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Insights on Issues & Trends that Impact Investments in Healthcare & Life Science Businesses

What Investors Should Understand About Investments in Hospice, Home Health and the Broader Post-Acute Sector – 3 Key Points

Posted in Healthcare Services Investing

The next in our series of posts sharing key takeaways from panels at the Healthcare & Life Sciences Private Equity and Lending Conference is authored by our colleagues Trey Andrews and Jeff Alberg.

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What Investors Should Understand About Investments in Hospice, Home Health and the Broader Post-Acute Sector – 3 Key Points

By Trey Andrews and Jeff Alberg

The post-acute care sector, with a focus on home health and hospice, continues to attract high levels of interest from investors due to organic growth opportunities and consolidation drivers. This is the case despite recent reimbursement changes affecting home health agencies that have been brought on by value-based care models implemented by the Medicare program, according to experts who spoke on a panel at the 17th Annual Healthcare Private Equity & Finance Conference in Chicago on February 19, 2020. The experts’ discussion highlighted current market conditions and trends for acquisitions in the post-acute space, attractive subsectors and markets for investments, and preliminary reactions to the implementation of the Patient-Driven Groupings Model (PDGM), the newest government reimbursement scheme for home health agencies.

Experts included Jonny Miller, Vice President, Revelstoke Capital Partners LLC; Jim Moskal, Managing Director, Livingstone Partners; Aaron Osmundson, Managing Director, Quadriga Partners; Whit Polley, Chief Development Officer, Angels of Care Pediatric Home Health; and Pete Tedesco, Principal, Health Enterprise Partners. The panel was moderated by Trey Andrews, Attorney, McGuireWoods LLP.

Here are three (3) key points from the panel discussion that investors should understand about the state of the current post-acute care market:

1. Implementation of the Patient-Driven Groupings Model (PDGM). The implementation of PDGM, on January 1, 2020, marked the most significant change to the Medicare program’s payment methodology for home health services in nearly 20 years. Consistent with the trend seen across the health care industry, PDGM shifts the reimbursement model for home health agencies from volume-based care to value-based care. As a result, investors interested in home health agencies have recently adjusted their investment strategies to allow the changes stemming from PDGM to take effect. Investors are in a “wait and see” mode resulting in a pause in investment in the home health sector. However, investors are also being presented with attractive opportunities for investments in the home health sector at discounted multiples due to an uptick in home health sellers that are not in a position to weather the reimbursement changes of PDGM. In sum, investors may have hit pause on actively shopping for home health agencies to wait and see how PDGM plays out, but when presented with opportunities, investors are still very active in the home health space. The panel experts predict that any potential slowdown in the home health sector will likely only be temporary, as the industry observes the practical effects of PDGM.

2. The Continued Rise of Interest in Hospice. Although investors could be throttling back on investments in home health agencies during the first half of 2020, they are not abandoning the post-acute space as a whole. Panelists instead indicated that they have shifted their sights towards the hospice sector based on an investment strategy keen on U.S. population demographics and an increased focus on post-acute care in general. Panelists indicated that the hospice sector continues to be highly attractive due to its lack of consolidation and continued fragmentation in regional areas. They also mentioned that the increased need for providing palliative care services to patients, the shifts to value-based contracting, and an aging U.S. population, all play into the attractiveness of investing in hospices. While PDGM could have an impact on home health investments, it appears that investors seem to be shifting their interest to the hospice sector, which has already been extremely active over the last six to twelve months.

3. Post-Acute Sleeper Sectors. When discussing ancillary or sleeper sectors in the post-acute space, the panel experts indicated that other areas of the post-acute care sector, which have traditionally garnered less investment and attention, particularly such pediatric home health, non-medical home care, and palliative care, are increasingly attractive investments in non-traditional post-acute care providers. First, the panelists highlighted the significant consolidation opportunities for investments in pediatric home health providers. Panelists expressed interest in pediatric home health providers as a gateway for offering patients additional services, such as private duty nursing, therapy, and even hospice services in some instances. While value-based care has not yet been implemented in pediatric home health, panelists emphasized that pediatric home health providers are building important relationships with payors now in order to be ready for its eventual implementation in the market. Second, panelists found attractive opportunities in the non-medical home care sector, which, despite not being covered by Medicare, offers investors the upside of less regulation and more robust reimbursement rates than those seen throughout the rest of the post-acute sector. Non-medical home care, like home health care, has experienced rapid growth as an aging U.S. population base seeks new post-acute services to allow them to maintain significant independence in their own home. Panelists also noted that there is growing interest in palliative care providers who bridge the gap for healthcare services between home health and hospice—currently a significant gap in the post-acute care model. Although not currently a reimbursable service under Medicare, investors are continuing to look at palliative care as a service offering to patients that is necessary and in high demand.

