Date of Award

January 2022

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Isaac Y. Kim


Private equity (PE) firms have recently begun acquiring urology practices, yet little is known about the scale and impact of these acquisitions. We sought to comprehensively assess the following: (1) trends and scope of PE acquisitions occurring between January 1, 2016 and March 15, 2021 using financial databases, practice websites, and internet keyword search (2) regional market effects of PE acquisitions on revenue and volume using 2012-19 Medicare data, (3) access for Medicaid patients at PE and non-PE-affiliated practices via the secret shopper methodology, and (4) amount of Provider Relief Funding received by PE-backed urology platforms during the COVID-19 pandemic. Across the study period, we identified 20 urology practices acquired by five PE-backed platforms. Acquisitions began in 2016 and focused on large practices (26.3+25.4 urologists) with multiple locations (14.5+14.8 clinical sites) and ownership of ancillary services. We estimate that 498 of 6,939 (7.2%) private practice urologists in the US are employed by PE-backed urology platforms. In New Jersey and Maryland, PE-backed urology platforms have achieved >25% workforce share. Based on analysis of ten PE-acquired urology practices across six states, we found that PE-affiliated urologists had greater mean Medicare payments ($246,977 vs. $160,038; p<0.001) and greater annual Medicare patient volume (839.7 vs. 674.2 patients; p=0.001) than non-PE affiliated urologists within the same state prior to acquisition. Post-acquisition, PE-affiliated urologists had an 9.8% increase in Medicare payments (p=0.119) and an 8.6% increase in patient volume (p=0.014). Non-PE affiliated urologists exhibited a 6.4% decline in Medicare payments (p=0.005) and a 1.3% increase in patient volume (p=0.309). In assessing access, we made 815 appointment inquiries to 214 PE and 231 non-PE-affiliated urology offices across 12 states. Medicaid patients had lower rates of appointment availability than commercially insured patients (59.8% vs 99.0%; p<0.0001). Medicaid patients had lower appointment availability at PE-affiliated offices than non-PE affiliated offices (52.1% vs 66.8%; p=0.003). In a multivariable model, state Medicaid expansion (OR 2.20; p=0.020) and PE-affiliation (OR 0.55; p=0.004) were independently associated with differential Medicaid access. Appointment wait times were similar for commercially insured versus Medicaid patients (19.2 vs 20.1 days; p=0.59), but PE-affiliated practices had shorter mean wait times than non-PE offices (17.5 vs 21.4 days; p=0.017). For Provider Relief Funding, as of July 2021, $106,649,831 of direct federal aid has been allocated to urology practices, with twelve PE-affiliated practices accounting for 19.6% of total aid. Taken together, these findings highlight the “buy-and-build” strategy that PE-backed urology platforms use to achieve significant regional market power. This practice may negatively impact the revenue of surrounding practices and raises concern for growing access disparities. In addition, the unprecedented scale of PE-backed platforms raises concerns for financial vulnerabilities in the setting of revenue interruptions as seen during the COVID-19 pandemic. Future work should monitor the state of acquisitions and analyze impacts on healthcare expenditures and outcomes.


This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.