Private equity (PE) firms are increasingly acquiring private practices in outpatient, procedural-based specialties.(1) PE positions itself as a complement to private practice that can streamline management, readily invest in innovative diagnostics and treatment options that bolster a practice’s competitive advantage, and free physicians from administrative burdens.(2,3) PE also offers independent physicians an alternative to selling their practices to larger hospital systems, which acquired more than 8,000 practices between July 2016 and January 2018.(4)
PE firms primarily engage in a “roll-up” strategy, where they acquire and consolidate smaller practices to aggregate their resources.(2,3,5) This strategy allows PE to increase its market share and power and better negotiate reimbursement rates or new medical equipment fees.(5) Consolidation also unlocks unique benefits for acquired practices, such as an increased referral base, expanded market reach, practice stability, and shared burden of operational costs.(6)
Risks of consolidation, however, include less provider autonomy, limited access to outside network providers, differences in priorities between leadership and providers, decreased physician competition, and a lack of integration of acquired practices.(6)
With respect to acquisitions, PE typically targets urban, metropolitan markets due to greater profitability.(7,8) PE firms then implement strategies to maximize returns within three to seven years and then “exit” or sell practices, often to larger PE firms through secondary buyouts.(5)
In general, PE firms will pay physician partners large amounts of money in exchange for equity and offer future financial gains (referred to as the “second bite of the apple”) when they exit.(9) PE uses debt to finance its investments, but the responsibility of servicing debt falls on the practice.(8) If a practice does not generate enough profit to do so, the “second bite of the apple” for physicians may never materialize as a result.(8)
Ophthalmology, which makes up 70.4% of all physician private practices in the United States as of 2024, has been among the most targeted specialties by PE firms because of its fragmented market, opportunities for capitalization and consolidation, and growing provider demand from a sizeable aging population.(10-12) In 2022, nearly 8% of ophthalmology practices and optometry practices and 30% of retina practices were affiliated with PE.(13,14)
PE typically creates a platform company before investing in an ophthalmology practice by either acquiring larger practices or preexisting ophthalmology management groups, or by aggregating smaller practices or platforms into a larger, novel platform company.(12) PE-backed platforms then facilitate consolidation by adding on practices under the umbrella of the platform company.(12)
While PE-backed hospitals have poorer clinical outcomes that have elicited highly publicized, negative reactions from healthcare providers and legislators, there is limited literature on physician perceptions of PE-backed private practices. In a recent survey of more than 500 physicians, 60.8% of respondents had negative views of PE in healthcare.(15,16) When surveyed about PE-backed practices, 52% of respondents felt that PE ownership was either “worse” or “much worse” than independent physician ownership.(16)
Given the rapid growth of PE-backed practices in ophthalmology, a clearer understanding of physician perceptions on these shifts in ownership is needed. This study explores the perspectives of private practice ophthalmologists with and without experience in a PE-backed setting and their attitudes on PE in private practice ophthalmology.
Design and Methods
This qualitative study was reviewed and deemed exempt by Georgetown University’s Institutional Review Board because of its minimal risk to participants. When prospective participants were contacted, an explanation of the study, the identity, affiliation, and contact information of all research investigators, a description of the interview length and intended usage of data, the voluntary nature of participation, and measures taken to protect participant privacy and de-identify data were provided. This study was exempt from obtaining written consent, but verbal informed consent was obtained from participants before conducting the study. No participants withdrew their consent for the duration of the study.
Recruitment and Inclusion Criteria
Study recruitment occurred from January 31, 2025, to May 25, 2025. Participants were identified via online searches for ophthalmology practices in the United States and through snowball sampling, in which enrolled participants referred investigators to additional eligible individuals for recruitment. The criteria for eligibility required participants to be currently practicing private practice ophthalmologists.
