Response to “How Should We Assess Quality of Health Care Services in Organizations Owned by Private Equity Firms?”

In “How Should We Assess Quality of Health Care Services in Organizations Owned by Private Equity Firms?,” our colleagues Drs La Forgia and McDevitt expressed concern that flawed reasoning and cherry-picked findings on private equity (PE) in health care might misinform the public.¹ As researchers guided by scientific evidence and facts, we fully agree with this point in principle. Unfortunately, however, their article exemplifies the very practices they critique.

They argue that a paper by Kannan, Bruch, and Song² received unwarranted attention because hospital-acquired conditions “are exceedingly rare, making up 0.2% of all hospitalizations.”¹ However, hospital-acquired conditions are a widely used quality measure and account for a greater proportion of total hospitalizations than other outcomes employed in work by McDevitt and colleagues (eg, in-hospital mortality for patients with acute myocardial infarction or 30-day mortality for patients with chronic obstructive pulmonary disease).³ They also take issue that not all hospitals contributed data for the full 3 years before and after a PE acquisition,² but this is common in this area of research, including in work by McDevitt and colleagues.⁴

They further contend that, because the rate of falls and trauma remained constant in PE-acquired hospitals but declined in the control group,² it is inappropriate to interpret the difference-in-differences estimate as evidence of deteriorating quality. This argument selectively ignores the logic of all difference-in-differences approaches, including those they rely on in their own studies of PE,⁴ and it misunderstands the role of the control group in causal inference. Advances in safety of hospital care reduced complication rates from 2010-2019 across US hospitals on average,⁵ so the fact that care quality stagnated (ie, did not improve) in PE-acquired hospitals is, in itself, concerning. 

La Forgia and McDevitt claim the article’s key takeaway should be the observed decrease in in-hospital mortality, without acknowledging that relatively higher transfer rates and possibly earlier discharge of sicker patients among PE-acquired hospitals all point to the likely bias in patient selection by PE hospitals shown in the study—that PE hospitals admitted relatively younger and fewer dually eligible (particularly disadvantaged) patients after acquisition. 

They conclude that PE is “good for fertility clinics.”¹ Yet the very study they cite on fertility chain ownership—coauthored by La Forgia—clearly states, “PE funding does not influence the live birth rate,” the main outcome evaluated.⁶ The authors conclude: “This result suggests quality improvements occur because of the chain, not the PE funding,” and PE funding instead drives an increased volume of in vitro fertilization cycles.⁶ In fact, the increase in live births after PE acquisition is no larger (and indeed a bit smaller) than after acquisition by non-PE, for-profit chains.⁶

Given the authors’ concern about media mischaracterization of research on PE, we are surprised to see their misrepresentation of their own findings and those of others in both this article and public commentary.^7,8 We respect colleagues who defend the role of PE in health care. In fact, we have consistently incorporated defenses of PE in our own lectures and public comments^9,10,11,12—both to illustrate the nuances in this field and to accurately represent what the evidence shows and what the range of opinions about PE includes. However, defenses of PE on the grounds of objective evidence or informed opinion are different from defenses based on the mischaracterization of evidence or selective departure from scientific methodology. This is the distinction we draw in this response.

We are concerned about research that is funded by PE and believe that scientifically rigorous and non-ideological commentary might offer a more objective starting point for such discussion about the role of PE in health care, given the patient outcomes at stake.