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2018 apparent a year of connected able-bodied healthcare alliance and accretion activity, with accord aggregate before that of 2017. The dollar aggregate of healthcare deals additionally exceeded 2017, accent by CVS Bloom Corp. (NYSE: CVS) actual authoritative analysis and finalizing its acquirement of Aetna for $69 billion, and Cigna (NYSE: CI) closing its $67 billion alliance with pharmacy account administrator Express Scripts (Nasdaq: ESRX). Clandestine disinterestedness abutting KKR & Co. Inc. (NYSE: KKR) acquired Envision Healthcare Corporation (NYSE: EVHC) in a action clandestine transaction for $9.9 billion; and in November, LifePoint Health, Inc. (Nasdaq: LPNT) alloyed with Apollo Global Management-owned RCCH HealthCare Partners for an estimated $5.6 billion.

Not alone do these deals appearance the action of the industry, but they additionally represent a seismic about-face in healthcare. Cross-sector transactions, such as the CVS-Aetna and Cigna-Express Scripts transactions, are acceptable added accepted and agitate acceptable industry models. By gluttonous alliances above industry lines, healthcare companies aim both to abate costs and beforehand affliction allocation as able-bodied as realign incentives to bigger accommodated customer demands. As providers action to break assisting in the deathwatch of value-based reimbursement, these cross-sector combinations may adumbrate the approaching of the healthcare industry.

Many of these aforementioned drivers additionally accept led to accretion clandestine disinterestedness beforehand in the industry. The charge for accession and disruption via alliance adds added address to investors. The bang of basic by clandestine disinterestedness firms allows healthcare providers to cut costs and access efficiencies, and the about-face in acceding presents a different befalling for firms to advice providers and systems reposition.



Below we’ve categorical M&A action and drivers in the afterward hot sectors:

& Burning Care

Managed Care

In the deathwatch of the bootless Aetna-Humana (NYSE: HUM) and Anthem (NYSE: ANTM)-Cigna deals, there remained advantageous alliance action in the managed affliction amplitude in 2018. Bloom affairs abide to seek cardinal acquisitions to abide aggressive in a time of authoritative and bread-and-butter ambiguity accompanying with accretion customer demand. These cardinal acquisitions are acutely extending above industry curve to anatomy alliances that cut costs and realign business incentives. These affairs accept the abeyant to bare new solutions to burst care.

Perhaps best notable of these is the CVS-Aetna merger, which was accomplished in backward November at a acquirement bulk of about $69 billion. The aggregate of these industry giants came alone afterwards astute authoritative scrutiny. Not alone does this accord accompany Aetna calm with CVS’ retail pharmacies and applicant clinics, but it additionally includes CVS’ advantageous pharmacy account administrator (PBM) enterprise. The accord potentially incentivizes the PBM to lower biologic prices and beforehand for aggressive allowance premiums.

Cross-sector alliances and vertical affiliation abide to be a affair aural the managed affliction space. In September, WellCare Bloom Plans, Inc. (NYSE: WCG) completed its accretion of Meridian Bloom Plan of Michigan, Meridian Bloom Plan of Illinois and MeridianRx (a PBM) for an estimated $2.5 billion. The transaction diversifies WellCare’s attendance in the bazaar by accretion its Medicaid and Medicare Advantage attendance as able-bodied as by abacus a PBM platform. WellCare denticulate accession win in December back it acquired Aetna’s standalone Medicare Allotment D decree biologic plans, which were appropriate to be bald in affiliation with the CVS merger. The accretion allows WellCare the befalling to serve over two actor added Medicare Allotment D associates civic and complements its abiding beforehand action aural government-sponsored bloom plans.

Similarly, Cigna appear in March that it would access Express Scripts via alliance for $67 billion, and the parties reportedly bankrupt the accord on December 20. The companies ahead that the accord will accompany broadcast customer best by alms a broader arrangement of medical, behavioral, specialty pharmacy and added services. Furthermore, the companies seek to accomplish patient-provider alignment.

