Healthcare Market Update Vertical Perspectives March 2023
Healthcare Market Update Vertical Perspectives March 2023
7.1%
US CPI-U YoY Change(1)
425 bps
2022 Increase in
Fed Funds Rate(1)
0.4%
Consensus 2023
Jan-21 Apr-21 Jul-21 Oct-21 Jan-22 Apr-22 Jul-22 Oct-22
U.S. GDP Growth
1) As of December 2022
CONSUMER PRODUCTS & SERVICES Page | 22
Investors Are Increasingly Selective as M&A Markets Begin
to Moderate
Deal volume moderated in 2022, and investors are picking their spots in 2023.
The M&A Market Remains Active; Buyers Have Shifted Their Mindset Since Mid-2022
2H 2020 Frothy capital markets Record M&A volume and COVID normalization and Speed and structure in Record Level Of Capital Deployment
+ and SPAC / IPO craze valuation levels priority on growth M&A processes via M&A
2021
2022 Volatile public equity and Moderating M&A Priority on stability, Flexibility and Heightened Focus on Quality,
+ credit markets volume and valuation sustainable growth, and “dealmaking” in M&A Market Leaders, and Recession
1H 2023 disconnect cash-flow generation processes Resilience
$801
5,818
4,741
4,406 4,322 4,495
4,160
3,726 $490
$443
2,941 $395
1Q21 2Q21 3Q21 4Q21 1Q22 2Q22 3Q22 4Q22 2019 2020 2021 2022
1) PitchBook data as of 12/31/2022 (latest data available); PitchBook middle-market deal size defined as $25M - $1.0B
CONSUMER PRODUCTS & SERVICES Page | 33
Healthcare Has Historically Been Resilient Through
Economic Cycles...
Healthcare has historically been more resilient than other industries and has proven to be a growth driver of the economy, with healthcare as a
percentage of U.S. GDP rising from 13% in 2000 to 20% in 2022.
COVID-19 Recession
Dot-Com Recession 2020
The Great Recession
2001
2007 – 2009
Gulf War Recession(1) Dot-Com Recession(1) The Great Recession(1) COVID-19 Recession(1)
S&P 500 Health Care S&P 500 Health Care S&P 500 Health Care S&P 500 Health Care
S&P 500 (Sector) S&P 500 (Sector) S&P 500 (Sector) S&P 500 (Sector)
(3%)
(14%)
(40%) (25%)
(31%)
(18%) (22%) (54%)
1) PitchBook
CONSUMER PRODUCTS & SERVICES Page | 44
...And Presents Great Investment Opportunities During a
Downturn
› Healthcare investments during the Great Recession returned a multiple on invested capital (MOIC) that was nearly a full turn higher than other
industries
› Healthcare assets also led the way coming out of the Great Recession, outperforming other sectors by ~14% from 2009 to 2015
Performance of North American Private Equity-Owned Healthcare Investments Made During the Great Recession(1)
+50% +14%
Recent Insights
Dental
+ Significant remaining fragmentation in the market presents a major opportunity for continued consolidation
+ Investors continue to look to add specialties to their general practice services, creating multispecialty, regionally dense platforms
+ Attractive resiliency as proven by a strong rebound after the Great Recession and COVID
- Payor negotiations have remained challenging for dental platforms, as payor rate increases have lagged behind labor / wage inflation and other input costs within
these businesses
- Clinical staff retention has been difficult in the tight labor market and continues to be a focus for most dental businesses
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Consumer Healthcare
Dermatology
+ Stabile demand drivers given medical necessity and proven recession resiliency
+ Sector grew through the Great Recession and will likely continue to receive more interest, on a relative basis, during this cycle
+ Resilient, recurring cosmetic spend (e.g., Botox, fillers) expected to continue despite the current economic environment
+ Greater focus on the appearance of the skin in the post-COVID world has accelerated growth in cosmetic services
+ More pricing opportunity within cosmetics helps offset inflationary pressures
+ Large number of organic levers to pull operationally within dermatology platforms; breadth of service offerings across medical and cosmetic dermatology allows practices to better
absorb changes in utilization patterns driven by economic cycles
- Labor shortages and wage inflation, specifically among medical assistants and support staff, have been the largest challenges facing dermatology practices
- An inability to pass on price increases to patients, particularly for medical dermatology services, has caused margin pressure for some dermatology practices
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Consumer Healthcare
Fertility
+ High degree of cash pay and greater ability to pass along price increases than virtually all other healthcare services sectors
+ International demand for U.S. fertility services is high, and with most travel restrictions now lifted post-COVID, patients will increasingly seek treatment in U.S.