Prospective participants were contacted via email. Private practice ophthalmologists were not excluded if they previously worked in or were jointly affiliated with an academic institution. No more than one physician from a distinct practice was recruited, but physicians were not excluded if they were in a distinct practice backed by the same PE group.
Data Collection
Semi-structured interviews with a combination of open-ended and closed-ended questions were conducted via phone call, asking physicians’ opinions and professional experiences for exploratory purposes. The interview questionnaire collected age, total years in private practice, and total years in a PE-backed setting, if applicable.
Open-ended questions explored perceived benefits, areas for improvement in PE management, and impacts on clinical decision-making. Closed-ended questions assessed views on PE’s alignment with medicine’s goal to provide quality care, the current degree of regulation, and patient cost burdens. Interview duration ranged from 25 minutes to 60 minutes, and data were transcribed verbatim.
Malterud, Siersma, and Guassora outline the information power framework as an alternative to thematic saturation for determining adequate sample size in qualitative studies.(17) Under this framework, smaller sample sizes are adequate when the study’s aim is narrow, and the dialogue is an in-depth analysis of participant narratives.(17) The aim of our study is to explore how ophthalmologists with and without PE affiliations perceive the positive and negative effects of PE on clinical practice and patient care delivery in ophthalmology. Our aim is also narrow because of the selectively desired perspectives from ophthalmologists representing a range of possible PE affiliations.
Given this narrow aim, the high specificity of our sample, and the richness of data collected, we applied this framework to determine an adequate sample size. Our study includes various, distinct PE and non-PE affiliated roles, from fully self-owned, self-owned but in a PE-backed ambulatory surgical center (ASC), to non-partner and partner physicians in PE-backed practices. Therefore, our sample size of six was deemed sufficient.
Data Analysis
Manual coding was conducted by one research investigator (AP) using an inductive approach to identify key recurring themes that emerged from the dataset to develop a codebook. The codebook included themes present in all six interviews. There was no predetermined limit set to the number of themes that could be identified. Once a codebook was developed, the raw dataset was reanalyzed and coded according to the identified themes. Data were classified as pertaining to one or more themes when applicable. After the compilation of themes, the themes were organized under overarching domains.
A second research investigator (RB) independently applied the codebook developed to the raw dataset and thematically coded data accordingly. The independently coded dataset analyses were jointly reviewed by all members of the research team (AP, RB, JL), and discrepancies were discussed until a consensus was reached. Closed-ended questions were not coded unless participants explicitly provided rationales for their choices.
Results
Our data (n = 6) consisted of physicians who solely owned their practice and did not operate in a PE-backed ambulatory surgery center (ASC), entirely self-owned their practice but operated in a PE-backed ASC, PE physicians who did not hold partnership or leadership roles in a practice, and PE physicians who held partnership positions in their practice and/or management roles within the larger group of practices. A total of six practices located in distinct states, specifically urban regions, and five PE firms were represented in the sample.
Participant A was the only provider not affiliated with PE in any capacity and the only provider in a single-provider practice. All other participants were part of a multi-provider practice. Participant E had experience as a partner physician in a PE-backed practice and held a leadership position in a practice management firm backed by the same PE firm. Participant F was a physician partner in a different practice under the purview of the same practice management firm.
Table 1 depicts sample demographics and the range of PE affiliation and setting. Three domains were identified in the data analysis: operations, profitability, and clinical practice.
Domain 1: Operations
The first domain identified was operations, with recurring themes of logistics and management structure. Illustrative quotes highlighting themes under this domain can be found in Table 2. Physicians, regardless of their affiliation status with PE, unanimously concurred that PE alleviated physicians of their administrative burdens, enabling them to focus on their clinical duties.
Differences were noted between partner and non-partner physicians in PE-backed practices. For example, participant D, who was a recent hire at a PE-backed practice and was not a partner, recalled barriers that impeded their ability to obtain necessary, higher-quality equipment. They felt that there was a disconnect between physicians and non-medical management, who were unable to understand the importance of opting for a more expensive piece of equipment.
