Banker Insights: BHASe and TCIV East

BHAse and TCIV EaSt key takeaways

healthcare transactions

We recently attended the Behavioral Health Summit (BHASe) and Treatment Center Investment & Valuation Retreat East (TCIV East) which took place in Miami and Palm Beach Gardens, Florida, respectively.  Both conferences were well-attended and provided Behavioral Health business owners with excellent forums for discussing the current trends and important topics facing the Autism, Mental Health, and Substance Abuse treatment sectors.  Below are some of the Key Takeaways that we observed:

M&A Activity: A New Market Reality

  • Overall M&A activity in the Behavioral Health sector was down about 35% in 2023 versus 2021 and 2022 (which were amazingly good years).  The reasons for this drop are numerous and sub-sector specific but can be boiled down to a few issues faced by Private Equity (“PE”) Groups, who by and large drive most M&A activity in Behavioral Health.  These include a higher interest rate environment and tighter bank lending standards, causing deals to take longer to close, as well as few high-profile company failures causing PE firms to enter deals more cautiously.  
  • While one investment banker (who shall remain nameless) painted a fairly bleak picture for Behavioral Health M&A (yes, we know, the data does not lie), Hexagon’s Healthcare team views the environment a bit differently, where demand for high quality, fast-growing, and mission-driven organizations are still highly sought after by PE buyers.  
  • This is evidenced by two of Hexagon’s recent client transactions in the space, Family First Adolescent Services (Mental Health/SUD – which closed in 2023) and Autism Spectrum Interventions (ABA – which went under LOI in 2023 and closed after the holidays in January 2024).  Both sold to PE buyers in highly competitive processes.

Value-Based Care: The Future on Hold?

  • Value-based care dominated conference discussions, with both providers and payors acknowledging its potential future role in reimbursement models. However, no confirmed implementations of value-based care arrangements were identified. This suggests the concept remains largely theoretical within the industry.
  • A thought-provoking suggestion emerged from a Behavioral Health company CEO. He proposed a shift in focus towards outcome-based care instead of value-based care. This perspective is presented as a potentially more impactful approach.

Alternative Treatments on the Rise

  •  We were intrigued to see a fair amount of discussion concerning alternative treatment modalities and their role in helping (particularly mental health) patients/clients in their treatment regimens.  One panel at TCIV East was devoted to the increasing use of psychedelics in treatment, and another panel featured two provider panelists offering dedicated Ketamine and TMS clinics, respectively.  
  • Hexagon has witnessed a number of its own Mental Health treatment company clients making use of Ketamine and TMS as a treatment option and as an ancillary revenue stream for the practices.  While these treatment modalities have been utilized for years, Hexagon predicts that a significant increase in their use by practitioners as regulatory and reimbursement factors are ironed out.

For more information or questions, please contact the Healthcare Team:

Paul Kacik, Managing Director: pkacik@hexagoncapitalalliance.com

Brad Erhart, Director: berhart@hexagoncapitalalliance.com

Daren Oddenino, Director: [email protected]

Banker Insights: Skilled Nursing Facilities

Skilled Nursing Facilities

healthcare transactions

Rebound and Growth Potential in the Skilled Nursing Facilities Market

Historically Challenging Environment for SNFs

Skilled Nursing Facilities (“SNFs”) have historically faced a demanding operating environment. The COVID-19 pandemic further exacerbated these challenges, leading to facility closures due to patients seeking alternative care and staffing shortages caused by the “Great Resignation.”

Signs of Recovery and Improved Efficiency

Despite ongoing operational challenges like rising interest rates, inflation, and labor shortages, some SNFs have emerged stronger. These facilities adapted to these challenges by streamlining operations, leading to improved efficiency benefits as occupancy rates rise and cost structures remain controlled.

Public Company Performance as a Leading Indicator

A review of Ensign Group (NASDAQ: ENSG), a publicly traded proxy for the SNF sector, reveals a robust year-over-year (YOY) stock performance of 18.7%. This positive performance is bolstered by rising occupancy rates (77.8% to 79.9%) and a significant increase in EBITDAR (Earnings Before Interest, Taxes, Depreciation, and Amortization Rents) of 15.0% (from $536.6M to $616.9M).

PACS Group IPO Highlights Investor Confidence

The recent Initial Public Offering (IPO) of PACS Group is another noteworthy development. The IPO priced at $21.00 (mid-point of the filing range) and experienced a post-closing rise of 16.9%. Additionally, PACS’s valuation metrics appear comparable to Ensign Group, suggesting investor confidence in the SNF market’s potential.

M&A Activity and Attractive Valuations

SNF M&A activity has remained steady over the past three years. This stability points to a highly fragmented market with significant consolidation opportunities, particularly among “mom and pop” operators. Furthermore, valuations appear attractive compared to other provider-based services, potentially offering value alternatives for investors seeking growth opportunities.

Long-Term Growth Potential

While the industry faces ongoing operational challenges like new staffing minimums, long-term macro trends remain positive. These trends include an aging population, increasing Medicare spending, limited access to alternative care options, and a decline in pandemic-related safety concerns. These factors combine to create exceptional opportunities for SNF operators and investors with a deep understanding of the market dynamics.

For more information or questions, please contact the Healthcare Services team:

Paul Kacik, Managing Director: pkacik@hexagoncapitalalliance.com

Brad Erhart, Director: berhart@hexagoncapitalalliance.com

Daren Oddenino, Director: [email protected]

Market Monitor: Personal Care

Market Monitor: Personal Care

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Market Monitor: Personal Care

Making the right decisions for your business starts with having the most accurate and current information available. Our Personal Care Market Monitor keeps you up to date on the events, trends, and market forces that shape and guide the industry.

The Personal Care industry is witnessing a resurgence in mergers and acquisitions (“M&A”) activity after a slow 2023. This surge highlights the strategic use of M&A to drive growth and capitalize on market opportunities.

Beauty Sector Leads M&A Charge with Brand Portfolio Expansion

  • Spiking Deal Volume: Q1 2024 saw a significant increase in Personal Care M&A deals compared to Q1 2023, with nearly double the transactions closed (14 vs. 7).
  • Strategic Acquisitions for Brand Diversification: Beauty companies are actively utilizing M&A as a strategic tool to diversify their brand portfolios and expand into new product categories.

M&A Fuels Growth in the Vitamins & Supplements Market.

The global Vitamins, Minerals & Nutritional Supplements (VMS) sector boasts a promising future, with a projected CAGR of 9.1% from 2024 to 2030. This positive outlook is fueling M&A activity within this segment as well. 

  • Private Equity Investment in VMS Contract Manufacturers: Private equity groups are actively pursuing add-on acquisitions of contract manufacturers within the VMS space.
  • Scaling Manufacturing Capacity through M&A: These deals are primarily driven by the need to increase production capacity and expand manufacturing capabilities across various VMS product formats.

Overall Optimism Creates Opportunities for Continued M&A Activity

  • The positive M&A trends are further bolstered by continued optimism within the Personal Care industry. Contract manufacturers and packaging companies report stable to slightly increased volumes, indicating a healthy underlying demand for personal care products.

New Product Innovation Drives Packaging M&A Potential

  • New product innovations and marketing campaigns are spurring additional designs, artwork, and packaging formats. This trend bodes well for both contract manufacturers and packaging materials companies, potentially leading to further M&A activity in these sectors.

For more information or questions, please contact our contributors:

Rich Anderson, Managing Director: randerson@hexagoncapitalalliance.com

Andrew Suen, Managing Director: asuen@hexagoncapitalalliance.com

Johnny Sherwood, Director: jsherwood@hexagoncapitalalliance.com