by Andis Robeznieks
With healthcare approaching 20 percent of the nation’s economy, it’s no surprise that medical groups are getting attention from investors. And with physicians facing the uncertainties of complex payment reforms and a new president, many are more than willing to sell their practices.
“Insecurity causes groups to seek shelter,” Pat Free, McKesson vice president for radiology, said at the recent Radiological Society of North America (RSNA) meeting in Chicago.
Starting in 2017, Medicare begins its transition from volume- to value-based payments as the first stages of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 commence. MACRA is incentivizing physicians to participate in alternative payment models, such as the patient-centered medical home practice model, which emphasizes care coordination.
So investors are merely following the Wayne Gretzky strategy of “skating to where the puck is going to be” and looking for newer, and often smaller, opportunities that may not blossom overnight.
“If you’re an investor and Medicare says, ‘We’re going to focus on medical homes,’ then you’re going to focus on medical homes,” said Rulon Stacey, managing director of healthcare at Chicago-based Navigant consultants. “They’re seeing something that accrues to their financial interest going forward.”
The Patient Protection and Affordable Care Act was fueling healthcare mergers and acquisitions, according to a KPMG survey of 553 executives conducted in October 2015. Fifty-one percent of respondents said they thought healthcare M&A activity was being driven by the Affordable Care Act. This included seeking advantages of scale.
But Stacey said he doesn’t see the possible repeal of the ACA reversing current trends in healthcare.
“The progression from volume to value will continue,” he said. “Our future is tied to increases in quality and decreases in cost. It’s just what we have to deal with.”
Stacey’s colleague, Jimmy Burnett, Navigant managing director and national business unit leader for physician enterprise solutions, agreed.
“If the Trump administration continues down the path of payment reform via MACRA — a law with bipartisan support — we can expect additional acquisitions, especially smaller practices that don’t have considerable experience with quality measurement, a robust information technology infrastructure, and the appetite to accept high levels of risk,” Burnett said.
Another reason for investor interest in smaller practices is because many of the larger ones are already taken.
“The reality is that many of the larger physician groups have already been acquired or are in strategic partnerships with a health system,” Burnett said.
A Bain & Co. report stated that within the healthcare private equity landscape, “demand outpaced available assets,” and competition was strong across the board, particularly for “gem” assets.
In one of the biggest deals of the year, one private equity firm, New York–based Harvest Partners, acquired Advanced Dermatology & Cosmetic Surgery, from Boston-based Audax Private Equity for a reported $600 million. With 150 locations, Maitland, Fla.–based ADCS is considered to be the largest dermatology provider in the U.S.
“There has been a very strong push by private equity to invest in physician groups, especially high-end specialty practices such as anesthesia, emergency medicine, hospitalists, and radiology,”
– Burnett said.
He pointed to Blackstone Group’s acquisition of Team Health and Envision Healthcare’s merger with ambulatory surgery provider AmSurg as prime examples.
New York–based Blackstone is buying Team Health in a $6.1 billion deal. Blackstone had acquired the Knoxville, Tenn.–based Team Health for $1 billion back in 2005 before taking it public in 2009. Before the deal, Team Health had rejected a $5 billion offer from AmSurg.
The Envision-AmSurg merger creates a company reportedly worth $10 billion. AmSurg had acquired Sheridan Healthcare, a physician-management group, for a reported $2.3 billion in 2014.
The 93 private equity deals in healthcare’s provider and related services sector totaled $12.7 billion in 2015 compared to $8.1 billion in 2014, according to Bain, and accounted for about half of all healthcare deals.
Not every deal is a merger or acquisition. Boston-based Summit Partners made a $250 million investment in the DuPage Medical Group, which, with more than 560 doctors, is believed to be the largest independent physician group in Illinois.
Representatives from both Summit and DMG were not available to comment for this article, but Michael Kasper, DMG chief executive officer, spoke about the deal this past September at the Creating Clinically and Financially Integrated Delivery Systems conference put on by World Congress, a Woburn, Mass.–based event-organizing company.
Kasper said Summit was selected from 23 potential partners and was not the highest bidder. They were chosen, in part, because they agreed to work in an environment where they would “not be calling the shots.” Kasper described the arrangement as Summit “having influence — but not control.”
Summit managing director Darren Black was named to the board of directors for the group’s practice management business, DMG Practice Management Solutions, but the medical group’s board remained in place with all seats occupied by physicians.
This decision was an important factor as DMG has staked out its territory in the Chicago suburban market.
“We want to be the option for physicians who don’t want to be employed,” Kasper said at the conference.
Independence is also important as there remains an underlying concern regarding the introduction of for-profit entities into the patient-care environment.
During his RSNA presentation, Free noted that he works with 390 radiology groups of various sizes, and he thinks some hospitals have concerns with investor influence among potential physician group partners.
Noting that he was basing his views on observation and not any empirical studies, Free said that hospitals may not want a “PE- or VC-backed group involved with their system” and that “hospitals may not want to partner with a publicly traded entity.”
Free later clarified his remarks in an email.
“Purely speculation on my part as I was involved in a large hospital system that asked 10 radiology groups to merge, and when one of the groups sold to a VC/PE-backed firm, their hospital contract was canceled,” he wrote. “While I do not know the circumstances, perhaps the system was nervous about their not-for-profit being challenged or otherwise being pressured by for-profit obligations.”
Burnett said that companies like Nashville-based HCA, the nation’s largest for-profit hospital provider, help to alleviate this concern with their high scores on quality measures.
“Though always a perceived risk, we’ve yet to see specific research showing significant differences between for-profit and non-profit quality,” Burnett said.
Arlen Meyers, M.D., a professor emeritus at the University of Colorado School of Medicine and president and CEO of the Society of Physician Entrepreneurs, said “there needs to be a public conversation” about the role of for-profit investments in healthcare delivery.
“There are legitimate concerns, and it gets down to the fundamental notion of what should healthcare be and what should its mission be in the U.S. Is it a right? Should it be controlled or be subject to market forces?”
While Meyers’s organization, an international network of healthcare professionals, entrepreneurs, and investors, is growing with 26,000 followers on LinkedIn and 20 chapters around the world, he lamented the current state of entrepreneurship in the U.S. in general and in healthcare in particular.
Meyers cited data from the U.S. Bureau of Labor Statistics that shows that the number of jobs created by companies less than a year old has decreased from 4.1 million in 1994 to 3 million in 2015 though healthcare entrepreneurs are doing better than those in other industries.
Of the healthcare and social assistance companies that started in 2004, 40.5 percent are still around, compared to only 25.4 percent in the construction industry.
Meyers is not impressed, however, and he said the problem is that what the U.S. has is a “sick care” industry rather than a healthcare sector.
“You have to create something a customer wants — whether it’s a drug or a medical device,” Meyers explained. “You have to address a job they want the product to do. You have to eliminate the pain they are experiencing. You have to exceed customers’ expectations.”
Most get that wrong, according to Meyers, who added that, in sick care, new products or services are often “a solution looking for a problem.”
Outside private equity investors could be a solution, he said.
“I’m optimistic that we’re going to solve these problems, but I don’t think that sick care can fix itself from the inside,” Meyers said. “If private equity were to do this right, they would create a business model that is sustainable.”
For example, he envisions investors developing business processes for outsourcing physician-office scheduling, revenue-cycle management, sales and marketing, and human resources operations that could be standardized and turnkey “like downloading an app.”
If done right, every year on June 30 when residency training ends, new doctors can open practices right away.
“Medicine is continuously changing,” Meyers said. “It’s continually evolving from a ma-and-pa operation hanging a shingle outside the house.”