Table 2.

Revenue Generation and its effects on quality (Q), access (A) and cost (C) with respect to patient care

Cited Example(s)	Setting	Effect on Patient Care (Q, A, C)	Comments
Dermatologists see a larger volume of patients in PE owned clinics. No changes were seen in the volume of procedures [18].	Dermatology Clinic	Leads to less time spent per patient visit to address patient concerns adequately (Q).	1) This study has been critiqued that the modest effects seen is because it did not capture a major wave of dermatology acquisitions beginning in 2017. 2) This study also does not include elderly patients from Medicare and Medicare Advantage patients, which accounts for a large percentage of the procedures.
PE firms provide care by hiring physician extenders to work in unsupervised settings to generate additional revenue [22].	Dermatology Clinic	This often leads to performing procedures that are expensive and unnecessary, and leading to complications. (C, Q)	One firm in this study performed intralesional injections and skin biopsies in nursing homes, where 75% of the patients had Alzheimer’s disease.
PE owned dermatology clinics have seen an increase in kickbacks, self-referrals and aggressive coding of procedures [21, 22].	Dermatology Clinic	Leads to overutilization of procedures (C). Dermatologists also make less than optimal referrals in response to patient needs. (Q)	Many instances of violating the Stark Law and the Antikickback Statute are noted in the study [22].
1) Some ophthalmologists report concern of performing more procedures, while physician extenders and optometrists provide eye care in the clinic [23]. 2) Other ophthalmologists stated no change to their practice under PE management.	Ophthalmology Clinic	It can lead to inadequately trained optometrists and physician extenders providing eye care.  (Q)	The results are mixed in this study and more studies are needed to determine the effects of PE in ophthalmology.
1) Some behavioral specialists in PE have noted a change in the patient base that is more favorable for reimbursement (i.e., young insured patients using opioids vs. older patients with alcoholism paying with cash 2) PE marketing brings a surplus of eating disorder beds and pressure to fill these beds [34].	Behavioral Health Clinic	There maybe a deliberate preference for insured patients and provide less access for addiction care among those that are uninsured. (A)	More studies are needed to demonstrate the effects of PE on behavioral health.
PE owned hospitals have demonstrated higher operating margins, increased charge/cost ratios and a decrease in Medicare share of patients [14,16, 17].	Hospital	1) This suggests operational changes that ensure higher payouts by insurers (C) and a preference for privately insured patients (A). 2) These studies also demonstrate cost-cutting measures by limiting staff growth despite higher reimbursements (Q).
PE owned hospitals add more profitable service lines (I.e. interventional cardiology, digital mammography) while discontinuing less profitable ones (I.e., psychiatric care) [25].	Hospital	This study demonstrates restricting access to certain crucial services (A), while charging higher prices for the more profitable service lines (C).	This is the first study demonstrating preferential service lines by PE firms in the hospital setting.