Letters
while in-person only was commonly selected by PGY-2 and 4. National Resident Matching Program. Virtual experience and holistic
PGY-3 residents (41% and 36%) (Table 2). Results were not
markedly different between USMGs and IMGs or between
males and females.
Discussion | Only 3% of respondents preferred virtual-only re-
cruitment, the AAMC recommendation for the current sea-
son. These findings suggest that a virtual-only recruitment pro-
cess compared with in-person recruitment may be a factor in
decisions to apply to and interview with more programs. A
study limitation was the survey lacked data on race and eth-
nicity, geography, or application or interview numbers. The
findings support the development of new recruitment ap-
proaches that better balance equity, costs, and convenience;
control application inflation; and allow for opportunities to visit
programs.
Alec B. O’Connor, MD, MPH
Kelly McGarry, MD
Kathleen M. Finn, MD, MPhil
Linda Harris, AAS
Aimee K. Zaas, MD, MHS
Author Affiliations: Department of Medicine, University of Rochester School of
Medicine and Dentistry, Rochester, New York (O’Connor); Department of
Medicine, Alpert Medical School at Brown University, Providence, Rhode Island
(McGarry); Department of Medicine, Tufts Medical Center, Tufts University
School of Medicine, Boston, Massachusetts (Finn); Research and CME
Compliance, American College of Physicians, Philadelphia, Pennsylvania
(Harris); Department of Medicine, Duke University School of Medicine, Durham,
North Carolina (Zaas).
Accepted for Publication: January 21, 2023.
Published Online: April 24, 2023. doi:10.1001/jamainternmed.2023.0281
Corresponding Author: Alec B. O’Connor, MD, MPH, Box MED, HMD, Strong
Memorial Hospital, 601 Elmwood Ave, Rochester, NY 14642 (Alec_oconnor@
urmc.rochester.edu).
Author Contributions: Dr O’Connor and Ms Harris had full access to all of the
data in the study and take responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: O’Connor, McGarry, Finn, Zaas.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: O’Connor, Zaas.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Harris.
Administrative, technical, or material support: O’Connor, McGarry, Harris.
Supervision: O’Connor, Finn, Zaas.
Conflict of Interest Disclosures: None reported.
Data Sharing Statement: See Supplement 2.
Additional Contributions: The American College of Physicians included in the
2021 Internal Medicine In-Training Examination Resident Survey the survey
questions that informed this research. The APDIM Survey and Scholarship
Committee of the Alliance for Academic Internal Medicine provided assistance
with reviewing the survey questions, especially Michael Kisielewski, MA,
assistant director of Surveys and Research. These groups received no financial
compensation for their contributions.
1. Labiner HE, Anderson CE, Maloney Patel N. Virtual recruitment in surgical
residency programs. Curr Surg Rep. 2021;9(11):25. doi:10.1007/
s40137-021-00302-9
2. Simmons RP, Ortiz J, Kisielewski M, Zaas A, Finn KM. Virtual recruitment:
experiences and perspectives of internal medicine program directors. Am J Med.
2022;135(2):258-263.e1. doi:10.1016/j.amjmed.2021.10.017
3. Association of American Medical Colleges. Electronic Residency Application
Service. Accessed December 27, 2022. https://www.aamc.org/media/39376/
download
jamainternalmedicine.com
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review in the transition to residency: an examination of the 2021 and 2022
main residency matches. Accessed October 31, 2022. https://www.nrmp.org/
wp-content/uploads/2022/07/2022-Virtual-Exper-Research-
Brief_Final.pdf
5. Association of American Medical Colleges. AAMC interview guidance for the
2022-2023 residency cycle. Accessed October 31, 2022. https://www.aamc.
org/about-us/mission-areas/medical-education/aamc-interview-guidance-
2022-2023-residency-cycle
6. Alliance for Academic Internal Medicine. AAIM guidance for virtual residency
interviewing. Accessed October 31, 2022. https://www.im.org/resources/ume-
gme-program-resources/guidance-virtual-interviewing
HEALTH CARE POLICY AND LAW
Private Equity Acquisition of Oncology Clinics
in the US From 2003 to 2022
Over the past 2 decades, private equity (PE) firms have be-
come increasingly involved in the acquisition of health care
practices across the US, particularly in oncology.1,2 These PE
firms use capital from institutional funds and investors to cre-
ate or invest in so-called plat-
form companies, then seek fi-
Editorial page 511
nancial returns by acquiring
practices, opening new clin-
Supplemental content
ics, reducing costs, and in-
creasing revenues.3 Although
this approach may enable operational efficiencies, critics point
to potential conflicts of interest and the implications for the
accessibility and affordability of care.4
To date, PE-backed investments around oncology clinics
have not been well characterized. We used a systematic and
reproducible method to characterize PE-backed acquisitions
of medical and radiation oncology clinics in the US.
Methods | In this cross-sectional study, using financial data-
bases and publicly available data (including press releases,
news sources, clinic websites, and financial 10-K reports), we
screened for PE-backed transactions involving medical and ra-
diation oncology clinics from 2003 to 2022. The PE-backed
transactions were defined as any financial investment, includ-
ing partnership, recapitalization, and direct acquisition of clin-
ics. Detailed search methods are provided in eMethods in
Supplement 1. We used the Medicare Care Compare Database
to approximate the total number and location of oncology clin-
ics as well as practicing medical and radiation oncologists dur-
ing the study period.5,6 This study followed the STROBE re-
porting guideline. Institutional review board approval was not
sought per the Common Rule (45 CFR §46) because of the use
of publicly available data.
Our final database included PE-backed platform compa-
nies and each oncology clinic acquired, as well as acquisition
date, practice location, type of oncology service, and number
of affiliated oncologists. ArcGIS (Esri) was used to map clinic
locations and the proportion of PE-affiliated oncology clinics
per state. GraphPad Prism version 8.0 (Dotmatics) was used
to generate charts.
Results | During 2003 to 2022, 724 oncology clinics (53% ra-
diation, 32% medical, 15% multi-oncologic) became affili-
(Reprinted) JAMA Internal Medicine June 2023 Volume 183, Number 6 621
 Letters

