Other People’s Money and the Rise of Private Equity in Dermatology, Part 1: Behind the Buyout

A close friend and dermatologist colleague spent 25 years building her business from a solo-provider practice into a successful 5-provider clinic with a loyal patient base and a 3-room surgical suite for her Mohs surgeon. Nothing was given to her, and it wasn’t easy; she did it the old-fashioned way, one referral at a time, one lease negotiation at a time, one staff hire at a time. Over her career, she missed weddings, funerals, and family reunions, always busy, always taking care of her patients and employees. She called me unexpectedly, less than a year ago, to discuss my thoughts about an unexpected phone call she received from someone in a city she had never visited, representing a firm she’d never heard of, offering to buy her life’s work for a number beyond anything she’d ever expected. She didn’t fully understand the offer, but neither did she have a buyer ready to take over the practice when she retires in 3 years. She took the meeting.

Two time zones away, a physician associate (PA) 3 years into his career at a private equity (PE)-backed group is seeing 34 patients a day in a practice that changed hands last year when the platform recapitalized. He didn’t understand the change, only that his manager told him, “Nothing is going to change! Don’t worry, we’ve got you!” True enough, his compensation formula stayed the same on paper; the overhead allocation within the practice did not. His take-home pay dropped, his wife and family began to stress over money, and the physician who originally recruited him was long gone.

Lastly, a young dermatologist finishing fellowship is staring at a job market where a growing share of available positions are affiliated with PE-backed groups,¹ while 65% of her fellow residents say they aren’t willing to work for such a practice.²

Three separate providers. Three very different career stages. One financial model connecting all of them. Most clinicians have strong opinions about this model, for better or worse; yet, very few can explain what PE is or how it truly works.

This column is the explanation.

So, What Is Private Equity, Actually?

PE is not a corporation. It is not a hospital system. It is not an insurance company. It is a fund.³

A PE fund pools capital from institutional investors: pension funds, university endowments, insurance companies, sovereign wealth funds, and accredited individuals. Those investors are called limited partners. They write the checks but make no decisions in the day-to-day management of the fund’s operations. The firm managing the fund maintains its position as the general partner, and the general partner has total control over where the money goes, how it is utilized, and how the fund’s investments are managed.³ Each fund has a predetermined life span, typically 10 years, when proceeds are due back to the limited partners. Within that window, the general partner must deploy the capital, grow the investment, and return it to the limited partners at a profit. That timeline is not optional, but a contractual requirement. Everything in the PE calculus flows from it.

So where does a fund on a 10-year clock put its money? It hunts for businesses with 3 traits: demand that doesn’t vanish in a downturn, revenue that a reliable payer actually pays, and a fragmented market with room to consolidate. Now reread that list. It’s a description of American medicine. Patients don’t stop getting sick when the market drops. Claims get paid by insurers and Medicare, whether the S&P or Dow Jones is up or down. And, even in 2026, the majority of medical practices in the US, dermatology especially, are still owned by the clinicians practicing within them, one small to medium practice at a time. That’s why private equity found medicine, and why, sooner or later, a fund shows up at a practice owner’s front door carrying an offer too good to be true, offering a financial windfall before retirement.

When a PE firm evaluates a practice, the entire conversation runs through 1 number: EBITDA, earnings before interest, taxes, depreciation, and amortization. In plain English, it’s what the practice earns before the accounting adjustments. The purchase price is expressed as a multiple of that number. A dermatology practice generating $2 million in EBITDA, purchased at a 7 times multiple, sells for $14 million.⁴ Nobody taught any of us that math in training, yet it drives the entire deal. As Jonathan Banta, CEO of The 44 Group Healthcare Consulting Services, puts it, “nearly every acquisition ultimately relies on a financial model that applies an EBITDA-based valuation methodology to determine the economics presented in the initial term sheet.” Banta advises physician-owned practices and private equity–backed platforms on transactions, operations, and growth. He works to align physicians and investors, driving organic growth and leading acquisition and roll-up transactions. So, as he emphasizes, the objective from the moment of acquisition is simple: Grow that EBITDA, grow the platform, and sell the entire enterprise at a higher multiple to the next buyer, typically within 3 to 7 years.

Here’s a detail most clinicians never consider. When OMERS Private Equity, the investment arm of the pension plan for Ontario, Canada’s more than 520,000 municipal employees, acquired Forefront Dermatology in 2016, the capital behind that purchase came from the retirement savings of firefighters, paramedics, and city workers.⁵ Ordinary people’s retirement money is the capital behind your colleague’s buyout. The PE fund’s fiduciary obligation is to those members, not to the dermatologists inside the platform; they are legally beholden to their investors, not the providers, patients or employees who make up the practices they purchase. That is not a criticism. It is the structure. Understanding that structure is the key to understanding everything else.

