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Comment by vkou | Hacker News Reader

No, you've completely misdiagnosed why PE is involved.

It is involved because there is slack on the system in the form of downtime, and it figured out that if it just buys up all the doctor's offices, makes the doctors rush through the cases, and keeps them busy seeing patients every working minute, the practice and it's owners will make way more money.

Quality of care will decline, but unless the doctor is actively doing surgery, or something else risky, whatever money they lose due to the decline in quality will be more than offset by grinding through patients quicker.

It's almost impossible to sue a doctor for malpractice in Texas, yet the exact same problem with PE is happening there, too.

Vets are another example where this is happening - and again, it's not because of frequent $XYZ,000 malpractice settlements. Anything that's not billable hours seeing patients is considered to be damage by the system, and capitalism tries to route around it.

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>It is involved because there is slack on the system in the form of downtime, and it figured out that if it just buys up all the doctor's offices, makes the doctors rush through the cases, and keeps them busy seeing patients every working minute, the practice and it's owners will make way more money.

This doesn't explain why doctors are selling though. Why aren't doctors just not selling their practices and taking a more relaxing job running things themselves? Why are they choosing the option that requires them to "rush through the cases, and [keep] busy seeing patients every working minute"? Surely if that was something they enjoyed doing, they could do that and capture all the "slack" for themselves? So why sell your office to someone else to capture all that slack while your own work load increases?

> This doesn't explain why doctors are selling though

Retiring doctors are selling because this lets them cash out their practice for way more than they'd otherwise get for closing it and auctioning off the equipment.

> Why aren't doctors just not selling their practices and taking a more relaxing job running things themselves?

The ones that are selling are the ones exiting the rat race, the downsides aren't affecting them.

So why aren't new doctors opening their own practices? What has changed in the last 20/30/40 years that are leading up and coming doctors to choose working for someone else instead of opening their own practice?

I think they will over time if PE deals start to implode or reveal themselves to be as bad as people claim. But the reaction will take a while to happen.

With partnership-based models, it's not necessarily the case that most of the doctors who owned their practices were necessarily that entrepreneurial. Many probably joined the practice and then became partners after a few years with buy-in and sweat equity. There's some risk and business management involved, but not the same as really doing your own thing. The path was laid out. (Kind of like lawyers at big law firms.)

The real entrepreneurs were the ones who initially founded a practice from scratch. But for some specialties where PE has taken hold, you need a group of people with enough capital to do that, negotiate contracts with hospitals for admitting privileges, wait-out a non-compete from a prior practice, etc. That takes time, and meanwhile, the net share of PE held firms may still increase for a while as other firms continue to sell out.

Possibly medical school debt.

And of course nobody has sympathy for doctors with student loan debt, but the debt may still have important effects on the economy down the line.

Because the ROI dropped precipitously. Governments were paying much better, insurance companies were paying much better, liability was a lot less, documentation and paperwork was a lot less.

The 80s to 00s doctor years were very good. Now the power is in the hands of the government and huge insurance companies, and to compete with them, you need to be part of a large healthcare provider group, which ends up happening as an employee.

Plus medical school debt and increasing years to become fully practicing like having to do longer residencies and fellowships.

> So why aren't new doctors opening their own practices?

For the same reason that nobody builds out a second set of power lines to compete with an incumbent power utility.

It's capital-intensive, the size of the medical market for the area is fixed, and you'll just be fighting the established practice for it in a zero-sum game.

You can win, but it's going to be way more work for less reward than just finding a PE practice that's hiring/a traditional practice with spare space that's looking for a partner.

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