- While legislative clarity is still forthcoming in some states, there is limited anticipated impact on the broader sector based on the Dobbs decision
- While scaled platforms are extremely well positioned to continue to recruit physicians and grow their businesses, it is becoming increasingly difficult to create new
platforms given overall physician supply
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Consumer Healthcare
OB/GYN
+ Platform providers seek ways to increase broad service offerings, including through MFM, imaging, oncology, behavioral, and digital health offerings
- The U.S. continues to experience modest birth rates consistent with many other developed nations
- Offset by primary care nature of many services (i.e., many women see OB/GYN in lieu of primary care provider) as well as growing prevalence of
underlying conditions driving higher-complexity pregnancies (e.g., obesity, advanced maternal age, etc.)
▪ Very limited exposure to consumer ▪ The next group of platform OB/GYN companies is gaining
Exposure to LOW HIGH
Consumer Spending
spending due to primary care nature of scale and is more likely to transact in 2024 or beyond
appointments
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Consumer Healthcare
Physical Therapy
+ Largest platforms continue to grow and expand through aggressive de novo, tuck-in acquisitions, and the accelerating pace of combinations with other platforms
+ Emergence of the next wave of midsized platforms with ~150 clinics or more as well as numerous smaller, private equity-backed providers at early stages of their
growth trajectory will provide actionable opportunities over the next several years
+ A number of platforms beginning to experiment / pursue growth in complementary service lines (e.g., pediatric/ABA, chiro, hospital partnership/JV, etc.)
- Availability of physical therapists and wage pressure have been experienced by many, but not all, providers of scale; labor management and recruitment provide
meaningful point of differentiation for platforms
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Consumer Healthcare
Veterinary Services
+ The veterinary services sector has seen a considerable level of consolidation between 2018 and 2022, and momentum is expected to continue through 2023, with
an emerging trend of "consolidation of the consolidators"
+ Sector continues to draw high levels of interest as tailwinds such as the humanization of pets and growing pet ownership rates continue to accelerate
+ DVM recruitment and retention represent areas of continued focus and investment
+ In today’s tight labor market, we’ve seen heightened focus on DVM development programs and initiatives to improve the mental health and well-being of
DVMs
+ Increased focus on varied de novo growth strategies vs. traditional acquisition-driven growth
- Rising interest rate environment presents a challenge to roll-up strategy, and acquirers have become more circumspect about practice acquisitions, causing
multiples to decline, though activity remains strong
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Consumer Healthcare
Vision
+ Large number of PE-backed platforms beginning to reach typical hold periods likely to provide consistent transaction volume in sector over next several years
+ Emergence of multiple active and viable strategic acquirers for other PE-backed platforms (e.g., EyeCare Partners/Partners Group and Eye South/Olympus
Partners)
+ Several potentially promising new retina drugs could provide tailwinds within retina subspecialty
- Like many other sectors, midlevel clinical labor supply remains relatively tight
▪ Consumer spending typically elective (e.g., ▪ High degree of physician compensation, which tends to
Exposure to LOW HIGH premium IOLs, LASIK); expenditure levels be productivity-based and therefore variable, makes
Consumer Spending small relative to quality of life sector less sensitive to wage pressure than other retail
considerations
health sectors on a relative basis
▪ Low exposure to capital spending given the
Exposure to Capital LOW HIGH
relatively low fixed costs associated with
(B2B) Spending
clinics
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Physician Practice Management
Gastroenterology
+ Stable reimbursement environment, with professional and facility fees in line with prior years and some reimbursement rates increasing given further hospital
price transparency as ambulatory surgery center (ASC) reimbursement rates move in line with hospital-based outpatient department (HOPD) rates
+ Highly fragmented market where significant consolidation opportunity remains, with 1,300+ unconsolidated practices across the country (1)
