Healthcare Transactions Q1 2022

Bass, Berry & Sims PLC

2022 started strong for healthcare transactions with some reports suggesting a record-breaking January. Although deal activity cooled in February and March, transaction pipelines still indicate that 2022 is on pace to match or exceed the historically high activity of 2021. Between this financial outlook and COVID-19 being (seemingly) in the rearview mirror, the healthcare industry has reason to be optimistic.

Physician & Dental Practice Management

Investment in physician practices got off to a strong start in 2022, with an estimated 109 deals from January 1 to March 15, up from a reported 99 deals over the same period last year, according to LevinPro. Much of this investment came from private equity (PE) firms in the form of new platforms and add-on affiliations with established platforms across multiple specialties—dentistry, fertility and ophthalmology remaining particularly hot.

Gen4 Dental Partners, a dental services organization (DSO) backed by Thurston Group, was an especially active player in the dental services space during Q1, acquiring in January both Arizona-based, cosmetic dentistry provider Harris Dental and Michigan-based, multi-specialty dentistry provider Smile One Services. The same month, U.S. Oral Surgery Management (USOSM), a DSO that is exclusively dedicated to the specialty of oral and maxillofacial surgery and backed by Oak Hill Capital, announced a partnership with Northwest Florida Oral and Maxillofacial Surgery, its second in the state of Florida. USOSM quickly followed that partnership with the public announcement of three more in February and March: Central Mass Oral Surgery PC, Esmail Oral, Facial and Dental Implant Surgery, and Parkside Oral Surgery & Implant Center, located in Massachusetts, Washington and California, respectively.

Several PE-backed ophthalmology platforms likewise continued to expand their footprint throughout the end of 2021 and the early part of 2022. In December, US Eye, backed by Pamlico Capital, acquired Southwest Florida Eye Care. Not to be outdone, in Q1 of 2022, Vision Innovation Partners, backed by Centre Partners, acquired Advanced Eye Care, a comprehensive eye care practice with an onsite med spa located in Bel Air, Maryland, Memorial Eye Institute, a general ophthalmology practice and surgical center in Harrisburg, Pennsylvania, and SIEHT, a leading eye and laser center with two locations in Fredericksburg and Stafford, Virginia, solidifying its presence in the Mid-Atlantic Region. Moreover, EyeSouth, backed by Shore Capital Partners, completed affiliations with Georgia Center for Sight and Gadsden Eye Associates, Vision Alabama and the Northeast Alabama Eye Surgery Center, expanding its network to 29 practices with over 140 locations, including 19 surgery centers throughout Georgia, Texas, Louisiana, Florida, Tennessee, Ohio, Kentucky, Pennsylvania and Alabama.

Continuing one of the trends from 2021, PE firms continue to show interest in women’s health. In March, Pinnacle Fertility, backed by Webster Equity Partners and considered one of the nation’s fastest-growing fertility care platforms, added three fertility clinics to its portfolio: ORM Fertility, which has four practice locations across Oregon and Washington, Advanced Fertility Care, which has two practice locations in the Phoenix Metropolitan Area, and California Fertility Partners, known as an “international destination” located in Los Angeles, California. Investment in fertility clinics has increased year-over-year and will be a specialty area to continue to watch in the coming months.

Orthopedics is another specialty area garnering increased interest, as orthopedic care is one of the fastest-growing healthcare industry segments, offering numerous revenue streams through ancillary services such as imaging and physical therapy, and yet remains highly fragmented. Following Welsh, Carson, Anderson & Stowe’s announcement of a new orthopedic platform, Resurgens Orthopaedics, in December, PE firms Chicago Pacific Founders and A&M Capital Partners announced new orthopedic platforms of their own in January, Trias Global and Novum Orthopedic Partners, respectively. These platforms will no doubt be active in the coming year. Meanwhile, in the same continuum of care, physical therapy platforms Golden Bear, backed by Shore Capital Partners, and publicly-held U.S. Physical Therapy, Inc. (NYSE: USPH) completed a handful of acquisitions over the last few months, expanding their presence in Southern California and South Carolina, respectively. Many observers forecast that PE firms will increase investments in orthopedics and physical therapy in 2022 and beyond, particularly after the news that General Atlantic acquired majority ownership in physical therapy platform PT Solutions from Lindsay Goldberg for a reported $1.2 billion.

Finally, also noteworthy is Partners Group’s February acquisition of OMERS Private Equity’s majority stake in dermatology platform Forefront Dermatology for a reported $1.5 billion, after the platform doubled in size since OMERS invested in February 2016. Although deal activity in dermatology has slowed in recent years, this significant transaction may reignite interest in the still-fragmented specialty.