Figure 1. Cumulative Private Equity (PE)-backed Transactions and Clinics Gaining First-time PE Affiliation

1200 1200
1100
1000 1000
Transactions involving clinics, No.

900
800 800
PE-backed transactions
700

Clinics, No.
600 600
500
400 400
Clinics gaining PE affiliation
300
The separation between the 2 curves
200 200
suggests that some clinics underwent
100 multiple PE-backed transactions and
0 0 ownership changes after initially
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 gaining PE affiliation, due largely to
Year consolidation between PE-backed
platform companies.

Figure 2. Geographic Distribution of Oncology Clinics and Platform Companies Involved

in PE-backed Transactions

A Types of oncology clinics gaining PE affiliation Clinic type

Medical oncology
Radiation oncology
Multi-oncologic
Proportion of total clinics
affiliated with private equity
>25% to 30%
>20% to 25%
>15% to 20%
>10% to 15%
>5% to 10%
0% to 5%
A. Geographic location of all oncology
clinics involved in a PE-backed
transaction from January 2003 to
June 2022. Each color-coded circle
indicates an individual clinic. States
are shaded based on the proportion
of total oncology clinics in that state
B Geographic distribution of PE-backed platform companies and associated clinics Platform company that are affiliated with PE firms.
GenesisCare B, Geographic footprint of oncology
OneOncology clinics acquired by PE-backed
US Oncologya platform companies as of June 2022.
Vantage Oncologyb
Each color-coded circle indicates an
Integrated Oncology
Network individual clinic. The map excludes de
The Oncology Institute novo clinic expansion and does not
of Hope and Innovation represent the full geographic
Akumin footprint of each platform company
Solaris today. Certain clinic locations no
WellMed
longer appear due to the platform
Envision
United Urology
company terminating operations or
Duly Health and Care selling the clinic to a non-PE entity.
Verdi a
US Oncology prior to their
PinnacleHealth acquisitions by McKesson, a public
company.
b
Vantage Oncology prior to their
acquisitions by McKesson, a public
company.