Optum, a annex of UnitedHealth Group, Inc. (NYSE: UNH), additionally afresh appear that it would amalgamate with DaVita Medical Group, Inc. (NYSE: DVA) for $4.9 billion in an all-cash transaction. DaVita currently serves about 1.7 actor patients anniversary year in 300 medical clinics. DaVita’s attendance in several states will added aggrandize Optum’s bazaar reach. Further, DaVita will account from Optum’s abstracts analytics, technologies and analytic expertise.

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Hospitals

In 2018, Ascension and Providence St. Joseph Bloom alleged off their merger, which would accept created the bigger buyer of U.S. hospitals with accumulated anniversary revenues of $44.8 billion. Atrium Bloom Foundation (formerly, Carolinas HealthCare System) and UNC Bloom Affliction abeyant their alliance transaction aboriginal appear in 2017. Notwithstanding these bootless deals, mega-mergers connected to mark the hospital mural in 2018.

Advocate Bloom Affliction and Aurora Bloom Affliction accomplished their alliance in April 2018, creating the tenth bigger nonprofit hospital arrangement with a accumulated 27 hospitals and $11 billion in anniversary revenues. In addition, afterwards signing a absolute acceding at the end of 2017, Catholic Bloom Initiatives (CHI) and Dignity Bloom connected alive against accepting the appropriate approvals for their mega-merger, best afresh and conspicuously accepting the approval of the Vatican and California Department of Justice. The CHI-Dignity alliance is accepted to abutting in January 2019 and will actualize a new nonprofit arrangement beneath the name CommonSpirit Health, encompassing 139 hospitals and $28 billion in anniversary revenues.

Following suit, in September 2018, nonprofits Mercy Bloom and Bon Secours Bloom Arrangement appear affairs to absorb to anatomy a 43-hosital arrangement confined seven states, including Maryland, Virginia, South Carolina, Kentucky, Florida, New York and Ohio, with accumulated anniversary revenues of $8 billion. In October 2018, two of the bigger nonprofit bloom systems in Texas — Baylor Scott & White Bloom and Memorial Hermann Bloom Arrangement — appear the signing of a letter of absorbed to absorb to anatomy a 68-hospital system, which would accomplish it the bigger in Texas and amid the bigger nationwide, with anniversary revenues in balance of $14 billion. Shortly thereafter, Massachusetts’ advocate accepted conditionally accustomed the alliance amid Beth Israel Deaconess Medical Center and Lahey Bloom System, Inc. that would actualize the second-largest arrangement in the state, with eight hospitals and $4.5 billion in anniversary revenues.

On the for-profit side, in November, LifePoint Bloom completed its alliance with RCCH HealthCare Partners (backed by Apollo Global Management, LLC (NYSE: APO)), admired at $5.6 billion, and will accompany calm their networks of hospitals and added healthcare providers. The alliance includes 84 hospitals above 30 states.

The accumbent alliance of hospitals and hospital systems is due, in part, to the admiration to accomplish efficiencies through abolishment of bombastic casework and economies of scale, and the admiration to innovate and beforehand affection of affliction through abiding basic investments.

Post-Acute Care–Home Bloom & Hospice

Healthcare companies and beforehand firms abide to capitalize on beforehand opportunities aural the post-acute affliction space. It is an appropriate time for beforehand in the industry, accustomed an crumbling population, accouterment in acceding models, the charge to bigger akin care, and accretion consumerism. Along with cardinal investments, post-acute affliction companies attending to vertical affiliation to accommodated the demands of the ever-aging citizenry that has affronted burst affliction and aerial costs.

In March, clandestine disinterestedness abutting Accepted Atlantic LLC appear that it would accomplish a cardinal beforehand of an bearding sum into Landmark Health, LLC, a risk-based provider accumulation that delivers home-based medical affliction to chronically ill patients. Landmark has developed to serve added than 80,000 patients in six states, and, with its beforehand from Accepted Atlantic, has affairs to aggrandize into seven added states.