Under the theme of management structure, responses suggested that a higher degree of physician input and collaboration in a PE firm’s practices increases its favorability among private practice doctors. Participant C found that the success of their ASC positively correlated with the degree of physician input and management flexibility. Participant E, who held a management position in the larger group that oversaw multiple practices, and participant F, a partner in a PE-backed practice, both viewed PE management positively. In contrast, participant B and participant D reported that they were not partners in their respective practices and expressed negative sentiments toward PE firms’ management structure.
Additionally, participant A, a non-PE-affiliated physician, felt that PE decreases the level of physician investment in a practice’s success compared to the investment among physicians with self-owned practices.
Domain 2: Profitability
The second domain identified was profitability, which was divided into themes of physician compensation, competitive advantage, and revenue. Illustrative quotes highlighting themes under this domain can be found in Table 3. Attitudes varied with regard to physician compensation.
Participants who held partnership positions in PE-backed practices had more positive outlooks on physician compensation than physicians who owned their practice or were not partners at a PE-backed practice. Participant A was uninterested in higher pay at the cost of losing autonomy under PE management. Participant C expressed skepticism in the PE compensation model for partners post-exit, but viewed the compensation increase that was secondary to an influx of patients seen post-PE acquisition positively. Participant D, who formerly owned their practice but moved to a different practice and was not a partner, felt well compensated but acknowledged their exclusion from decision-making conversations.
Participants aligned on PE’s ability to strengthen a practice’s competitive advantage through its roll-up practice that results in greater leveraging power. However, the mechanism behind the competitive advantage was viewed negatively by physicians who did not hold partnership roles, with participant D stating that the financial interests of PE would supersede the medical interests of the practice.
Finally, participants aligned on PE’s ability to generate more revenue but were divided along the lines of how incorporated they were into the practice management structure and whether revenue-increasing measures were a cost or benefit to the practice. Participants A, B, C, and D felt that PE implemented revenue-increasing measures that compromised patient care and raised questions about misalignment between PE’s mission to maximize returns on investment and physicians’ mission to deliver the best care. Participant F, a partner in a PE-backed practice, noted a decrease in the amount of pro bono care provided, but did not explicitly state whether they felt positively or negatively about it.
Domain 3: Clinical Practice
The final domain identified was clinical practice, which contained themes of physician autonomy and quality of care. Illustrative quotes highlighting themes under this domain can be found in Table 4.
With respect to physician autonomy, participant A valued their autonomy and viewed PE as a threat. Physicians who were not partners expressed negative views on their sense of autonomy under PE’s management. On quality of care, non-PE affiliated, and non-partner PE affiliated participants thought that PE’s influence will not necessarily impact a doctor’s clinical decision-making, but can still undermine the quality of care. PE-affiliated participants who were partner physicians felt that PE’s handling of administrative duties and capital investment allows doctors to solely focus on patient care and offer more treatments and services that translate to higher quality of care.
Closed-Ended Question Responses
On closed-ended question responses, participants ranged from neutral to slight agreement that PE aligns with the mission of medicine to deliver quality patient care in private practice settings. Participants C and F felt that it was context-dependent. Context-dependent refers to the relationship between PE investors and physicians in a practice. They cited that PE groups can differ in their goals, and mission alignment depends on management transparency and willingness for collaboration.
Participant F strongly agreed that medicine’s and PE’s missions align in their personal experience. With respect to regulation, almost all participants felt that PE is unregulated or under-regulated. Participants C and F felt that the lack of regulation does not mean that regulation is necessary. Participant C believed that the lack of regulation was because of the early nature of PE’s presence in medicine and slow regulatory processes. Participant F felt that medicine is overly regulated, such that it creates an environment where private practices need PE to manage the administrative burdens (i.e., regulatory compliance, reimbursement optimization).
