St. Louis-based Ascension, one of the largest nonprofit Catholic health systems in the country, has spent the last decade building a private equity portfolio worth more than $1 billion — largely without triggering the regulatory review that would accompany buying those companies outright, according to a report from the Private Equity Stakeholder Project.
The report examines how Ascension has used a joint venture with TowerBrook Capital Partners, a private equity firm that manages more than $140 billion, to acquire stakes in companies that do business with Ascension’s own hospitals.
Ascension and TowerBrook formed the venture, now known as the Ascension TowerBrook Healthcare Opportunities Fund, in late 2015. Ascension holds a 95.6% stake in the fund, valued at $1.17 billion as of Dec. 31, 2025, the report found. Since then, the fund has taken stakes in R1 RCM, a medical billing and collections company; Trimedx, a medical equipment management firm; Compassus, a hospice and home health provider; Regent Surgical Health, which manages ASCs; US Acute Care Solutions, a hospital staffing company; PT Solutions Holdings, a physical therapy chain; and Maxor, a pharmacy services company now doing business as VytlOne.
TowerBrook has described the arrangement as a two-way advantage. In a November 2025 investor statement cited in the report, the firm said it “leverages their relationship with Ascension, one of the largest nonprofit healthcare systems in the U.S., to provide the firm with a competitive advantage in sourcing healthcare investments.”
Because the portfolio companies are owned through the TowerBrook-managed fund rather than by Ascension directly, they may be less likely to draw the regulatory and antitrust scrutiny that would come with an outright acquisition, the report noted.
The structure also shapes how Ascension is taxed. Nonprofit hospitals have been able to profit tax-free from for-profit partnerships since a 1998 IRS ruling, and Ascension treats income from the TowerBrook fund as related to its charitable mission rather than the kind of unrelated business activity subject to the unrelated business income tax, according to the report. Ascension’s investment income grew from $11.8 million in 2021 to $20.3 million in 2024, the report found.
Ge Bai, PhD, a professor of accounting and health policy at Johns Hopkins University in Baltimore, said the strategy raises questions about mission alignment for a health system that reported $25.3 billion in revenue and $44.2 billion in assets in fiscal year 2025.
“That is quite an aggressive and controversial strategy, and it is not clear how those investment incomes or returns are aligned with Ascension’s charitable mission,” Dr. Bai said.
R1 RCM’s history illustrates both the financial upside and the reputational risk built into the structure. The company began as Accretive Health, which drew criticism over aggressive debt collection practices before Ascension and TowerBrook took it over in December 2015. Under their ownership, R1 RCM grew from 3,000 employees to 19,000 by 2020, and Ascension’s business accounted for 61% of its revenue in 2021. Ascension sold $306 million in R1 RCM stock in September 2022, weeks before the company reported disappointing quarterly results, the report found. TowerBrook and Clayton, Dubilier & Rice acquired R1 RCM for $8.9 billion in 2024.
The TowerBrook venture is not the only vehicle Ascension has used to build an investment portfolio. Ascension Ventures, a separate fund the system established in 2001, now manages more than $1 billion in capital across nearly 80 portfolio companies and includes 12 partner health systems, including Intermountain Health and Children’s Health, according to the report. That network suggests Ascension’s use of investment vehicles alongside its nonprofit hospital operations extends well beyond its arrangement with TowerBrook.
The report also ties the strategy to changes in executive compensation. Anthony Tersigni, Ascension’s former CEO, became chair of Ascension Capital, the system’s investment arm, with total compensation rising 43% to $10.6 million. Anthony Speranzo, Ascension’s former CFO, became president and CEO of Ascension Capital, with compensation rising 242% to $10.9 million. Craig Cordola, Ascension’s former COO, became an executive vice president at Ascension Capital, with compensation rising 238% to $6.3 million.
Whether the arrangement draws closer scrutiny from regulators or the IRS remains to be seen. But the report’s findings add to a broader conversation about how nonprofit health systems generate investment income from companies that also serve as vendors to their own hospitals — and how much distance a joint venture provides between a nonprofit system and the for-profit activity that finances it.
Becker’s has reached out to Ascension and will update this article if more information becomes available.
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