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Pharmaceuticals, Medical Device & Life Sciences Investments – 4 Key Points

Posted in Healthcare Services Investing

The next in our series of posts sharing key takeaways from panels at the Healthcare & Life Sciences Private Equity and Lending Conference is authored by our colleagues Brian King and Royce DuBiner, and Kathy Contratto of RSM US.

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Pharmaceuticals, Medical Device & Life Sciences Investments – 4 Key Points

By Brian King, Royce DuBiner and Kathy Contratto

Consolidation promises to be an ongoing trend in the medical device market in 2020. The industry appears focused on diagnostic imaging, telehealth, and wearable devices. According to experts who spoke on a panel at the 17th Annual Healthcare and Life Sciences Private Equity and Finance Conference on February 19 and 20, there could be significant market disruptions in the coming year as price transparency and Medicare-for-all continue to dominate policy discussions.

Experts included Kathy Contratto, Director, Healthcare Services, RSM; Matthew Evans, Managing Director- Healthcare, Monroe Capital; Stephen Morales, Senior Vice President, Marwood Group; and Dr. Dikesh K. Patel, Pharm.D., Supervisor, Pharmacy Team, RSM. The moderator was Phil Smith, Managing Director, Duff & Phelps.

Here are four key points from the panel discussion:

1. Market Consolidation. Consolidation remains a dominant trend in the medical device space. Experts emphasized increased activity in the diagnostic imaging space as well as wearable device technology. There has been a trend toward consolidation for the past few years, and experts anticipate the trend to continue.

2. Telehealth. New technologies continue to improve access to care via telehealth. Experts expect the flurry of activity surrounding new telehealth platforms to continue, as patients continue to become more comfortable with receiving their healthcare through telemedicine. Platforms like Teledoc allow patients to have access to specialists in minutes, and apps like Capsule promise to deliver drugs to patients with an Amazon-like business model. Companies like SpaRx allow patients to speak to a pharmacist in real-time via a kiosk and allow medications to be dispensed by a vending machine. Experts agree that they expect the market for wearable devices and novel telehealth platforms to continue.

3. Medicare-For-All. Experts expect policy discussions surrounding Medicare-for-all to have a substantial impact on the drug and device market. Significant uncertainty remains as to what effects the proposed Medicare-for-all would have on the market. Some proponents voice excitement in the increased coverage such a proposal would have, but others remain skeptical that such sweeping changes would receive Congressional approval.

4. Price Transparency. Regardless of the outcome of the 2020 presidential election, price transparency is expected to be at the center of the healthcare debate. Experts highlight the obvious concern that transparency efforts will likely have a negative effect on profit margins, and expect the market to respond to these pressures by finding ways to make operations more efficient. Whether we have a Republican or Democrat President in office later this year, there is certainty that price transparency will be a priority and first step toward putting the American patient in control.

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McGuireWoods’ COVID-19 Resources Keep Clients Current on Latest Developments

Posted in Healthcare Services Investing

The McGuireWoods COVID-19 Response Team has been incredibly active and remained ahead of the game with informing clients of the most significant legal and business issues affecting healthcare. You can access all coronavirus webinars (recorded and upcoming) and thought leadership pieces here.

One of the most unique pieces that healthcare investors and operators are finding valuable is our roundup of state governors‘ “stay-at-home” and prohibition on elective procedures orders. View the most current version of this piece here.
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Advanced PPM Topics: Payor Contracting Strategies & Value Based Care & Purchasing – 4 Key Takeaways

Posted in Healthcare Services Investing

The next in our series of posts sharing key takeaways from panels at the Healthcare & Life Sciences Private Equity and Lending Conference is authored by our colleague Nesko Radovic and Jessika Garis of RSM US.