+ Margin optimization capabilities through the expansion of ancillary service offerings, including ASCs, in-office endoscopy suites, anesthesia, and pathology
+ Emergence of value-based care as a service model is increasingly prevalent in the gastroenterology sector
- Shortage of GI physicians expected to exceed 1,600 physicians by 2025, resulting from increased demand for screening and preventive medicine by an aging
population(2)
- Many larger groups have transacted in the last several years, leaving mainly smaller players available as M&A targets for existing platforms
1) Definitive Healthcare
2) Merritt Hawkins
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Physician Practice Management
Orthopedics
+ Recession-resistant sector due to medical necessity of services; many treatments require near-term or immediate care
+ Favorable payor mix with very limited cash pay; reimbursement rates for orthopedic procedures have remained stable
+ Businesses have demonstrated “platform value” through favorable payor contracting, offering of ancillary services, and ability to acquire in-market physicians at
attractive prices
+ While value-based care models overall have low penetration in the sector, market leaders range from exploring to capitalizing on value-based care
+ Value-based care models create opportunities for leading orthopedic practices to generate incremental revenue while improving patient outcomes and
lowering cost for the system
- Inability to pass on cost inflation to patients can result in margin pressure
Exposure to Capital LOW HIGH ▪ Capex generally required for growth of ASCs
(B2B) Spending or other ancillaries
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Physician Practice Management
Urology
+ Significant demand tailwinds, given the growing 65+ U.S. population and a high urological disease incidence rate, including prostate cancer, urinary incontinence,
and BPH
+ Scaling platforms can unlock significant value creation opportunities, including greater economies of scale, better access to ancillary services, and more efficiently
navigating the reimbursement and regulatory landscape, in excess of what smaller practices can realize
+ Complex reimbursement environment and high barriers to entry provide significant opportunity for scaled platforms and drive urologists to join larger
organizations
+ Highly fragmented landscape with limited national platforms
- Similar to supply/demand trends in other specialties, demand for urologists is expected to outpace provider supply
- Urologists, in terms of physician age, are above average, with 50% over the age of 55(1)
1) American Urological Association: 2021 | The State of the Urology Workforce and Practice in the United States
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Behavioral Health
Behavioral Health
+ Persistent supply-demand imbalance for services, growing demand from adolescent and young adult patient populations most adversely affected by COVID crisis
+ School systems are becoming an increasingly important care setting for the provision of behavioral and mental health care
+ Destigmatization of mental and behavioral health issues driving more patients to seek treatment
+ Greater awareness; public figures’ openness about suffering from mental health issues
+ Acceptance of mental and behavioral health as a medical issue
+ Increased support from governmental and commercial insurance funding sources
+ COVID increased the attention paid to behavioral health, while also creating significant demand for behavioral health services due to the population’s isolation and feelings of fear and insecurity
+ Innovative care delivery models and technologies expected to continue to drive the sector forward
+ Shift to multidisciplinary services
+ Integration of primary and behavioral health care; value-based care alternative treatment and payment models
+ Reduction of regulatory barriers to dispensing MAT; rise in technology-enabled home-based MAT and SUD treatment; normalizing of psychedelic-assisted therapy
- Labor markets continue to be a headwind as the sector struggles to recruit and retain line therapists and other non-M.D. clinical staff
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HCIT
HCIT
+ Employers, health systems, and payors are increasingly focused on cost containment technology solutions
+ As labor markets have tightened, cost containment solutions are becoming increasingly relevant as employers seek to manage medical costs to manage narrow networks, reference-based
pricing, and other reimbursement structures