Participants had mixed views on patient cost burden changes. However, multiple participants believed that insurance companies, not patients, should shoulder any increased cost burden. Responses are summarized in Table 5.
Discussion
Regulatory complexities and administrative burdens place significant demands on physician-owned private practices and often require larger-scale infrastructure to address them. Unsurprisingly, private practices have increasingly forged partnerships with hospitals and PE firms to meet these demands.
In 2024, 34.5% of private practice physicians worked in a hospital-owned practice, compared to 23.4% in 2012.(10) The percentage of physicians in PE-backed practices also increased from 4.5% to 6.5% in 2022 and 2024, respectively.(10) The top three reasons cited by physicians who sold their practices, in order of importance, were to better negotiate payment rates with payors, improve access to costly resources, and better navigate payor regulatory and administrative requirements.(10)
We found that physicians agreed with PE on their advertised benefits, such as increased leveraging power and decreased administrative burdens for clinicians. This alignment is consistent with findings by O’Donnell and colleagues, who interviewed investors and physicians and found both parties to agree on the advertised benefits of PE in ophthalmology private practices.(2)
However, differences in PE’s favorability were most prominent between partner and non-partner physicians in PE-backed practices. Non-partner physicians in PE-backed practices viewed PE least favorably compared to self-owned practice physicians, followed by partner physicians in PE-backed practices, who viewed PE most favorably.
Existing literature has shown different attitudes on PE between older and younger ophthalmologists, with the former receiving equity post-PE acquisition and expressing positive attitudes, and the latter receiving less equity post-acquisition and expressing negative attitudes.(2) In contrast, Nolte, Miedaner, and Sülz found that younger physicians from multiple specialties viewed the decreased administrative burden in PE-backed practices more favorably than older physicians.(18)
We found that non-partner physicians viewed PE less favorably compared to partner physicians across all three domains. Thus, PE favorability is not necessarily related to a physician’s age or financial stake, but instead a combination of partnership status and degree of physician input in decision-making processes. Partners likely have more managerial input, whereas non-partners may feel the effects of decreased autonomy and increased clinical oversight more directly.
Current literature from multiple specialties has shown that waning physician autonomy under PE is a leading concern among private practice doctors.(18) We found this to be true among non-partner physicians in PE-backed practices, and with participant A, who refused to sell to PE and cited loss of autonomy as the inhibiting factor. When asked if PE has any influence on physicians’ clinical decision-making processes, participants had mixed views but largely endorsed no effect. Non-partners like participant B likened PE oversight to “big brother,” whereas participant E, a partner, enjoyed the increased access to treatments and services for patient care. This contrast suggests that autonomy and managerial input inform attitudes on PE.
Our findings highlight a common belief that PE optimizes reimbursements for healthcare services, with participants discussing PE’s increased leveraging power and expertise in navigating MIPS to maximize physician compensation. Participant F, a partner, endorsed better MIPS navigation in their PE-backed practice. While it has been shown that PE-backed practices negotiate higher prices for services and increase revenue by optimizing billing practices, one study found that PE-backed practices in urology had significantly worse MIPS performance post-acquisition and a decrease in the percentage of urologists who were given bonus payments.(19,20) More research on the aggregate financial performance between non-PE and PE-backed practices is needed to establish meaningful differences.
Many participants emphasized PE’s success and favorability to be dependent on the context of the relationship between physicians and investors. Factors that determined the physician-investor relationship context included openness to physician input, physician incorporation in the management structure, and mission alignment between physicians and PE firm employees.
Closed-ended question responses showed that participants think PE can align with the medicine’s ethical mission, either from direct experience or witnessed observations. The value placed on practice and firm alignment has been documented among urologists, who believe that evaluating alignment is critical when choosing which PE firm to partner with, as well as in existing ophthalmology literature.(2,21)
The context-dependent nature of PE favorability raises concerns about its sustainability as a short-term actor in a private practice’s lifespan. For example, participant C, who operated in an ASC held by two different PE firms, described differing experiences that reflected firm-specific approaches. Participant C’s experience highlights how the variability in relationships between investors and physicians strongly affects PE favorability among physicians. Additionally, PE’s short lifecycle and the prevalence of secondary buyout exits could negatively impact PE favorability if a practice is sold to a firm that is less receptive to physician input and participation.