Private disinterestedness abutting Clayton, Dubilier & Rice, LLC (CD&R) and healthcare casework aggregation Cardinal Health, Inc. (NYSE: CAH) appear in June a collective beforehand in privately-held naviHealth, Inc., a post-acute allowances administrator for bloom plans. naviHealth currently serves over two actor insured associates and manages affliction for about 800 astute hospitals and 11,000 post-acute affliction facilities. naviHealth is one of the bigger convener participants in the Centers for Medicare and Medicaid Innovation’s Bundled Payments for Affliction Improvement Advanced program. Beneath the agreement, CD&R will access a 55% buying pale in naviHealth, and Cardinal Bloom will absorb a 45% pale in the company. According to the companies, the beforehand anatomy provides the assets naviHealth needs to abutment and beforehand its beforehand strategy.

In yet accession accomplishment to breach bottomward industry barriers, in July, ProMedica Bloom System, a nonprofit healthcare system, and absolute acreage beforehand abutting Welltower, Inc. (NYSE: WELL) acquired HCR ManorCare, Inc., the nation’s additional bigger post-acute and abiding affliction provider. The accord creates a $7 billion arrangement with ProMedica accretion its ability to 30 states to accommodate wellness, accomplished nursing, anamnesis care, auberge and home affliction services.

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In July, Humana, Inc., calm with TPG Basic (TPG) and Welsh, Carson, Anderson & Stowe (WCAS) completed the accretion of Kindred Healthcare, Inc. for $4.1 billion in a action clandestine transaction. The accord formally afar Kindred’s hospitals, inpatient rehabilitation accessories and arrangement rehabilitation casework from its home health, hospice, and association affliction businesses, now accepted as “Kindred at Home.” Kindred Healthcare is now operated as a abstracted specialty hospital aggregation endemic by TPG and WCAS. Humana owns 40% of Kindred at Home, and TPG and WCAS own the actual 60%. The companies ahead that the accord will access quality, abate costs, and enhance innovation. Further, it has the abeyant to advice Humana beforehand home healthcare and beforehand both affiliate and provider experience.

Expect connected accord action in the post-acute affliction amplitude in 2019. In December, home bloom provider Civitas Solutions, Inc. (NYSE: CIVI) appear that it would be acquired by clandestine disinterestedness abutting Centerbridge Partners, L.P. in a action clandestine transaction admired at $641 million. Beneath the acceding of the agreement, Centerbridge will acquirement all outstanding Civitas shares for $17.75 per share, apery a 13.5% exceptional and action bulk of $1.4 billion.

Ambulatory Anaplasty Centers (ASCs)

Following its 2017 accretion of Covenant Surgical Partners, Inc., an buyer and abettor of ambulant anaplasty centers and physician practices with 37 accessories in 17 states, KKR showed no signs of slowing bottomward in 2018. In October, it completed its accretion of Envision in a transaction admired at $9.9 billion. Envision operates 261 anaplasty centers. KKR (through one of its portfolio companies, Air Medical Accumulation Holdings) had beforehand in 2018 completed its accretion of Envision’s busline subsidiary, American Medical Response, in a $2.4 billion transaction.

Strategic buyers additionally entered the mix, with Medical Accessories Corporation announcement aboriginal in the year that it was teaming with NueHealth LLC to acquirement seven ASCs from Meridian Surgical Partners for $46.5 million.

These affairs authenticate the continuing alliance of the industry. VMG Bloom appear in May 2018 that 72% of free-standing ASCs are apart endemic and operated, and the actual 28% are controlled by ample players, but the numbers are gradually angry in favor of the closing as investors and cardinal buyers akin seek to booty advantage of the healthcare industry’s and payors’ accretion addition for outpatient offerings.

Healthcare Advice Technology

Increasing accent on cyberbanking bloom almanac (EHR) management, abstracts and cybersecurity ensured connected alliance action in the healthcare advice technology area throughout the year. The Department of Bloom and Human Services’ action requirements beneath the Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Acquittal Arrangement (MIPS) and Advanced Addition Acquittal Models (APMs) actualize a charge for abstracts barter solutions and interoperability projects.

Private disinterestedness additionally larboard its mark on the healthcare advice technology space. Clandestine disinterestedness abutting Veritas Basic and Elliott Administration Corporation appear in November that it would access athenahealth, Inc. (Nasdaq: ATHN) in an all-cash transaction admired at $5.7 billion. In its aboriginal days, athenahealth offered a cloud-based addition to the software arrangement acclimated by medical offices, and it has broadcast to now accommodate casework for acquirement aeon administration and billing, EHR systems, accommodating engagement, affliction coordination, and citizenry bloom services. Post-closing, athenahealth will amalgamate with Virence Health, Veritas’s healthcare casework company, while befitting the athenahealth name.

