By Keith Abell, RPh MI cMTM cWHC cVP
I want to start in a graveyard.
Not as a metaphor. Literally. I was walking through one of the famous old cemeteries in New Orleans, the kind with stone mausoleums stacked like little houses for the dead, running my fingers across names carved into marble. And I kept asking myself the same question Les Brown has been asking for years:
How many of these people died with their dreams still inside them?
How many books never got written? How many conversations never happened? How many patients never got the care they actually needed, not because the knowledge didn't exist, but because the system had other priorities by the time they arrived?
That last one is the one I want to talk about today.
Because I am a pharmacist. Thirty-one years behind the counter. And what I have watched happen to this profession, and to medicine broadly, is not an accident. It is the predictable result of what happens when the wrong incentive becomes the primary incentive.
Is Your Hospital Owned by Someone Trying to Double Their Money in Seven Years?
There is a greater than one in ten chance that it is.
If you live in Kentucky, your odds are one in six. In New Mexico, more than one in three.
Walk into an emergency room tonight. There is a forty percent chance the physician who treats you does not work for the hospital at all. He or she works for a staffing company owned by private investors.
Private equity firms invest money on behalf of pension funds, universities, sovereign wealth funds, and wealthy individuals. They buy healthcare providers with one expectation: a better return than the stock market, typically within seven years.
Now. Let me tell you the rest of the story.
How Does Private Equity Actually Make Money in Healthcare?
Three ways. And each one matters.
The first is debt loading.
When a private equity firm acquires a hospital or physician practice, they finance the deal mostly with borrowed money, often putting in only ten to forty percent of the purchase price themselves. The rest comes from lenders. But here is the part that surprises most people: the borrower is not the investor. The borrower is the hospital. The institution takes on the debt used to purchase itself, and then must service that debt while also paying management fees to the equity firm.
A 2025 study of more than two hundred hospitals found that those resold to another private equity group saw operating margins decrease more than eight percent compared to those sold to other for-profit owners. The debt does not always leave. It compounds.
The second is asset stripping.
One common tactic is the sale-leaseback transaction. The firm sells the hospital's real estate to a real estate investment trust, then leases it back. The hospital loses ownership of its own building and pays rent indefinitely. On a spreadsheet it looks like a capital infusion. In practice, hospitals that sold their real estate this way were approximately six times more likely to close or file for bankruptcy than other hospitals, according to a 2025 study.
Critics noted that in the Steward Health Care collapse, thirty-one hospitals, the largest private hospital bankruptcy in American history, this exact tactic had been used before the chain was sold and eventually failed in 2024.
The third is staff reduction.
After private equity acquisition, provider staffing was reduced by six percent over four years and remained there long-term. Support staffing was cut an overall twenty percent. That saved roughly seven percent in wage costs in the first four years, and up to nine percent after eight years.
The doctors, nurses, and care providers eventually bounced back in number. The people who checked you in, handled your billing, scheduled your follow-up, and answered the phone when you had a question, they did not.
What Does That Look Like from the Patient's Side of the Billing Statement?
I can tell you from personal experience.
In June I had outpatient surgery. I was there a few hours. The physician and the anesthesiologist billed separately, that is its own conversation. But my hospital bill alone came back at approximately four hundred thousand dollars.
Insurance ultimately paid approximately ninety-five thousand dollars.
The same procedure at a freestanding outpatient surgery center: approximately eleven thousand dollars.
I am not naming the hospital. What I will tell you is this: when I finally received that bill, months later, I called to ask why it had taken so long. The billing department had been consolidated. One location, handling billing for hospitals across the entire state. Their own staff acknowledged they did not have enough people to process the volume.
Consolidation looked efficient on a spreadsheet. In the real world, it meant patients waited months for bills they could not understand, billing errors they could not easily dispute, and phone lines that rang without answer.
This is what efficiency looks like when the measure is cost reduction rather than patient experience.
Was Healthcare Already Broken Before Private Equity Arrived?
Yes. And that is the most uncomfortable part of this conversation.
Physician burnout existed before private equity became a major hospital investor. Consolidation was already underway. Reimbursement pressure was already squeezing margins. Physicians were already seeing more patients per hour. Hospitals were already closing in rural communities.
So the honest question is not simply: is private equity bad for healthcare?
The honest question is: if the patient is already sick, do you help heal it, or do you extract what value remains?
Critics would argue that in too many cases the answer has been the latter. When a hospital is already operating on a one to three percent margin, adding debt, selling real estate, paying management fees, and demanding investor returns does not stabilize a fragile institution. It can accelerate its decline.
The Steward bankruptcy is instructive because neither side disputes that many of those hospitals were struggling before acquisition. The disagreement is whether private ownership improved the situation or simply extended it long enough to generate a return before the collapse.
When a retailer fails, consumers shop elsewhere.
When a community hospital fails, emergency travel times increase. Specialist access disappears. Jobs leave. The only place within forty miles to deliver a baby closes. That is a different category of consequence entirely.