ated with a PE-backed platform company (Figure 1), consti- acquisition, constituting an estimated 10% (1318 of 13 531) of
tuting 10% of an estimated 6919 oncology clinic locations in practicing medical oncologists and 15% (742 of 4886) of
the US. At least 2060 oncologists (64% medical, 36% radia- radiation oncologists. 5,6 Thirty-three percent of clinics
tion) were affiliated with clinics at the time of initial PE underwent multiple changes in PE ownership, with a total

622 JAMA Internal Medicine June 2023 Volume 183, Number 6 (Reprinted) jamainternalmedicine.com

© 2023 American Medical Association. All rights reserved.

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of 1074 PE-backed transactions occurring during the study
period.
We loc ated 715 of 724 (99%) PE-affiliated clinics
(Figure 2). The PE-backed transactions spanned 45 states,
with many in Florida (19%) and California (16%). The
PE-affiliated clinics accounted for more than 20% of all
oncology clinics in 7 states, including Tennessee (28%),
Florida (27%), and Nevada (26%).
We identified 23 PE-backed platform companies, of which
10 were acquired by another PE-backed entity or public com-
pany. Many platform companies had a regional focus and ex-
panded their geographic footprint through acquisitions in areas
with little competition.
Discussion | There has been a marked increase in PE acquisi-
tion and consolidation of oncology practices over the past 2
decades. Similarly, PE-backed platform companies have un-
dergone substantial consolidation through mergers and ac-
quisitions. The number of medical and radiation oncologists
identified at PE-affiliated practices was estimated to consti-
tute 10% to 15% of practicing oncologists in the US. Given that
we focused only on clinics involved in PE-backed trans-
actions and excluded clinics that were newly opened, our
results likely underestimate the true total footprint of
PE-backed involvement in oncology clinics.
Involvement of PE in oncology should continue to be
evaluated to determine implications on patient outcomes
and health care costs. As increasing consolidation continues
to affect the landscape of independent oncology practices,
patients may face additional barriers to both accessibility
and affordability of care.
Kevin Tyan, BA
Miranda B. Lam, MD, MBA
Michael Milligan, MD, MBA
Author Affiliations: Harvard Medical School, Boston, Massachusetts (Tyan,
Milligan); Harvard Business School, Boston, Massachusetts (Tyan); Department
of Radiation Oncology, Dana-Farber Cancer Institute, Brigham & Women’s
Hospital, Boston, Massachusetts (Lam, Milligan).
Accepted for Publication: January 31, 2023.
Published Online: May 1, 2023. doi:10.1001/jamainternmed.2023.0334
Corresponding Author: Kevin Tyan, BA, Harvard Medical School, 25 Shattuck
St, Boston, MA 02115 (kevin_tyan@hms.harvard.edu).
Author Contributions: Mr Tyan and Dr Milligan had full access to all the data in
the study and take responsibility for the integrity of the data and the accuracy
of the data analysis.
Concept and design: Tyan, Milligan.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Tyan.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Tyan, Milligan.
Supervision: Lam, Milligan.
Conflict of Interest Disclosures: Mr Tyan reported receiving personal fees from
Blackstone Life Sciences consulting role outside the submitted work. No other
disclosures were reported.
Data Sharing Statement: See Supplement 2.
1. Miner M, Kickirillo VM. Oncology on the rise: private equity investment in
cancer care. VMG Health. Accessed July 10, 2019, 2019. https://vmghealth.com/
thought-leadership/blog/oncology-on-the-rise-private-equity-investment-in-
cancer-care/
