Study links for-profit hospital ownership to higher death rates, points to nurse staffing

Patients treated at for-profit hospitals had higher death and readmission rates than those treated at nonprofit hospitals, and the gap was driven in large part by thinner nurse staffing, according to a study released Tuesday night by researchers at the University of Pennsylvania's Center for Health Outcomes and Policy Research. The study is among the largest to date to compare hospital ownership and patient outcomes directly, and it arrives as private investment in American hospital care continues to grow.

The findings were published open-access in the journal Medical Care under the title "Patient Outcomes and Nurse Understaffing in For-Profit Hospitals." Researchers examined outcomes for more than 1.17 million patients across 941 adult acute-care hospitals in 10 states: 143 for-profit facilities and 798 nonprofit ones.

The numbers

Compared with nonprofit hospitals, for-profit hospitals had roughly 11 additional deaths per 1,000 medical admissions and five additional deaths per 1,000 surgical admissions. Thirty-day readmissions ran 2.04 percentage points higher for medical patients and 1.76 percentage points higher for surgical patients, equivalent to about 20 and 18 additional readmissions per 1,000 discharges. Differences in nurse staffing explained 16 percent of the gap in medical readmissions and 30 percent of the gap in surgical readmissions, and staffing was described as a main driver of the higher mortality as well. Patients also gave for-profit hospitals lower overall ratings, a pattern the researchers again tied largely to staffing.

The staffing figures behind those outcomes were stark. Seventy-one percent of nurses in for-profit hospitals said their assigned patient workloads were unsafe. Nurse burnout was significantly higher at for-profit facilities, and nurses there were far less likely to recommend their own hospital to friends and family, either as a place to receive care or as a place to work.

How the researchers got here

The study builds on a smaller 2025 analysis by some of the same researchers, which looked only at 113 hospitals in Illinois and found that for-profit facilities invested less in nursing despite showing no significant difference in operating margins from nonprofits. That early finding left open whether the pattern held nationally or was a quirk of one state's hospital market. The new study, spanning 10 states and more than eight times as many hospitals, was designed as that broader test.

For-profit ownership of American hospitals has been expanding for years, increasingly through private equity firms that acquire struggling nonprofit or public hospitals and run them for investor returns. Previous research had already established that for-profit hospitals tend to have higher mortality and rehospitalization rates than nonprofits, but it was unclear how much of that gap came from staffing decisions specifically, as opposed to differences in the patients each type of hospital treats or the services it offers. The new analysis adjusted for case mix and hospital characteristics and still found that nurse staffing levels accounted for a measurable share of the disparity.

Who the finding affects

The study's reach is broad: for-profit hospitals now account for a substantial share of acute hospital beds nationally, and patients in the 10 states studied had no way of knowing from the outside how an individual facility's ownership structure might affect their odds of survival or readmission. The findings are likely to matter most immediately to state lawmakers. Illinois, Pennsylvania, Massachusetts and Washington are each weighing legislation that would set minimum nurse-to-patient staffing ratios, proposals the hospital industry has often resisted on cost grounds.

Nurses themselves are also directly implicated. The study's burnout and turnover findings point to a workforce strained enough that understaffing may be self-reinforcing: nurses leave the hospitals with the worst conditions, which can worsen staffing further for those who remain.

Matthew D. McHugh, the study's lead author and director of Penn's Center for Health Outcomes and Policy Research, framed the results as a case for treating staffing as a patient-safety requirement rather than a line item hospitals can cut when margins tighten.

"Treating safe nurse staffing as a core component of quality rather than a discretionary operating expense is especially important where incentives to cut labor costs are strongest. Minimum safe staffing requirements and ownership transparency are practical safeguards for patients and nurses."

The study's other co-authors are Karen B. Lasater, K. Jane Muir, Trissa Lyman and Linda H. Aiken, all of Penn Nursing and the Leonard Davis Institute of Health Economics, and Angelo Petto. The authors conclude that minimum staffing requirements and greater transparency about hospital ownership could improve outcomes for patients and conditions for nurses regardless of who owns a given hospital. The research was funded by the National Institute of Nursing Research, part of the National Institutes of Health, under three grants.

What happens next

The same research group has already signaled where it plans to take this line of work next: toward disentangling how private equity ownership specifically, as distinct from for-profit status more broadly, affects nurse staffing and patient outcomes, since investor-owned chains have drawn particular scrutiny from regulators and lawmakers in recent years. Extending the analysis beyond the 10 states covered in the current study is also a stated goal.

In the meantime, the legislative fights already underway in several states give the findings an immediate test case. Pennsylvania's own House of Representatives passed a minimum-staffing bill in 2023 by a wide margin, though it stalled in the state Senate and has not become law. Whether new evidence of a direct, quantified link between ownership, staffing and mortality shifts that calculus in Harrisburg or elsewhere is likely to become clear only once state legislative sessions resume and hospital industry groups weigh in on what a minimum ratio would cost them to implement.