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Advanced PPM Topics: Payor Contracting Strategies & Value Based Care & Purchasing – 4 Key Takeaways

By Nesko Radovic and Jessika Garis

As value-based care gains momentum in the healthcare industry with over ten million Medicare beneficiaries assigned to an accountable care organization, providers and payors are looking for new ways to move away from traditional fee-for-service models and toward some form of value-based care. Experts at the Annual Healthcare and Life Sciences Private Equity & Finance Conference in Chicago on February 19, 2020 provided insights into how value-based care is affecting payor contracting and the impacts these changes are having on private equity investors.

Experts included Michelle Werr, Principal at HealthScape Advisors and Tom Goila, Partner at Comvest Credit Partners. Jessika Garis, Director at RSM US LLP, moderated the panel.

Here are four key takeaways from the panel discussion:

1. Physician Practices must understand the types of markets that are available and where those markets are heading, to position themselves for a successful value-based arrangement. As markets increasingly favor value-based arrangements, a practice’s position will depend on its line of services, current payor contracts, and financing mechanisms available. Practices must understand a variety of markets, from Medicare Advantage, which is leading the value-based care movement, to commercial markets, which are implementing new models, to Medicaid markets, which vary depending on the state and whether the state has a developed value-based strategy.

2. Payors and providers are shifting toward a more collaborative approach. More physician practices are engaging consultants or hiring business managers to understand the various reimbursement models and the impact that those models may have on their practices. Providers are also joining pilot programs without financial burden, which offer a practical view of the models’ application. Finally, practices are trending toward consolidation based on their specialty or geographic location to gain leverage over payors.

3. Private equity investors provide an opportunity for physician practices to increase their size and scale, and better position themselves to negotiate with payors. This leverage with payors is often a significant factor in staying profitable and competitive in the current market. As markets transition to value-based arrangements, investors will place value on practices that have experienced leadership, infrastructure and knowledge to pivot their practice to value-based reimbursement models.

4. Experts projected that moving towards value-based contracting will ultimately eliminate the risk of high healthcare costs associated with private equity investments in specialty care. This is an important part in providing price transparency and revealing the actual value that the physician practice supplies to the market. Based on that value, practices will attract payors and join in more value-based arrangements, resulting in overall growth in business.

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McGuireWoods Launches ‘Across the Table Podcast’ on Healthcare Private Equity

Posted in Healthcare Services Investing

We see various opportunities for distressed investing, both with respect to platform transactions as well as tuck-in transactions as certain businesses struggle to emerge from the COVID-19 pandemic

The authors have launched a new podcast called “Across the Table Podcast.” This podcast provides timely and relevant discussions with specialists and professionals of the healthcare private equity and finance industry. We’ll share latest developments, provide insight, identify issues and talk takeaways.

In the first episode, Mark Freedlander, Pittsburgh partner, discusses distressed investing in the healthcare sector, including an overview of the out-of-court and formal-bankruptcy process, common issues in distressed M&A and the importance of diligence. As the financial markets and economy negatively reacts to COVID-19, we are focusing our attention on opportunities for investing in distressed healthcare businesses. Successfully closing a transaction when the target is in financial distress presents some unique challenges. Whether the business has sought bankruptcy protection or is outside of the formal court process, there is opportunity for significantly cheaper deals, albeit with greater risk, available.

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Looking Ahead to New Perspectives in Pharmacy Investing: 5 Key Points

Posted in Healthcare Services Investing

The next in our series of posts sharing key takeaways from panels at the Healthcare & Life Sciences Private Equity and Lending Conference is authored by our colleagues Lauren M. Graff and Richard Grant.

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Looking Ahead to New Perspectives in Pharmacy Investing: 5 Key Points

By Lauren M. Graff and Richard Grant

While the market for middle market investments in pharmacy providers has leveled off, there are plenty of big pharma pain points that leave the door open for new solutions and growth in the industry. According to experts who spoke on a panel at the McGuireWoods 17th Annual Healthcare Private Equity & Finance Conference in Chicago on February 19, investors simply need to be willing to look more broadly to pharma-adjacent companies for new investment opportunities.

