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That means Congress must step in to protect insured patients from unfair and unexpected medical charges.


And that puts lawmakers up against the powerful and influential private equity industry, which plays a major role in supplying hospitals with physicians. And they are using the typical tools to protect their investments from a legislative onslaught: lobbying cash, dark-money front groups, and allies in Congress pushing loopholes and half measures. Private equity funds use substantial debt to acquire doctors' practices through leveraged buyouts, and to finance mergers of practices into large staffing firms. Emergency medical and specialist practices are a prime buyout target, because patients who need emergency care cannot haggle over price, and third-party payers guarantee payment.

Private Markets

Researchers at the Kellogg School of Management found that most individual acquisitions were below the dollar threshold that would have required the transaction to be reported to antitrust regulators. But while doctors maintain autonomy over medical decisions, they also admit they are likely to be pressured to achieve higher patient volumes and revenues. In a typical contract, physicians receive a large up-front cash payment, which is calculated based on a multiple of the group's EBITDA earnings before interest, taxes, depreciation, and amortization —with recent contracts reaching 12 times EBITDA.

In addition, the doctors pay for an equity investment in the company by taking a large salary cut—up to 30 percent of their compensation. The deal is particularly attractive to senior doctors who are nearing retirement, although that leaves the more junior doctors saddled with lower pay and greater uncertainty. Private equity firms have accelerated buyouts of physician practices in the last decade.

These two firms have cornered 30 percent of the market for outsourced doctors, and collectively employ almost 80, health care professionals that staff hospitals and other facilities across the U. Its sprawling organization supplies doctors in physician practices to hospitals and ambulatory surgical centers throughout the United States. Its emergency physician staffing company, EmCare Holdings, provides ER doctors, anesthesiologists, radiologists, hospitalists, and other specialists covering intensive care, medical, neonatal, pediatrics, psychiatric, skilled nursing, rehabilitation, and other inpatient units.

Its outpatient ambulatory surgical arm AMSURG provides trauma and acute care general surgery in facilities in 35 states. TeamHealth was established in by a consortium of private equity firms as a platform for a physician staffing company. The Blackstone Group acquired it in in a leveraged secondary buyout.

With passage of the Affordable Care Act in , TeamHealth anticipated revenue growth via bundled payments and started buying up a series of ER and physician specialist practices—51 companies between and It also bought IPC, a hospital management services company, allowing it to diversify across a wider range of care areas.

Two of the three air transport companies that together control two-thirds of this U. Air Methods, sold in to private equity firm American Securities, reported that it accounts for nearly 30 percent of total U. Its profit increased sevenfold from to Our recent paper at the Institute for New Economic Thinking goes into more detail on these companies.

Surprise billing has increased substantially because hospitals, under financial pressure to reduce overall costs, have turned to outsourcing expensive and critical services to third-party providers as a cost-reduction strategy. In an April survey , 41 percent of Americans reported they or a family member received an unexpected medical bill, with half of them attributing that bill to out-of-network charges.

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Rates of surprise billing are highest among patients treated in an emergency room. In a review of A team of Yale University health economists examined what happened when private equity—owned companies EmCare part of Envision and TeamHealth—the two largest emergency room outsourcing companies—took over the emergency departments at hospitals. An EmCare takeover translated into an 82 percent increase in charges for caring for patients.

Blackstone's TeamHealth has taken a different approach to billing that has nonetheless led to higher physician charges. TeamHealth emergency physicians typically would go out of network for a few months, then rejoin the network after bargaining for higher in-network payment rates—on average 68 percent higher than in-network rates received by the previous ER doctors.

These practices contribute to higher health care costs—and ultimately higher insurance premiums for everyone—even if they do not directly lead to surprise medical bills.

Coverage and Affordability in the Private Insurance Market

Patients in a hospital may encounter out-of-network physicians among ER doctors, specialties such as radiologists and anesthesiologists, assistants to a procedure, or hospitalists who check in on a patient. Surprise ambulance bills are even more common, occurring 86 percent of the time when an ambulance took a patient to the ER. The result is another perfect opportunity for surprise medical bills, and a perfect target for unscrupulous investment funds.