+ Health systems seek operational and administrative tools that monitor costs purchasing, labor management, and asset utilization, among others
+ Life sciences technology continues to see activity as clinical trial volumes continue to increase based on pharma and biotech funding, as well as smaller trials supporting a need for innovative solutions
that can rapidly scale
+ Specialty EMR and practice management solutions continue to attract investors across specialty clinics, while larger “traditional” outpatient specialties that have achieved meaningful scale and
profitability look to expand into core markets and adjacencies
+ Expansion of investor interest from pure software solutions into tech-enabled solutions, such as cost containment, quality of care, and care utilization
+ The addition of a services element accompanying software increases stickiness and expands addressable market opportunity
- As investors prioritize profitability, HCIT companies must demonstrate a strong, proven economic model, rather than only a “growth at all costs” mentality, in order to attract investor interest
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Home Health & Hospice
+ Family caregiving model (a.k.a. consumer-directed home care) is gaining traction as an attractive way to provide nonmedical home care
+ Model drastically expands the labor force and reduces caregiver turnover, leading to continuity of patient care and improved quality
+ Introduction of advanced technology solutions into the field enables caregivers to deliver improved care of scale
+ Highlighted by recent partnerships between Amedisys / Aetna and CenterWell / Humana, Medicare Advantage partnerships are gaining traction
- Labor force challenges have begun to normalize; however, they will continue to be top of mind for operators in 2023; many home health and hospice platforms
have made permanent cost structure changes to assuage wage pressures
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Medical Products and Devices
+ Manufacturers and service providers continue to consolidate key suppliers to ensure on-time deliveries, production of high-quality products, and reduction of
down time of hospital equipment
+ The drive for innovation remains constant, as both startup and established players develop next-gen products and devices to improve patient care and reduce
costs to patients and providers, resulting in higher-value products with attractive margins
+ Medical products and devices companies have a variety of attractive organic and M&A growth levers they can pull on, such as product portfolio expansion,
geographic expansion, addition of new and complimentary manufacturing or service capabilities, and new/existing customer growth
- Medical products and devices companies expect continued labor and supply chain challenges, which may impact a company's ability to meet demand
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Outsourced Provider Services
+ Highly favorable long-term trends support robust demand for outsourced provider services, amplified in the travel nursing and contingent labor sectors
+ Rising incidence of chronic diseases coupled with rapidly aging population (number of adults 65 and older increasing at 3.2% per year)(1)
+ Contingent labor utilization increasing as a result of permanent staff not meeting hospital staffing needs and growing clinician interest and awareness of
travel nursing as an appealing career path
+ The continued shift in work preferences, with a bend toward flexibility and higher compensation potential, particularly among younger providers, has led to a great
number of healthcare employees seeking flexible work models and a greater acceptance within the healthcare industry for using contingent labor
- “Normalized” travel nurse bill rates in excess of $110/hr. driven by persistent clinician shortages in the face of rapidly rising demand over the foreseeable future
- Nurse retirement at inflection point (avg. age is 52; 19% of nurses are 65+); burnout and vaccination mandates driving more nurses away from the bedside(1)
- Nurses have worked 24+ months at higher wages and have a low propensity to accept materially lower wages in the future
1) U.S. Bureau of Labor Statistics, U.S. Census Bureau, NSI Nursing Solutions Inc., Journal of Nursing Regulation
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Payors & Payor Services
+ Increasing demand for specialty benefit management as employers and health plans seek solutions to address accelerating spend across kidney care, surgery,
DME, behavioral health, fertility, and other high-spend categories, creating opportunities for best-in-class solution providers addressing these needs