Given these variables, PE lacks a stable, sustainable model for practices that will outlast the firm’s holding period. Future research should examine physicians’ attitudes and their degree of input on PE firms’ exit strategies.
Participants across affiliations believe that physicians who view themselves as stakeholders in the practice are more invested in the practice’s success compared to physicians who view themselves as employees. We found this to be true among partner physicians in PE-backed practices as well, as evidenced by participants E’s and F’s more positive outlooks.
It should be noted that participant E held a leadership position in a PE-backed practice management firm, and participant F was a partner in a practice under the purview of the same practice management firm. It is therefore possible that participants E’s and F’s positive views stem from a uniquely collaborative firm outlier. One study found that younger (40–60 years old) physicians and older physicians (60+ years old), who tend to hold partnership positions, were more likely to leave PE-acquired practices compared to those working in non-PE-backed practices.(11) Our findings are therefore limited in their applicability to other partner physicians’ views on PE.
With respect to legislation and patient cost burdens, many participants thought that there was little to no regulation of PE in medicine, but a few participants with differing degrees of PE affiliation did not believe that this was necessarily an issue. Participant F felt that overregulation of medicine in general fostered an environment where practices need PE’s help.
Participants had mixed views on the patient cost burden change following PE acquisition. Participant D added that pressure to perform more elective, out-of-pocket procedures can also be seen in non-PE-backed practices and, therefore, is not unique to PE-backed practices. However, some participants added that the increased cost burden is shouldered by patients’ insurance and not patients themselves. This phenomenon has been documented in retina practices, where PE-backed practices demonstrated increased Medicare spending and were found to prescribe more costly versions of anti-vascular endothelial growth factor drugs compared to non-PE-backed practices for patients with the same diagnoses.(22)
This study has limitations. The sample included two partners from different practices affiliated with the same PE firm who endorse favorable attitudes towards PE. While not personally affiliated with PE, Participant A disclosed anecdotes of partner colleagues in PE-backed practices who regret selling to PE.
The lack of partners from more than one firm limits the generalizability of our findings in characterizing PE-affiliated partner physicians’ attitudes on PE. Physician recruitment was found to be challenging because of non-disclosure agreements among many PE-affiliated physicians, causing hesitancy to participate. While we aimed for a diversely affiliated range of participants, the small sample size may misrepresent broader opinions among practitioners.
Finally, our findings are restricted to ophthalmology, limiting our study’s applicability to other PE-targeted specialties. Despite these limitations, this study is the first to investigate private practice physician attitudes on PE among physicians who represent a diverse range of relationships with PE. Our findings are exploratory in nature but provide greater insight into how physicians view PE in a field where its presence is prominently established, shedding light on the possible trajectories and implications for physicians contemplating PE firm management.
Conclusion
Private practice ophthalmologists viewed PE more favorably when physicians have greater input in decision-making processes, are incorporated into the management structure, align on respective interests, and have clinical autonomy. While physicians understand PE’s claimed benefits, opinions differed based on partnership status, with non-partners expressing negative attitudes and partners expressing positive attitudes.
Most participants believed PE can be successful in private practice medicine, depending on their alignment with the goals of the firm and those of a practice. PE firms’ short lifecycles, management style variability, and prevalence of secondary buyout exits raise concerns about their stability and sustainability for private practices that will outlast their holding periods.
Given this growing trend and inevitable relationship between PE and private practice medicine, it is important that PE firms and private practice physicians foster relationships where doctors are viewed as equally valued stakeholders to synergize quality care delivery and desired returns on investments.
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