Mirroring broader trends in health care, urology practices have undergone substantial consolidation over the past several decades.¹ The latest trend in practice consolidation has been the development of private equity (PE)-backed urology platforms, which differ from prior consolidations in their scale and market power.² Although there is no singular strategy, PE firms have historically used capital raised from institutional investors to institute “buy-and-build” strategies, partnering with a large regional practice to form a platform and subsequently build market influence through acquisition of smaller practices. Since 2016, PE-backed platforms have achieved significant regional and national market power, with some platforms achieving over a quarter of the urology workforce share within some states and others spanning multiple noncontiguous states.² As of June 2022, 6 PE-affiliated platforms have developed across 16 states (see Figure).³ Recently, the first urology platform sale occurred in January 2022 with the sale of a large urology practice to a multispecialty group.⁴ It remains to be seen how other PE firms will “exit” the urology space over the next few years, but already, PE investments are beginning to make an imprint on the practice of urology.

Figure 1. Geographic distribution of PE urology platforms in 2022.

Changes to the consolidation landscape raise questions about how PE’s growth in urology could impact how care is delivered. Specifically, does PE acquisition lead to increasing patient volume and health care expenditure? Using publicly available Medicare data, we sought to examine changes to patient volume and revenue following PE acquisition as well as the impact on urologists not affiliated with PE-acquired practices within the same states.⁵ We found that following PE acquisition, there was the suggestion of increasing inflation-adjusted Medicare payments (11.0%, 95% CI: −0.2%–22.3%; p=0.054) and a significant 12.5% increase in patient volume (95% CI: 6.5%–18.6%; p <0.001). In comparison, geographically similar non-PE-affiliated urologists experienced a 6.0% decline in inflation-adjusted Medicare payments (95% CI: 2.8%–9.2%; p <0.001) and a 2.7% increase in patient volume (95% CI: 0.4%–4.9%; p=0.02) within the same time period.

Interestingly, we found that patterns were diverging between practices that were acquired by PE platforms in the years before consolidation occurred. Urologists in practices acquired by PE had increasing Medicare payments preceding acquisition, while non-PE urologists declined slowly over time. With respect to volume, PE-affiliated urologists had higher Medicare patient volume and exhibited greater volume growth, with the gap widening between PE and non-PE urologists across the study period. Importantly, the observation that changes predated PE affiliation indicates that we cannot necessarily attribute their existence to acquisition but might provide insights into performance leading up to acquisition.

Inroads into urology by PE may also impact economically vulnerable patients, particularly Medicaid-insured individuals.⁶ To assess how urological care access differs between PE-affiliated and non-PE-affiliated practices, our team performed an appointment audit study to learn about availability for a simulated patient with hematuria seeking care.⁷ We found that PE-affiliated practices had significantly lower Medicaid appointment availability than non-PE affiliated practices (52.1% vs 66.8%, p=0.003). Although we did not find differences in appointment wait times for the insurance types, we did find that PE-affiliated offices offered shorter mean wait times than non-PE-affiliated offices (17.5 vs 21.4 days, p=0.017). In a multivariable model, state Medicaid expansion status (Medicaid expansion versus Medicaid nonexpansion: OR 2.20; CI 1.14–4.28; p=0.020) and PE affiliation (OR 0.55; CI 0.37–0.83; p=0.004) were associated with Medicaid access. Because we could not assess patient access rates prior to PE investment, these differences cannot be attributed to the impact of PE investment but nonetheless do provide a contemporary estimate of access.

With the availability of capital and opportunities to consolidate in new markets, PE acquisition of urology practices is likely to continue. Looking ahead, some of most urgent questions will be the larger impact on health care quality. Evidence outside of urology appears to show mixed results.^8,9 However, there is also enormous and yet unmet potential for innovation and optimization.⁹ Lastly, as PE firms begin to exit the urology space, there are ongoing opportunities to examine employment opportunities, physician autonomy and access.