+ Continued growth among independent third-party administrators to help an increasing number of employers who are self-insuring recognize the benefits of
network design, care management, and cost containment
+ Accelerating demand for cost containment solutions to help payors and employers manage healthcare costs that are expected to increase in 2023 as rates for
providers increase to compensate for inflation
+ Further penetration of value-based care in the commercial employer sector as the gap is narrowed with penetration in government-reimbursed healthcare
- Uncertainty around how the implementation of new regulations (most notably the price transparency and no surprise billing regulations) will play out
+ New regulations have driven significant growth for cost containment platforms that help plan sponsors navigate the complex legislation, identify and
measure the appropriate qualified payment amount (QPA), and comply with requirements to avoid penalties
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Pharma Services
Pharma Services
+ R&D costs have risen and the challenges of commercializing products have increased, which is driving outsourcing by biopharmaceutical manufacturers
+ Small pharma and biotech are increasingly leading novel compounds through commercialization, driving a new wave of customers for outsourced pharma services
and tech providers; these smaller companies are even more likely to outsource than large pharma
- The biotech funding cycle will likely be the greatest question in 2023
- More likely to impact businesses in early phase R&D, as opposed to late-stage or commercialization platforms, which will be minimally affected
- Longer term, little concern on the funding cycle, as small pharma and biotech will continue to drive innovation and attract capital to fund research and
development activities
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Pharmacy
Pharmacy
+ Pharmacy models that have unique differentiation or add more value to the healthcare ecosystem than pure play pharmacy models are in favor with investors and include:
+ Value-added outsourced service providers to health systems, such as outpatient specialty pharmacy management, that create a new revenue stream for the health system and allows it to
retain chronic patients
+ In-home and ambulatory infusion centers that are taking advantage of payors’ desire to push patients into lower-cost environments
+ Businesses that are moving closer to pharma manufacturers, such as rare-disease-exclusive distribution pharmacies that are providing white-glove patient service
+ Increased prevalence of home-based care, which was heightened as a result of COVID, has driven demand for home-based pharmacy services, whether that relates to e-commerce,
technology to drive adherence, or alternative site of care
- Payors are putting additional pressure on reimbursement rates for specialty drugs
- PBM continues to be a challenging subsector due to concerns around the sustainability of profits from rebates and their value-add in the healthcare system
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Primary Care
Primary Care
+ New Medicare payment models (e.g., ACO REACH) enabling value-based primary care for seniors
+ In 2022, CMS converted the existing Global & Professional Direct Contracting Model to ACO REACH, which will officially go live January 1, 2023
+ Increased consumerization of healthcare, with patients seeking choice to find affordability and convenience
+ Patient choice is increasingly important, as patients want affordability and greater convenience, e.g. access to clinics in attractive locations, online/virtual
scheduling, telehealth/ability to message physician, app-based connectivity, etc.
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TABLE OF CONTENTS
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Healthcare & Life Sciences
Morgan Linden
Clearlake Symplr Stanley Five
Nordic Capital eSolutions Thomas Capital Lee
Capital Athilio Heartland Arrows
Equian Waud Capital Berkshire H. Lee Partners Equity
Five Pharma Dental
The Vistria Arrows eSolutions Partners Partners
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PRIMARY OTHER DEAL PRIMARY OTHER DEAL
COVERAGE EXPERIENCE COVERAGE EXPERIENCE
▪ Med Products & ▪ HCIT ▪ Outsourced ▪ MedTech
Devices ▪ Multisite Pharma Services
▪ Providers
▪ Outsourced Healthcare ▪ HCIT
Pharma Services Services ▪ Therapeutics
▪ Consumer ▪ Behavioral
▪ Pharmacy ▪ Behavioral
Healthcare
▪ Life Sciences &
▪ Consumer
Tools
Healthcare
▪ Med Products &
▪ Med Products &
Devices
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