Is the Art of Medicine Dying, or Just Being Managed Out of Existence?
Medicine has always had two dimensions.
The science: diagnoses, protocols, medications, procedures, evidence-based guidelines.
The art: listening, judgment, context, the extra question, noticing something that does not fit, understanding the person behind the symptom.
When you compress appointments, cut support staff, and reward throughput over outcomes, you do not simply lose efficiency. You lose the second dimension. The encounter becomes transactional. Instead of: tell me what has been going on, it becomes: let us get through today's checklist.
More than four in ten physicians reported symptoms of burnout in 2025, according to the American Medical Association. One reason cited repeatedly is the pace: physicians who once saw four or five patients per hour are now seeing seven. The extra paperwork gets done after hours. The clinical judgment, the part they spent a decade in training to develop, gets compressed into the margins.
As one anesthesiologist with more than twenty years in practice put it: they are not in the business of providing the best medicine. They are in the business of providing good-enough medicine for the largest number of people.
I have watched this from the pharmacy side for thirty-one years. The pharmacist who has time to counsel is worth more to a patient than a prescription dispensed in four minutes. But the metric that gets measured is the four minutes. The counseling is invisible on a productivity report.
Physicians feel it. Nurses feel it. Pharmacists feel it. The professionals who entered healthcare to use their cognitive abilities to care for patients now spend a significant portion of every shift satisfying administrative, financial, and documentation requirements designed by people who have never sat across from a frightened patient.
Who Is Actually Making the Rules in American Healthcare?
Three forces are shaping the system, and the patient and the practitioner are not among them.
Big insurance determines what gets covered, how long a patient can stay, and what a physician is permitted to prescribe.
Big Pharma has spent decades cultivating a culture in which the pharmaceutical intervention is the default answer to every clinical question, not lifestyle, not nutrition, not the root cause, but the prescription. I spent thirty-one years dispensing medications for conditions that, in many cases, had nutritional deficiency at their foundation. That is not something I learned in pharmacy school. I had to go looking for it.
Private equity brings a seven-year investment horizon to institutions that communities may need for fifty years.
The patient and the clinician, the two people actually sitting in the examination room, have the least power in that equation.
What I hear from colleagues across every discipline is not that profit is wrong. Healthcare organizations have to be financially sustainable. The concern is a simpler one:
Profit should support patient care. It should not define it.
When financial performance becomes the primary metric, the things that are hardest to measure, trust, continuity, clinical judgment, time spent listening, get squeezed out. Not because anyone decided they did not matter. But because they do not show up neatly on a financial statement.
What Are Practitioners Actually Doing About It?
Something interesting is happening.
Physicians are building concierge and direct primary care practices. Pharmacists are moving into consulting, functional medicine, deprescribing coaching, and wellness education. Nurses are creating independent education and coaching businesses. Clinicians are appearing on LinkedIn, Substack, podcasts, and YouTube, building audiences directly, outside the system that once defined their reach.
This is often described as entrepreneurship. Sometimes it is. But often it is something more fundamental than that.
It is practitioners trying to reclaim ownership of their professional judgment.
The irony is not lost on me: the more healthcare becomes dominated by investors, insurers, PBMs, and large health systems, the more practitioners seek paths where they can spend time with patients, exercise independent judgment, and be compensated for expertise rather than volume. The system may be creating its own competition.
I built an AI brain clone. After thirty-one years behind the counter, after long COVID stopped me long enough to ask the question I had been avoiding, I decided to capture what I know, my clinical reasoning, my way of explaining complex things in plain language, and build a system that works beyond my shift. It publishes. It educates. It reaches people I will never meet in a pharmacy.
The knowledge does not have to retire when I do.
That system lives at PharmacyAIAcademy.com. The free Brain Clone training is there. If you are a healthcare professional who wants to see what it looks like to use what you know to reach more people than a single shift allows, that is where I would start.
And Now, the Rest of the Story
The graveyard I walked through in New Orleans is full of names on marble.
Some of those people died with their dreams inside them. But some of them, the ones who ended up in that graveyard before their time, may have had a different story. A story about a hospital that was not there when they needed it. A pharmacist who was too rushed to catch what needed catching. A physician who had seven minutes and needed twenty.
That is the real cost of profit over patient care.
Not the debt on a balance sheet. Not the management fees. Not the asset sales.
The real cost is measured in the gap between the care that was possible and the care that was delivered, and in the practitioners who burned out before they could give everything they had been trained to give.
Some of us are choosing a different ending to that story.
The question is whether the system will change fast enough to make that a choice everyone can make, or whether the people with the big money will keep writing the rules while the patient and the practitioner sit in the examination room, doing the best they can with what they have left.
If you are a healthcare professional who feels the art of medicine slipping away and you want to use what you know to reach more people than a single shift allows, the free Brain Clone training at PharmacyAIAcademy.com is where that conversation starts.
Keith Abell, RPh MI cMTM cWHC cVP
Pharmacist | Wellness Educator | PharmacyAIAcademy.com