The Rollup: How the Money Actually Moves

In dermatology, the PE model runs on a concept called the rollup, and the math behind it is simpler than most clinicians assume.

Step 1: A PE firm acquires a large, established practice as the anchor, called the platform. Platform-ready practices, typically those generating $5 million or more in EBITDA, currently command valuations of 10 to 15 times earnings.⁶ Step 2: The platform buys up smaller practices, called add-ons or tuck-ins, at far lower multiples, often 2 to 7 times EBITDA.^6,7 Buy the small practices cheap, fold them into the platform, and every dollar of their earnings is suddenly valued at the platform's higher multiple. That repricing is the arbitrage, and it is the entire business model.

Scale is what makes it work. A bigger group wrings out inefficiency and commands a premium that a solo practice never could. But size alone doesn't earn the top of the range. As Banta, who holds a master of jurisprudence in health care law and risk management from Texas A&M University, puts it, the multiple tracks the fundamentals that a seller controls: quality of earnings, clean coding, revenue-cycle integrity, governance, and payer contracts. The messier the books, the lower the number.

In most states, nonphysicians can’t directly own a medical practice under the corporate practice of medicine doctrine.³ PE works around this through a management services organization, or MSO. The MSO owns the business side: billing, human resources (HR), marketing, information technology (IT), real estate, and operations. A separate physician-owned professional corporation retains clinical control. In theory, the physician runs the medicine and the MSO runs the business. In practice, the MSO controls the budget, staffing, scheduling, and overhead. The practical effect between “administrative support” and “de facto control” is where the friction points between clinicians and the new owners occur, and where Oregon just drew a hard line.⁸

Providers selling rarely receive 100% of the purchase price in cash; PE firms wish to have some control to ensure smooth operations during the transition. Thus, a common structure is for a majority of the price to be paid in cash at closing, typically 70% to 80%, with the remainder rolled into equity in the new platform.⁶ That rollover equity is the mechanism behind the “second bite of the apple.” When the platform recapitalizes 3 to 7 years later, the physician’s rolled equity can multiply. Dramatically.

Let’s postulate a practice sold for $10 million, and $3 million was retained as equity in the new structure. In 5 years, the firm sells the new amalgamated entity, and that “second bite of the apple” of $3 million equity now has a 12 times return; that is $36 million. Some practice owners make more on the recap than the initial sale.⁹ Still, Banta counsels sellers not to bank on it: “There may never be a second bite of the apple, so certainty should always be weighed alongside potential future value.”

One example tells the story better than a textbook. Kenneth Katz, MD, founded Dermatology Associates of Wisconsin in 2001.¹⁰ In 2014, Varsity Healthcare Partners, a PE firm, acquired a majority stake when the practice had roughly 40 clinics across 4 Midwestern states.¹¹ Less than 2 years later, Varsity sold its interest to OMERS Private Equity, the Canadian pension fund; by then, the practice had grown to 82 clinics across 11 states.⁵ In 2022, OMERS was sold to Partners Group, a Swiss-based global private markets firm. The price was, according to sources familiar with the terms of the deal, approximately $1.5 billion, roughly 15 times adjusted EBITDA of more than $90 million, up from the mid-$30 million range when OMERS first invested.¹² Three PE owners in 8 years. The physicians reinvested at each transition. OMERS’ global head called the sale an “excellent outcome for more than 525,000 members of the OMERS pension plan.”⁵ That entity’s physician president, known now as Forefront Dermatology, praised the partnership for “ensuring full physician autonomy at all times.”¹³

That’s one practice. It went from a Wisconsin dermatology group to a $1.5 billion platform in less than 2 decades. The money came from Canadian pensioners, flowed through a Los Angeles PE firm, then a Toronto pension fund, then a Swiss investment house. The dermatologists inside the platform kept practicing and reinvesting and became extremely wealthy. In their eyes, everyone won. That’s how the rollup concept works.

How Did We Get Here?

This isn’t Wall Street’s first attempt at consolidating physician practices. In the 1990s, physician practice management companies tried a similar strategy, significantly overpaying for practices, failing to properly integrate them, and ultimately collapsing.¹⁴ Yet, the concepts that prompted the attempt continued: fragmented specialties, stable demand, aging workforce. PE firms learned from this failure and returned armed with a better playbook. Let’s call it PE 2.0.

