Portal de Periódicos da CAPES

Association of private equity ownership with increased employment of advanced practice professionals in outpatient dermatology offices

2020; Elsevier BV; Volume: 84; Issue: 4 Linguagem: Inglês

10.1016/j.jaad.2020.05.024

1097-6787

Meliha Skaljic, Jules B. Lipoff,

Diversity and Career in Medicine

To the Editor: The recent trend of private equity investment in dermatology groups has been met with controversy.1Sharfstein J.M. Slocum J. Private equity and dermatology—first, do no harm.JAMA Dermatol. 2019; 155: 1007-1008Crossref Scopus (9) Google Scholar, 2Resneck J.S. Dermatology practice consolidation fueled by private equity investment: potential consequences for the specialty and patients.JAMA Dermatol. 2018; 154: 13-14Crossref PubMed Scopus (39) Google Scholar, 3Konda S. Francis J. Motaparthi K. Grant-Kels J.M. Future considerations for clinical dermatology in the setting of 21st century American policy reform corporatization and the rise of private equity in dermatology.J Am Acad Dermatol. 2019; 81: 287-296.e8Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar One concern is that private equity–backed groups may hire more advanced practice professionals (nurse practitioners and physician assistants) per office because of lesser compensation than physicians. However, although advanced practice professionals often have broad scopes of practice,4Resneck J.S. Kimball A.B. Who else is providing care in dermatology practices? trends in the use of nonphysician clinicians.J Am Acad Dermatol. 2008; 58: 211-216Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar they receive various training levels, with evidence suggesting lower accuracy in diagnosing skin cancer compared with physicians.5Anderson A.M. Matsumoto M. Saul M.I. et al.Accuracy of skin cancer diagnosis by physician assistants compared with dermatologists in a large health care system.JAMA Dermatol. 2018; 154: 569-573Crossref PubMed Scopus (38) Google Scholar We aimed to evaluate whether ownership by private equity–backed groups had association with advanced practice professional employment by these practices compared with independently owned practices. This study was institutional review board exempt. We queried databases (Capital IQ, CB Insights, Zephyr, ThomsonONE, PitchBook, and Factiva) and press releases to identify dermatology practices acquired by private equity–backed groups from May 2012 to November 2018 (private equity ownership for >1 year); 100 of these 229 practices were selected for comparison using a Microsoft Excel (Redmond, WA, USA) random-number generator (RANDBETWEEN). We identified independent private practices for comparison by using the Medicare Physician and Other Supplier National Provider Identifier Aggregate Report, a database listing providers submitting Medicare Part B noninstitutional claims from 2012-2017. A random sample of 100 dermatology providers was selected, and Google search (provider name + "dermatologist") identified private practice employers of providers. The number of providers employed was determined via practice website or, when not available, by calling the practice directly. The 2017 American Community Survey 5-Year Estimates were used to identify zip code sociodemographic data for offices. Offices were grouped into geographic regions based on official US Census Bureau categorization. Sociodemographic data and provider counts were compared with Wilcoxon rank sum tests. P < .05 was considered significant. Analysis was performed with Stata/IC (version 15.0). Private equity–owned and independent practices were located in zip codes with similar mean household income (mean $102,452 [standard deviation {SD} $46,629] for private equity–owned practices vs $101,091 [SD $45,522] for independent practices; z score = –0.32; P = .75) and population (mean 33,071 [SD 13,866] vs 33,458 [SD 17,283]; z = –0.08; P = .93) (Table I). Private equity–owned practices employed more total providers (4.23 [SD 2.49] vs 3.12 [SD 2.06]; z = –3.57; P < .001), physicians (2.54 [SD 1.49] vs 2.17 [SD 1.49]; z = –2.24; P = .03), advanced practice professionals (1.69 [SD 1.75] vs 0.95 [SD 1.13]; z = –3.56; P = .01), and advanced practice professionals per physician (0.83 [SD 0.86] vs 0.56 [SD 0.79]; z = –2.77; P = .01) per clinic compared with independent practices.Table ISociodemographic and practice-level features associated with private equity ownershipFeaturePE-owned practice (n = 100)Independent practice (n = 100)Test statistic∗Statistically significant at P = .05.P valuePE-backed dermatology group, no. of practices Advanced Dermatology and Cosmetic Surgery23——— US Dermatology Partners12——— Epiphany Dermatology9——— California Skin Institute8——— Qual Derm7——— Forefront