Ambulatory Surgery Centers

As noted above, several physician practice transactions included the acquisition of affiliated ambulatory surgery centers (ASCs). Adding an ASC in a physician practice transaction adds EBITA by capturing ancillary services, particularly as more outpatient procedures are being shifted to ASCs away from hospital outpatient departments. Thus, much of the activity in the sector rose from private equity investment in the context of platform creation and add-on acquisitions.

Hospitals

Activity within the hospital sector was off to a slow start in Q1, as deal volume decreased from Q4 of 2021. Continuing one of the main trends from 2021, Q1 has been marked by the ongoing divestiture by systems of smaller hospitals, including the announcement by Community Health Systems (NYSE: CYH) (transferring the lease of AllianceHealth Seminole to SSM Health Oklahoma). Significant transactions during Q1 included the acquisition of University Health Care System, a three-hospital system in Augusta, Georgia, by Atlanta-based Piedmont Healthcare (the largest healthcare system in Georgia) on March 1 for an undisclosed amount—expanding Piedmont’s system to 19 hospitals and committing $1 billion of investment into the hospitals formerly known as University Hospital, University Hospital Summerville and University Hospital McDuffie. Later in the same month, Pipeline Health announced that it signed a letter of intent to sell its two remaining Chicago-area hospitals to Resilience Healthcare, a newly created healthcare firm, for $92 million.

In conjunction with President Biden’s executive order calling for increased competition and further scrutiny of hospital consolidation (discussed in our 2021 report), the FTC announced its plans to strengthen enforcement against illegal mergers and revise its merger guidelines. Already faced with a backlog of merger applications, the possibility of shifting FTC guidelines is likely to exacerbate the low deal volume in the hospital space.

At-Home & Hospice Care

The post-acute care sector, including home health, home care and hospice services, remained active throughout the first quarter of 2022, with the announcement or closing of several transactions. In February, Arkansas Hospice acquired First Choice Senior Care of Little Rock, Arkansas for an undisclosed sum. First Choice provides personal care, companion services, and other programs to address the nonmedical needs of senior adults and the seriously ill. 24 Hour Home Care, a nonmedical in-home care provider, announced the acquisition of Bright Moon Care Services, a home care agency that specializes in personal care for seniors based in Ventura County, California. 24 Hour Home Care launched in Los Angeles, California. Since 2008, it has expanded to 23 locations across California, Arizona, and Texas. The acquisition of Bright Moon allows 24 Hour Home Care to further expand the reach of its services regionally. Additionally, Amedisys, Inc. (Nasdaq: AMED), announced that it has signed an agreement to acquire certain home health assets from AssistedCare Home Health, Inc., and RH Homecare Services, LLC, doing business as AssistedCare Home Health and AssistedCare of the Carolinas. The transaction is expected to close early in Q2.

On the hospice side of the industry, in March, Bristol Hospice acquired Hope Hospice for an undisclosed sum. This transaction is Bristol’s first in the Missouri market and its ninth acquisition since 2020. To date, Bristol has established operations in Arizona, California, Colorado, Florida, Georgia, Hawaii, Louisiana, Michigan, Oregon, Texas, Utah, Washington, and Wisconsin.

We expect M&A activity to increase in the hospice and home health spaces this year. The COVID-19 pandemic kept patients from entering hospitals and clinics, which caused more providers to look to home-based care or telehealth. Keeping patients home and out of the hospital is a continued focus for providers and payors alike, which should contribute to continued growth in this industry. It is estimated that this sector will grow between 9% and 14% by 2024.

Digital Health & Health Information Technology

Transactional activity kept pace with the funding of digital health and health information technology ventures. Building on its recent acquisition of Ginger, Headspace Health expanded its digital health portfolio through its acquisition of Sayana, an app-based artificial intelligence company that helps users track their moods to be mindful of the connections between their feelings and the life events occurring around them. The terms of this deal were not disclosed. Together with its acquisition of Ginger, Headspace Health is positioned to create an integrated digital health platform that will allow users to address mental health issues holistically.

Other notable transactions include Kindbody’s acquisition of Vios Fertility Institute and its network of clinics across six states. Kindbody provides virtual, at-home, and in-person fertility services, including in vitro fertilization and genetic testing. Additionally, SimpleHealth acquired Emme, a healthcare technology company focused on women’s health. This transaction is expected to expand SimpleHealth’s digital offerings related to reproductive care. The financial terms of these transactions were not disclosed.

Funding for digital health companies continues to be strong, signaling a potential continuation of high transaction volumes as companies attempt to scale their businesses. For example, Transcarent, a digital health platform for self-insured employers, closed a $200 million series C funding round last quarter, while Dexcare, a digital health operations spinoff of Providence, closed a $50 million series B funding round.