In one study of air ambulance charges, Johns Hopkins University researchers found extremely large rate increases between and Private market investments represent alternative opportunities that are not available through public markets. Compared to public markets, there is less public information available about private companies.

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  8. Using this to their advantage, PE and VC funds that invest in such instruments obtain legitimate access to non-public information and leverage on them to outperform the markets. It is not a surprise then that PE investments have shown greater returns over the long term more than 10 years compared to public markets. According to Preqin, top-performing private fund managers have exceeded the PE median benchmark by 9.

    Source: Preqin Investor Interviews, December — The idea here is that companies nowadays grow in the private markets over longer periods of time, such that if and when they undergo an IPO, there is relatively little room remaining for growth. This means that public investors are missing out on the growth value of these private companies and therefore earn considerably lower returns than private equity investors. There are two main reasons why an IPO is no longer as appealing as before. The second reason is that many companies are now able to raise sufficient capital for growth without tapping on the public markets, due to the extensive development of private capital markets.

    According to MarketWatch, the median age of a company at IPO has doubled to 12 years since , driven by increases in IPO expenses and funding liquidity in private markets. A public listing therefore serves more as a means to provide existing shareholders with a liquid market and an exit to the capital they already hold, than to raise capital for growth. Before the s, tech companies like Microsoft and Amazon had IPO market capitalisations that were relatively modest as compared to their growth post-IPO, but such success stories are harder to come by these days.

    A recent PitchBook study found that only 4 out of 10 US tech unicorns that went public between and increased in valuation post-IPO, while the remaining 6 had already reached their peak valuations within the private markets and subsequently fell in value. This is disappointing news for public market investors who were late to the party, as growth value had already accrued to the private investors by the time of listing.

    The little remaining upside available to public investors is a far cry from that of tech firms in the past.

    English SUSEP — SUSEP

    Therefore, it has become more beneficial for investors to get in early as companies stay private for longer periods of time and accumulate value before exiting. Private market investments represent an alternative investment vehicle to the more traditional public equities, bonds and other alternative investments. Due to the relatively low correlation with public stocks or bonds, investments in PE funds and VC funds can further reduce concentration risk, protecting investors from sudden sharp market downturns.

    There are also commingled funds — a portfolio of PE funds structured to provide diversified exposure to PE across managers, strategies, industries and geographies. Think of it as a mixture of different funds, allowing investors to enjoy greater diversification than a single PE manager while still investing within their risk appetite, return objectives and liquidity requirements.

    If you already possess a sufficiently diversified portfolio of public market investments, private market investments are definitely a worthy consideration. The relative exclusivity of private markets offers compelling investment opportunities for investors to beat the public markets and further diversify their portfolio.

    He helps to form strategic partnerships and collaborative relationships with growth companies that are raising growth funding or seeking pre-IPO capital. He is also a qualified legal practitioner in Australia, and was admitted to practice in the Supreme Court of the Australian Capital Territory in Ronald is highly passionate about venture capital and financial innovation, which was fuelled by his work-experience stint at Vickers Venture Partners during his undergraduate years.

    Why private capital will dominate markets for the decades to come

    Siu Wai leads the Compliance team at CapBridge. He is a senior compliance professional with more than 14 years of compliance experience in the capital markets. His extensive compliance experience span across various businesses such as corporate banking and investment banking including corporate finance, ECM, loan syndication and global markets business.

    Siu Wai began his career in the financial industry at the Singapore Exchange, where he was involved in regulatory work relating to pre-listing and post-listing on the exchange.

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    Haritha Malsani is an experienced Technical Architect with 9 years in IT industry with exposure to various technologies like Salesforce, Java and Javascript. Her journey as a developer started with a project in Canada in banking domain. From then on, her working skills spanned across different verticals like such as Retail and Health Insurance. She possesses international experience leveraging solution through Sales Cloud, Service Cloud, and Force. During her working tenure with different companies globally, she was recognized for outstanding performance and for her innovative skills in bringing the solution in fast paced environment with a big picture in mind.

    She is a Salesforce certified professional. She is extremely passionate about learning new technologies. He has a proven track record in building large and innovative IT systems for government, healthcare and fintech customers.