The presenting experts included Mike Alberts, Vice President of Cohere Capital Partners, Kent Berkley, Vice President of Frazier Healthcare Partners, and Dexter Braff, President of The Braff Group. The panel was moderated by Richard Grant, a McGuireWoods LLP partner.

Here are five key points from the panel discussion.

1. Pharmacy provider investing has grown too large for mid-level private equity. The wave of deals in the early 2000s has caused a supply issue in the pharmacy investment space. One expert estimated that between 2004 and 2015 there were over 200 transactions involving the purchase of pharmacy providers. The fast-moving market has left very few opportunities for mid-level private equity investing; the issue is not in demand but in supply. Currently, opportunities for direct investing in pharmacy providers are essentially open to only large investors that have the ability to drive provider costs down, i.e. insurance companies. However, these large providers are not without their pain points — including the search for further cost containment — and they are generally open to discussions with anyone that can present a possible solution to their problems. As one expert summarized, it is easy to focus on the overcrowding of the inpatient and outpatient hospital space, but investors should get creative with their perception. It is not the elimination of mid-level private equity investment opportunities, but a new focus on how to help large providers with their pain points.

2. The good news is pharma is a $300 billion medication problem in search of technological solutions. Not surprisingly, the answers to large providers’ problems are tech-based. Pharma encompasses retail space, long-term care, and hospital pharmacy, each with their own individual pain points presenting an opportunity for a new solution. There is already a lot of pharma-related technology on the market, however, and providers are faced with the issue of communication across technologies. Software that can communicate with other software is the gap in the market, particularly software that keeps both patient data and the patient within its purview. Large providers, insurance companies, and hospitals are unwilling to buy numerous applications and software that cannot successfully communicate with one another.

3. Focus on customer service and revenue will follow. Experts on the panel also noted that it is too easy to get caught up in the search for the margin in pharmacy investing, and urged investors to instead focus on the intersection of margin and where one can build a business. They suggested that, in the current market, if one can build a business by focusing on bettering provider and patient engagement, revenue will follow. Patients want convenience, both in obtaining their medication and in getting their questions answered, which seems to suggest a balance between technology efficiency and a people-forward model. Experts noted the new CVS model – bringing its pharmacists up front, out from the back of the store – encourages direct interactions with customers, providing patient care in the same place prescriptions are filled and creating a healthcare hub. This model is on one side of the spectrum while Amazon’s PillPack prescription delivery service may be on the other. Both are trying to meet customer needs with different approaches.

4. Growth in the industry: Central Filling Facilities. While opportunities for direct investing in pharmacy providers are falling, they may not have altogether disappeared. Experts argued central filling facilities is a fast-growing area. The model is centered around a single facility that produces large amounts of scripts that are sent through multiple channels: directly to patients at their homes, to hospitals, or to retailers, focusing on large-scale production at a high efficiency rate. While the typical model is a large facility filling all types of scripts, central filling facilities may also specialize in a particular area of medication or medicine.

5. Pharma-adjacent spaces provide opportunities for pharma-like investing. With the consolidation of pharmacies putting direct investment opportunities out of reach of mid-level private equity, specialty providers may be the answer. The panel suggested that behavioral health may have some roll-up opportunities, and the market may see a growth in this area as pharmacies turn more of their focus towards it. Methadone clinics particularly show a developing interest, but the underlying thesis of such clinics is not pharma but rather therapeutic intervention. Creative partnerships may also be the key; experts cited the recent partnership between Humana and the private equity firm of Welsh, Carson, Anderson & Stowe, which should result in the launching of more primary care centers aimed towards the Medicare Advantage population. Long-term care facilities provide a unique platform that may lend itself well to such partnership opportunities.

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Healthcare & Life Sciences Private Equity Deal Tracker: Northlane Capital Invests in VMG Health

Posted in Healthcare Services Investing

Northlane Capital Partners (NCP) has announced it has invested in VMG Health.

VMG, based in Dallas, is a valuation and transaction advisory firm focused exclusively on healthcare.