Dermatology6——— Platinum Dermatology6——— Anne Arundel Dermatology6——— Schweiger Dermatology5——— Pinnacle Dermatology5——— Riverchase Dermatology5——— United Skin Specialists3——— West Dermatology3——— United Derm Partners1——— Dermatologists of Central States1——— Total100100Years since PE acquisition, mean (SD)2.84 (1.45)—Region of the US, number of practices South Atlantic (DE, FL, GA, MD, NC, SC, VA, WV)24220.34.74 East North Central (IL, IN, MI, OH, WI)1417–0.59.59 West South Central (AR, LA, OK, TX)17121.00.32 Mid-Atlantic (NJ, PA, NY)816–1.74.08 Pacific (AK, CA, HI, OR, WA)1112–0.22.82 Mountain (AZ, CO, ID, NM, MT, NV, UT, WY)1652.54.01†Represents z value for 2-sample test of proportion and z score for Wilcoxon rank sum test. West North Central (IA, KS, MN, MO, NE, ND, SD)750.60.55 East South Central (AL, KY, MS, TN)35–0.72.47 New England (CT, ME, MA, NH, RI, VT)06–2.49.01†Represents z value for 2-sample test of proportion and z score for Wilcoxon rank sum test. Total100100Sociodemographic features of practice location Zip code mean income, $102,452 (46,629)101,091 (45,522)–0.32.75 Zip code population33,071 (13,866)33,458 (17,283)–0.08.93Providers per practice, mean (SD) Total providers4.23 (2.49)3.12 (2.06)–3.57<.001†Represents z value for 2-sample test of proportion and z score for Wilcoxon rank sum test. Physicians2.54 (1.49)2.17 (1.49)–2.24.03†Represents z value for 2-sample test of proportion and z score for Wilcoxon rank sum test. APPs1.69 (1.75)0.95 (1.13)–3.56.01†Represents z value for 2-sample test of proportion and z score for Wilcoxon rank sum test. APPs per physician0.83 (0.86)0.56 (0.79)–2.77.01†Represents z value for 2-sample test of proportion and z score for Wilcoxon rank sum test.AK, Alaska; AL, Alabama; APP, Advanced practice professional; AR, Arkansas; AZ, Arizona; CA, California; CO, Colorado; CT, Connecticut; DE, Delaware; FL, Florida; GA, Georgia; HI, Hawaii; IA, Iowa; ID, Idaho; IL, Illinois; IN, Indiana; KS, Kansas; KY, Kentucky; LA, Louisiana; MA, Massachusetts; MD, Maryland; ME, Maine; MI, Michigan; MN, Minnesota; MO, Missouri; MS, Mississippi; MT, Montana; NC, North Carolina; ND, North Dakota; NE, Nebraska; NH, New Hampshire; NJ, New Jersey; NM, New Mexico; NV, Nevada; NY, New York; OH, Ohio; OK, Oklahoma; OR, Oregon; PA, Pennsylvania; PE, private equity; RI, Rhode Island; SC, South Carolina; SD, South Dakota; SD, standard deviation; TN, Tennessee; TX, Texas; US, United States; UT, Utah; VA, Virginia; VT, Vermont; WA, Washington; WI, Wisconsin; WV, West Virginia; WY, Wyoming.∗ Statistically significant at P = .05.† Represents z value for 2-sample test of proportion and z score for Wilcoxon rank sum test. Open table in a new tab AK, Alaska; AL, Alabama; APP, Advanced practice professional; AR, Arkansas; AZ, Arizona; CA, California; CO, Colorado; CT, Connecticut; DE, Delaware; FL, Florida; GA, Georgia; HI, Hawaii; IA, Iowa; ID, Idaho; IL, Illinois; IN, Indiana; KS, Kansas; KY, Kentucky; LA, Louisiana; MA, Massachusetts; MD, Maryland; ME, Maine; MI, Michigan; MN, Minnesota; MO, Missouri; MS, Mississippi; MT, Montana; NC, North Carolina; ND, North Dakota; NE, Nebraska; NH, New Hampshire; NJ, New Jersey; NM, New Mexico; NV, Nevada; NY, New York; OH, Ohio; OK, Oklahoma; OR, Oregon; PA, Pennsylvania; PE, private equity; RI, Rhode Island; SC, South Carolina; SD, South Dakota; SD, standard deviation; TN, Tennessee; TX, Texas; US, United States; UT, Utah; VA, Virginia; VT, Vermont; WA, Washington; WI, Wisconsin; WV, West Virginia; WY, Wyoming. Our results demonstrate that, compared with a group of independent practices with similar underlying sociodemographic features, private equity–backed dermatology practices employ both a greater number of advanced practice professionals and a higher ratio of advanced practice professionals to physicians (though still less than 1). Limitations include sample size, overrepresentation of private equity–backed groups with greater acquisition transparency, and geographic representation differences. In addition, our study does not capture qualitative practice supervision differences; state models of advanced practice professional oversight vary. Finally, although we demonstrate private equity–owned practices' association with greater advanced practice professional employment, this shows only correlation, not causation. We limited study to private equity–backed practices with greater than 1-year ownership, although private equity buyers may be acquiring practices that already employ more advanced practice professionals. Further study is necessary to appreciate the clinical influence of potential differences in practice management, particularly given ongoing discussion regarding scope of advanced practice professional practice in dermatology.