Association of Private Equity Investment in US Nursing Homes with the Quality and Cost of Care for Long-Stay Residents

Abstract

Importance: Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. Objective: To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. Design, Setting, and Participants: In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity-acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Exposure: Private equity acquisitions of 302 nursing homes between 2013 and 2017. Main Outcomes and Measures: This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care-sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Results: Of the 259403 residents in the study (170687 women [65.8%]; 211154 White residents [81.4%]; 204928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity-acquired nursing homes and 249771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336072 of 2383491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412344 of 2383491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P =.02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P =.003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P =.02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (-0.2 percentage points; 95% CI, -1.7 to 1.4 percentage points; P =.83), severe pain (0.2 percentage points; 95% CI, -1.1 to 1.4 percentage points; P =.79), or pressure ulcers (0.5 percentage points; 95% CI, -0.4 to 1.3 percentage points; P =.30). Conclusions and Relevance: This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.