NCP, based in Bethesda, Md., is a middle-market private equity firm focused on healthcare and business services. Founded in 2003, the firm seeks investments in North American companies with EBITDA of $5 million to $30 million.

Terms of the investment were not disclosed.

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The Evolution of Sub-Specialty Investment Strategies: Five Takeaways

Posted in Healthcare Services Investing

The next in our series of posts sharing key takeaways from panels at the Healthcare & Life Sciences Private Equity and Lending Conference is authored by our colleagues Amanda Roenius  and Timothy Fry.

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The Evolution of Sub-Specialty Investment Strategies: Five Takeaways

By Amanda Roenius and Tim Fry

Private equity investment in various sub-specialties, such as retina and oral surgery, continues to be a significant trend, providing even more opportunities for private equity to invest in the healthcare space. Experts spoke on a panel titled “Advanced PPM Topics: The Evolution of Sub-Specialty Investment Strategies” at the 17th Annual Healthcare and Life Sciences Private Equity & Finance Conference, held in Chicago on February 19 and 20, 2020.

Experts included Giovanni Barbat, President at American Vision Group; Roy Berjano, Co-Founder and CEO at Scale Physician Group; Richard Hall, President and CEO at US Oral Surgery Management; Todd Roland, Principal at GCM Grosvenor; and Timothy Wentink, Managing Director at Twin Brook Capital Partners. The panel was moderated by Tim Fry, an attorney in the Chicago office of McGuireWoods LLP.

Here are five key takeaways from the panel discussion.

1. Additional opportunities (and complexity). The growth of sub-specialties provides additional opportunities to expand the scope and target range of investment opportunities. As the experts opined, both multi- and single-specialties provide excellent growth opportunities within a specific sector. At the same time, investors should understand the unique challenges of investing in sub-specialties given the additional complexities surrounding payor relationships, referral patterns, and physician alignment. These complexities should be carefully weighed and addressed at the outset to maximize success.

2. Understanding payor reimbursement is key. Investment in sub-specialties requires a more thorough expertise in the specific sector, especially as it relates to payor reimbursement. For example, experts commented that as private equity investment in sub-specialties increases, payors will begin looking for more continuity of care and to better understand the investment structure. Additionally, although many sub-specialties remain heavily fragmented, certain sub-specialties tend to see a higher percentage of Medicare and Medicaid reimbursement, causing some investors to shy away. Understanding the reimbursement landscape not only better positions investors from a financial standpoint, but payment diversification will continue to play a major role for investment.

3. Create a clear vision for sub-specialties within the platform. Investors should have a clear vision for their sub-specialty investments. As the experts opined, in some healthcare sectors, sub-specialty investment has been slower to see growth. Accordingly, in those sectors, experts suggest investors focus their investments on fewer sub-specialties as opposed to “owning the market.” According to some experts, this strategy will, in turn, provide more time to focus on the day-to-day needs of growing a particular investment. On the other hand, some experts juxtaposed this discussion, looking to sectors such as vision in which it may make sense for investors to own more of the market and become vertically integrated. Ultimately, for success, private equity funds will need to create a clear vision for what their sub-specialty investments look like based on the overarching sector.

4. Growth models may differ. Understanding growth strategies and how they may vary between sub-specialties is important for success. As investors look to grow their sub-specialty investments, it is important to understand that not all sub-specialty investments can (or should) grow at the same rate. Accordingly, the experts encouraged investors to fully understand the business they are committing to and partnering with in order to best set forth a realistic growth model. Similarly, experts also caution that there is the potential for growing too quickly, urging investors to take careful consideration in selecting practices within a sub-specialty with whom to partner.

5. Physician alignment is mission critical. Alignment, especially amongst younger, entrepreneurial physicians, is a key component for sub-specialty investment success. In discussing how investors can best ensure alignment and incentivize new physicians, the experts suggested treating physician alignment as its own separate business model. Investors should provide physicians with a separate pitch deck and consider various incentive models, such as rollover equity or an associate equity pool to attract younger physicians and gain their buy-in to the overall model. Investors should seek to strike a balance in aligning with both the more seasoned physicians, who are better positioned to sell, while at the same time, attracting the next generation of providers who will help excel growth.