The modern era began approximately in 2012.¹⁵ The acquisition pace accelerated rapidly: 5 practices in 2012, 7 in 2013, 13 in 2014, 26 in 2015, 40 in 2016, and 59 by 2017.¹⁶ By mid-2018, 17 PE-backed dermatology management groups had acquired 184 practices comprised of 381 clinics across 30 states, with ongoing acquisitions growing at 65% annually.^16,17

By 2024, more than 35 PE-backed dermatology platforms operated across roughly 20 states, with approximately 85 acquisitions closing in 2023 alone.¹⁸ The phase shifted: Raw acquisition volume declined while mergers between existing platforms and recapitalizations accelerated.⁷ The model was no longer about buying practices; now it was about building greater economies of scale. PE investment in health care overall grew from $5 billion annually in 2000 to an estimated $104 billion by 2024,¹⁹ and dermatology remained one of the busiest outpatient specialties for deal activity.²⁰

OK… but Why Dermatology?

Dermatology wasn’t a random target. It checked every box PE looks for, every box any entrepreneur desires in starting or buying a business.

The dermatology market exceeds $10 billion annually.²¹ Forty percent of practices are solo, 73% have fewer than 5 providers, and the 4 largest groups hold under 2% of the market.³ The specialty is recession-resistant: It grew at 2.1% during the Great Recession while the US’s gross domestic product fell 4.3%.⁹ Skin cancer is the most common cancer in the US, with 1 in 3 American men getting skin cancer.³ Add cosmetic revenue growing at roughly 8.5% annually,²² and the financial profile is difficult for an investor to ignore.

Between 2013 and 2016, dermatologists represented roughly 1% of US physicians but accounted for 9.9% of PE physician practice investments.^15,23 By 2017, 1 in 11 dermatologists was practicing in a PE-owned setting.²⁴ No other specialty attracted this level of disproportionate interest relative to its physician workforce.

Dermatology is also remarkably inexpensive to operate. Unlike specialties such as orthopedics, cardiothoracic surgery, laboratory medicine, or imaging, dermatology carries virtually no high-cost equipment. A $1500 dermatoscope? A $31,000 cryostat? In the world of health care capital expenses, that's pocket change. It's a procedure-rich specialty where low overhead meets high returns, and it carries some of the lowest malpractice risk in medicine. For an investor, that combination is close to ideal as achievable in health care investing.

What PE Does Once It Is Inside

This is where the conversation gets honest, and where it must go in both directions. If you are reading this, odds are you have heard something, likely negative, about PE; the goal here is to be honest, in both directions.

The operational benefits are real. A PE-backed platform can centralize billing, negotiate group purchasing agreements on supplies and devices, build IT infrastructure, deploy compliance frameworks, and handle HR at a scale that is impossible for a small 3-provider practice. Ideally, some of those cost-saving synergies are passed on to employees as incentive bonuses to work harder, or to patients in the form of lower costs. Providers in some PE settings do report reduced administrative burden and more time focused on clinical work.¹⁵ A 2021 Health Affairs study found that dermatologists in PE-backed practices saw 3% to 5% higher commercial reimbursement rates within 18 months of acquisition, with no statistically significant increase in total spending per patient.²⁴ A 2024 update to the largest systematic review of PE in health care noted that “select PE firms perform well across aims, suggesting that management priorities and systems matter.”²⁵ Some positives, some upsides; not all PE is the same. That distinction matters.

The drawbacks are also real, and they are well documented.

PE-backed dermatologists see more patients. The same Health Affairs study found volume increases of 4.7% to 17% per dermatologist in the quarters following acquisition.²⁴ This increase in volume is sometimes balanced by decreases in operational, nonclinical administrative burdens, as previously noted. PE practices also typically employ a higher ratio of advanced practice providers: 4 per 10 dermatologists, compared with 3 per 10 in non-PE settings.²⁴ A 2025 analysis in the Journal of the European Academy of Dermatology and Venereology found that cosmetic work constituted 40% of clinical volume in PE-backed clinics, compared with 20% in non-PE clinics, suggesting that “less clinician resource is being directed to patients with genuine need.”²⁶

The most cited global systematic review, published in The BMJ in 2023, concluded that PE ownership is “often associated with harmful impacts on costs to patients or payers and mixed to harmful impacts on quality,” while also noting “almost exclusively negative impacts on patient satisfaction.”²⁷ A 2024 survey of physicians published in JAMA Internal Medicine found that only 10% viewed PE involvement positively, and that PE-employed physicians were more than 30% less likely to remain with their employer.²⁸

Then there are the cases that made headlines.

