely within 30 days of discharge.

A subsequent 2025 study extended the lens to emergency departments (EDs) and intensive care units (ICUs).³ Analyzing over 1 million ED visits by Medicare patients at 49 PE-acquired hospitals compared with 6 million visits at 293 matched controls over 10 years, the researchers found that ED mortality rose 13% post-acquisition, translating to seven additional deaths per 10,000 visits from a baseline of 52. The authors state that this is likely since, after acquisition, PE hospitals cut ED salary expenditures by 18%, ICU salary expenditures by 16%, and hospital-wide full-time employees by an average of 11.6% compared with non-PE hospitals.

"Staffing cuts are one of the common strategies used to generate financial returns for the firm and its investors," Zirui Song, senior author of the paper and associate professor of health care policy at Harvard Medical School, said in a statement from Harvard Medical School.⁴ "Among Medicare patients, who are often older and more vulnerable, this study shows that those financial strategies may lead to potentially dangerous, even deadly consequences."

Where the Regulatory Framework Falls Short

The ACP paper situates this clinical evidence within a regulatory structure that has been chronically outpaced by market activity.¹ With PE investment in health care rapidly growing, these firms have collectively invested roughly $1 trillion across nearly 8000 health care deals to acquire facilities such as fertility clinics, primary care centers, cardiology practices, and more. Acquisitions of physician practices alone increased more than sixfold between 2012 and 2021, with dermatology, ophthalmology, gastroenterology, and primary care accounting for more than 80% of recorded PE acquisitions in those specialties.

However, the authors note that the numbers may not reflect the complete picture due to inadequate transparency. Under the Hart–Scott–Rodino (HSR) Antitrust Improvements Act, only transactions exceeding $111.4 million trigger mandatory federal review, which is a threshold met by only a minority of PE acquisitions. PE firms frequently use "roll-up" strategies, consolidating markets through multiple smaller deals that individually fall below the reporting cutoff, effectively evading antitrust scrutiny while substantially reshaping local markets. In 28% of metropolitan statistical areas, a single PE firm holds a market share exceeding 30% in a given specialty; in 13% of markets, that figure surpasses 50%.

Enforcement capacity has also not kept pace. While PE acquisitions in health care grew 167% between 2010 and 2020, the number of full-time positions at the Federal Trade Commission fell 17% over the same period.

Calls for a strategic regulatory agenda have intensified within managed care and policy circles.⁴ A May 2026 analysis in The American Journal of Managed Care® outlined a framework for increasing transparency and safeguarding clinical autonomy in PE-heavy markets, arguing that robust policy must at minimum shield patients and providers from PE-associated risks and ideally position them to benefit from private investment where it serves genuine care gaps.

References

1. Johnson D, Manaker S, Algase LF, Watkins C Jr. Regulatory framework for private equity and corporatization in health care: a position paper from the American College of Physicians. Ann Intern Med. Published online May 26, 2026. doi:10.7326/ANNALS-25-03148
2. Kannan S, Bruch JD, Song Z. Changes in hospital adverse events and patient outcomes associated with private equity acquisition. JAMA. 2023;330(24):2365–2375. doi:10.1001/jama.2023.23147
3. Kannan S, Bruch JD, Zubizarreta JR, Stevens J, Song Z. Hospital staffing and patient outcomes after private equity acquisition. Ann Intern Med. 2025;178(11):1529-1538. doi:10.7326/ANNALS-24-03471
4. Miller J. Deaths rose in emergency rooms after hospitals were acquired by private equity firms. News release. Harvard Medical School. Published September 22, 2025. Accessed May 26, 2026. https://hms.harvard.edu/news/deaths-rose-emergency-rooms-after-hospitals-were-acquired-private-equity-firms
5. Berman ME, Tamirisa K, Rahim FO, Khachadoorian-Elia H, Witkowski ML. Regulating private equity in health care: a strategic policy agenda. AJMC^®. 2026;32(5):e138-e140. doi:10.37765/ajmc.2026.89938