Behavioral Health

Transaction volume in the behavioral health system space continues to be robust. Effective January 1, 2022, Acadia Healthcare Company (Nasdaq: ACHC), acquired CenterPointe Behavioral Health System. CenterPointe is the largest psychiatric provider in Missouri and operates four inpatient psychiatric hospitals with 260 acute care beds and 46 specialty beds for chemical dependency patients and 10 outpatient locations in Missouri and Illinois. In March, Loblaw Cos. Ltd., – a Canadian retailer encompassing franchise supermarkets, pharmacies, and medical clinics – announced its acquisition of Lifemark Health Group for $845 million. Lifemark, which was previously owned by Audax Private Equity, operates 300 clinics across the United States and provides physiotherapy and mental health treatment. In the same month, Mindpath Health – which offers a range of behavioral health services, including psychiatric treatment, medication management, counseling, and psychological testing – announced its purchase of Psychiatric Centers at San Diego, which included eight locations and 124 providers.

Substance-use disorder treatment continues to be a significant source of behavioral health transactions. UnitedHealth Group’s (NYSE: UNH) Optum, Inc. acquired Refresh Mental Health, which offers psychiatry and substance abuse treatment in 300 practice locations across the United States, from PE firm Kelso & Company. Although the terms of the transaction were not disclosed, Kelso & Company acquired Refresh for approximately $700 million in December 2020. In Q1, BayMark Health Services followed up an acquisitive 2021 with transactions targeting three residential treatment programs in Arizona and Colorado, six substance use facilities in Ohio, and five office-based opioid treatment programs in Indiana. BayMark also completed the acquisition of Kaden Health, an online addiction treatment platform.

The connection between digital health and behavioral health also continued to drive acquisitions. In February, LifeSpeak, Inc. (TSE: LSPK) purchased Wellbeats, Inc. for $92.5 million. Wellbeats is a virtual mindfulness, fitness, and nutrition platform. And at the start of Q2, Castle Biosciences, Inc. (Nasdaq: CSTL) purchased AltheaDx, Inc., – which provides pharmacogenomics testing for depression, anxiety, and other mental health conditions – for $65 million.

Managed Care

We have written about cross-sector, transformational transactions in the past, and it appears 2022 will continue to produce more of those, including some involving managed care and insurance companies. In addition to UnitedHealth’s purchase of Refresh, described above, on March 31, UnitedHealth announced it has agreed to pay $5.4 billion in cash to add home health provider LHC Group, Inc. (Nasdaq: LHCG), a home health and hospice provider, to its range of insurance and medical services. UnitedHealth will pay $170 per share for LHC, representing an 8% premium over the share price at the time of the announcement. LHC will become part of UnitedHealth’s Optum Health unit.

Earlier in March, a managed care company was involved in a transaction on the sell-side—LIBERTY Dental Plan Corporation – a dental benefits administrator, administering dental benefits in all 50 states, serving 5.8 million Medicaid, Medicare Advantage, commercial and exchange members, and seeking to accelerate growth – announced a sale of a majority stake in the company to Welsh, Carson, Anderson & Stowe. Anthem, Inc. (NYSE: ANTM) also participated as a minority investor. Terms of the deal were not disclosed. The deal will allow LIBERTY to expand its services to serve an even greater number of members.

Pharmacy & Life Sciences

Activity in the pharmacy and life sciences industry remains high, with multiple notable transactions occurring in Q1 of 2022. In the pharmacy space, Orsini Specialty Pharmacy – the leading specialty pharmacy focused on rare diseases, gene therapies, and complex conditions – entered into a strategic partnership with the global investment firm Carlyle and Consonance Capital Partners to further expand patient access to Orsini’s treatments. Other notable pharmacy transactions include Sandoz, a division of Novartis, acquiring Coalesce Product Development Limited, a UK-based device company that will build on Sandoz’s portfolio of respiratory medicines and complex therapies. The financial terms of these transactions were not disclosed.

In the life sciences space, IntegriChain, a comprehensive data and business process platform for life sciences access, acquired Blue Fin Group, a full-service professional management consulting firm delivering research, strategy, and implementation services to help manufacturers optimize market access. The terms of this transaction were not disclosed. Additionally, Oak HC/FT, a venture and growth equity firm investing in companies driving transformation in healthcare and fintech, raised $50 million in funding for Infusion for Health, a leading network of ambulatory infusion centers that provides therapies to patients with complex and chronic conditions.

Conclusion

We referenced in our 2021 year-end report the abundant supply of capital. It appears investors and strategic buyers alike are looking to 2022 to put that capital to use.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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