State and Federal Policy Changes Impacting Healthcare Markets – Six Key Points

Posted in Healthcare Services Investing

The next in our series of posts sharing key takeaways from panels at the Healthcare & Life Sciences Private Equity and Lending Conference is authored by our colleagues Scott Becker and Timothy Fry.

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State and Federal Policy Changes Impacting Healthcare Markets – Six Key Points

By: Scott Becker & Timothy Fry

Federal and state policymakers could impact healthcare investment markets in the coming year, particularly as more policymakers learn about private equity investment in the healthcare space, according to experts who spoke on a panel at the 17th Annual Healthcare and Life Sciences Private Equity and Finance Conference on February 20 in Chicago.

Experts included Governor James Hodges, President – State Government Relations, McGuireWoods Consulting LLC, Stephanie Kennan, Senior Vice President – Government Relations, McGuireWoods Consulting LLC, Thomas Londrigan, Sr. Vice President & Director, McGuireWoods Consulting LLC, Rick Kes, Partner, RSM and Scott Becker, Partner, McGuireWoods LLP.

Here are six key points from the panel discussion:

1. Surprise billing initiatives could enhance scrutiny of private equity investment in healthcare companies. Washington policymakers would like to end surprise out-of-network bills from hospital specialists. This initiative has introduced some elected representatives and their staff to the healthcare private equity model. Not all have viewed this investment favorably, as key interest groups have made their negative views known to both sides of the aisle. As such, investors should be aware that future efforts to curb surprise billing may also impact private equity investment, with at least one bill (H.R. 5825) introduced to target certain healthcare investors.

2. Significant voter interest remains in healthcare reforms, but the panel experts found it difficult to see pathways for significant federal change. Voters consistently cite healthcare as their top concern, and leading Democratic candidates at all levels are focusing their 2020 campaign messages on healthcare, like during the 2018 midterm election. That said, panelists were skeptical that proposals like Medicare-for-All could be enacted. Panelists even questioned whether reforms with bipartisan appeal, like prescription drug pricing efforts, could succeed in Washington’s current polarized environment.

3. Instead, panelists predicted that the courts will drive federal healthcare policy in 2020. Panelists discussed pending cases, including a third constitutional challenge to the Affordable Care Act, which is set for oral argument before the Supreme Court this fall. Even Medicare reimbursement issues may see more judicial action than congressional focus, as CMS is tied up in multiple site neutrality disputes/appeals that challengers have brought, and thus far won, against the agency.

4. Telemedicine investments may finally be boosted by policy headwinds. The panel experts agreed that policymakers increasingly view telehealth and telemedicine initiatives positively. Many states have enacted statutes addressing telehealth reimbursement. It appears that state legislators and CMS regulators now believe that such care can be high quality and cost effective after witnessing the success of initiatives like hospital remote monitoring efforts. Since the panel, the COVID-19 pandemic has led to additional telemedicine changes in federal law. All told, investors could use such policy changes to build telehealth platforms.

5. State diversification is one way for investors to mitigate policy risk. Business considerations often necessitate expanding operations beyond a core state of operations. Panelists suggested state policy may be another factor. For example, Illinois has had its share of budget challenges, which have resulted in delays of Medicaid payments to providers. A state-diversified platform is likely better positioned than a platform located only in Illinois to withstand cash flow challenges arising from these delays. Further, as states explore policies like benchmarking Medicaid to reduce costs, or adding beneficiary work requirements, provider platforms that are reliant on Medicaid reimbursement should consider expanding their businesses to other states. Expansion into other states may also have the added benefit of diversifying the platform’s participation in commercial third party payor networks.

6. Investors should consider adding a political strategy to their healthcare platforms. As noted above, private equity investors are facing enhanced scrutiny. Conversations with policymakers could help change the narrative if private equity is able to reach these policymakers before their views are set. Forming such relationships can also be critical when a platform is reliant on government contracts or is seeking state licensure or certificate of need approvals. While most investors may rely on overall industry conditions, certain investors may need to focus on specific initiatives to protect and grow their businesses.

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Note, since the panel, the scope of the COVID-19 pandemic has grown more significant and acute. Our panel likely would focus more on this topic if held today.

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