jamainternalmedicine.com
© 2023 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ by a University of Arizona Health Sciences Library User on 07/27/2023
Letters
2. Nelson R. Consolidation in US health care negatively impacts cancer care.
Lancet Oncol. 2022;23(11):1358-1359. doi:10.1016/S1470-2045(22)00598-8
3. Tan S, Seiger K, Renehan P, Mostaghimi A. Trends in private equity
acquisition of dermatology practices in the United States. JAMA Dermatol.
2019;155(9):1013-1021. doi:10.1001/jamadermatol.2019.1634
4. Singh Y, Song Z, Polsky D, Bruch JD, Zhu JM. Association of private equity
acquisition of physician practices with changes in health care spending and
utilization. JAMA Health Forum. 2022;3(9):e222886-e222886. doi:10.1001/
jamahealthforum.2022.2886
5. The Centers for Medicare & Medicaid Services. Doctors and clinicians data
archive 2022. https://data.cms.gov/provider-data/archived-data/doctors-
clinicians
6. Milligan M, Hansen M, Kim DW, Orav EJ, Figueroa JF, Lam MB. Practice
consolidation among U.S. radiation oncologists over time. Int J Radiat Oncol Biol
Phys. 2021;111(3):610-618. doi:10.1016/j.ijrobp.2021.06.009
COMMENT & RESPONSE
Recommending Higher Valent Pneumococcal
Conjugate Vaccine for Older Adults
To the Editor The recent study by Kobayashi and colleagues1 on
the effectiveness of 13-valent pneumococcal conjugate vac-
cine (PCV13) in preventing all-cause pneumonia hospitaliza-
tions in older adults supports broader use of higher valent PCVs
in this age group. Despite widespread use of PCV13 in child-
hood vaccination programs, there is still a burden of pneumo-
coccal disease among older adults that is worth preventing.
However, missing from the study is the idea that much of this
burden occurs in persons who have been recently discharged
from hospitals.
The rationale for hospital-based pneumococcal (and in-
fluenza) vaccination is unmistakable,2-4 yet it has not been
mentioned in the recommendations of the Advisory Commit-
tee on Immunization Practices.5 Now that PCV15 and PCV20
are available, it would be helpful to highlight this sensible idea
in all recommendations for pneumococcal vaccination.
David S. Fedson, MD
Author Affiliation: Retired, Sergy Haut, Ain, France..
Corresponding Author: David S. Fedson, MD, 57 Chemin du Lavoir, Sergy Haut,
Ain 01630, France (davidsfedson@gmail.com).
Published Online: April 10, 2023. doi:10.1001/jamainternmed.2023.0548
Conflict of Interest Disclosures: None reported.
1. Kobayashi M, Spiller MW, Wu X, et al. Association of pneumococcal conjugate
vaccine use with hospitalized pneumonia in Medicare beneficiaries 65 years or
older with and without medical conditions, 2014 to 2017. JAMA Intern Med.
2023;183(1):40-47. doi:10.1001/jamainternmed.2022.5472
2. Fedson DS, Baldwin JA. Previous hospital care as a risk factor for pneumonia:
implications for immunization with pneumococcal vaccine. JAMA. 1982;248
(16):1989-1995. doi:10.1001/jama.1982.03330160037022
3. Fedson DS, Houck P, Bratzler D. Hospital-based influenza and pneumococcal
vaccination: Sutton’s Law applied to prevention. Infect Control Hosp Epidemiol.
2000;21(11):692-699. doi:10.1086/501716
4. Fedson DS. PCV13 vaccination for older adults: another view. Vaccine. 2016;34
(38):4466. doi:10.1016/j.vaccine.2016.03.102
5. Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-valent pneumococcal
conjugate vaccine and 20-valent pneumococcal conjugate vaccine among U.S.
adults: updated recommendations of the Advisory Committee on Immunization
Practices—United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(4):109-117.
doi:10.15585/mmwr.mm7104a1
(Reprinted) JAMA Internal Medicine June 2023 Volume 183, Number 6 623