In 2017, The New York Times reported that Advanced Dermatology and Cosmetic Surgery, backed by a reported $600 million investment from Harvest Partners, had expanded its PA workforce by 400% since 2008, reaching 124 physician associates alongside 192 physicians.²⁹ The investigation documented PAs working without direct supervision across multiple states, a melanoma missed over serial examinations, and a supervising dermatologist who signed charts for patients he had never seen.²⁹ In Texas, a DermOne location backed by Westwind Investors used a faulty autoclave to sterilize surgical equipment, resulting in 137 patients requiring testing for HIV and hepatitis. Westwind ultimately sold the practice’s records and patient lists and dissolved the remaining offices, ultimately leaving patients without dermatologic care.³⁰

These cases don’t represent every PE-backed practice, nor is the stance of this article (by a doctoral PA no less!) a “hit piece” on the skill sets of advanced practice providers (APPs). Not at all. But these cases highlight what happens when rapid, unrestrained growth, paired with junior, new-to-the-specialty clinicians, can form a “perfect storm” that snowballs out of control. Essentially, they represent what can happen when the financial model’s incentives run ahead of clinical governance. The broader health care data make the tail risk harder to dismiss; in 2023, PE-backed organizations accounted for 21% of all health care bankruptcies, and 93% of the health care companies Moody’s rated as most distressed were PE-owned.^31,32

Here’s Why Your Colleague Sold

It’s easy to judge the physician who sold. It’s harder to sit down and do her math.

Nearly 40% of US physicians are over 50. One in 4 is 65 or older.³³ Over 25% is at or over retirement age. Read that again; 25%. Medicare physician reimbursement has declined 33% since 2001, when adjusted for inflation, while practice operating costs have climbed as much as 39% over the same period.³⁴ This is something, as a practice owner, I can tell you firsthand: Reimbursement is down, costs are up, and employee demands continue to increase. Practice owners are increasingly noting that surgeons, dermatologists, and APPs are demanding higher pay, more paid time off, and grander benefits, all as costs spiral out of control.

One dermatologist practicing within a PE-backed group put it plainly: With “declining reimbursement on the horizon with no fix in sight, it’s important to be part of a larger group that can get cheaper supplies and greater leverage with insurers for higher reimbursement on the commercial end.”¹⁵

Banta, who has sat across the table from many of these sellers, says the first question he asks is the simplest one: Why do you want to sell? The answer, he notes, shapes everything that follows. Traditionally, a practice owner would recruit a junior partner, typically a physician, transition into the practice, then arrange an owner-financed purchase with monthly payments spread out over a predetermined period of years. Unfortunately, those buyers are disappearing.

Sixty-five percent of dermatology residents say they will not work for PE firms, but 43% admit they don’t feel adequately informed about their practice options.² They are rejecting one model without fully understanding their alternatives. Meanwhile, a plurality of young physicians decline practice ownership, uninterested in the liability, overhead, and work-life complexity of practice ownership.³⁵ The pipeline of willing, potential internal successors is thinning, while more dermatologists are seeking retirement.

Rhetorically, why is PE ownership swelling? Simple. Young physicians do not want to work for PE firms; they also refuse to deal with the headaches of owning a practice. And the 25% of physicians sitting at retirement age? Shocking development: They actually want to retire. Somebody has to buy the practice and operate it. Guess who's ready, willing, and writing them a check?

And the economics work well for the seller. A majority of the purchase price in cash at closing, an ongoing compensation agreement, and rolled equity that can multiply at the next recapitalization is a final “cherry on top” for decades of work, risk, and sweaty equity.^6,9 Banta cautions that the rollover usually comes with strings, forfeited if the seller walks before the vesting period, typically around 5 years. Selling to PE often yields a higher total value than an internal sale or a sale to another private practice.³⁶ For a physician who spent 3 decades building something from nothing, that check reflects what the work was worth, measured by someone whose job is to quantify value.

This isn’t a villain story. This is a $10 billion specialty in which the people who built it didn’t plan for what comes after them, and outside capital stepped into the gap. Nature abhors a vacuum, and patients ultimately need dermatologic care. Whether the rise of PE in dermatology was the best outcome depends on what happens next.

In Part 2, coming up in the October issue, we’ll look at what happens after the sale: the provider experience inside PE, the contract provisions that differ from independent practice, the regulatory tide rising in Oregon, California, and beyond, and the question nobody in the profession seems willing to answer out loud, and the residency programs are simply not addressing: If you don’t want other people’s money running your specialty, what are you willing to do about it?

Joseph (Joe) Gatti, DMSc, MPAS, MBA, PA-C, is a board-certified dermatology physician associate, West Point graduate, and co-owner of a high-volume dermatology clinic and full-service medical spa. Through Azimuth Consultants, he advises clinicians nationwide on employment contracts, compensation strategy, and practice operations.

Disclosure: Gatti is the founder of Azimuth Consultants and maintains active ownership interests in a dermatology practice and medical spa.

References

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