In an accomplishment to access beforehand in provider-facing technology, Roche Pharmaceuticals acquired Flatiron Health, Inc. in April for $1.9 billion. Flatiron is a healthcare technology and casework aggregation that specializes in oncology-specific EHR software and affirmation for blight research. The aggregation has a technology belvedere advised to apprentice from the acquaintance of anniversary patient. The accretion is allotment of Roche’s action to accomplish alone healthcare, which involves application Flatiron’s software articles to position itself to beforehand the use of realworld affirmation at the point of care. The accretion will acquiesce both companies to beforehand advance against data-driven blight care.

The year additionally saw commonly non-healthcare companies breaking into the acreage application technology alliances. For example, Amazon (Nasdaq: AMZN) appear in June that it would access the online pharmacy PillPack for an bearding amount. PillPack is currently accountant to address prescriptions in 49 states. The accretion shows a movement against online bloom casework as able-bodied as companies’ alertness to accomplish adventurous moves to agitate acceptable healthcare account models.

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There are no signs of healthcare advice technology alliance action slowing in 2019. In December, technology behemothic 3M (NYSE: MMM) appear that it would buy the technology analysis of M*Modal, a analytic affidavit company, for $1 billion. M*Modal’s belvedere includes a cloud-based affidavit arrangement accurate by bogus intelligence, which seeks to beforehand advice accumulator and affluence the accountability on physicians to certificate information. 3M will accommodate this arrangement into its own bloom advice systems unit, which currently works with over 8,000 healthcare organizations. Pending authoritative approval, the accord is accepted to abutting in the aboriginal bisected of 2019.

Behavioral Health

While all-embracing M&A action in the behavioral bloom area collapsed off in 2018, the types of deals aural the area are acceptable added concentrated. In 2018, the cardinal of deals involving accessories that specialize in actuality use ataxia (SUD) analysis represented over 43% of the deals aural the behavioral bloom sector, which, according to advising abutting The Braff Group, represents the bigger allotment of the behavioral bloom accord breeze that it has apparent in 20 years of tracking this space. And clandestine disinterestedness firms collection abundant of this activity. Indeed, through November, there were 26 clandestine disinterestedness deals involving SUD analysis accessories accretion over $320 million, including InTandem Basic Partners, LLC’s’ accretion of Utahbased Turning Point Centers and BelHealth Beforehand Partners, LLC’s’ accretion of Floridabased Beach House Center for Recovery. Clearview Basic accustomed its charge to the SUD space, as it bankrupt a accord in March to access Association Bloom Casework and the 14 analysis accessories it operates in and about Arizona, and after appear in November that it had bankrupt accession accord to acquirement (through its anew acquired portfolio company, Association Bloom Services) two added SUD providers with accessories in Ohio, Indiana, Michigan, Wisconsin and Texas.

The advancing opioid crisis accompanying with contempo federal legislation should accomplish the behavioral bloom area a acceptable beforehand befalling into 2019 and beyond. On October 26, 2018, the Actuality Use-Disorder Prevention that Promotes Opioid Recovery and Analysis (SUPPORT) for Patients and Communities Act was enacted, accretion Medicare and Medicaid advantage for actuality corruption casework and putting into abode an all-payor kickback prohibition for referrals to assertive analytic analysis facilities, including SUD analysis facilities, which, commentators believe, will accept the aftereffect of wiping out “bad operators” who heavily await on these referrals and attenuated the arena field. In the meantime, stakeholders will no agnosticism be absorbed to see what unfolds with Acadia Healthcare Company, Inc. (NYSE: ACHC) in the deathwatch of its accounted buy-out and new leadership.

Physician Convenance Administration and Burning Care

2018 apparent a banderole year for clandestine disinterestedness beforehand in physician convenance administration platforms. Clandestine disinterestedness dollars connected abounding to the accepted suspects — dermatology, radiology and ophthalmology — but, as predicted in this firm’s 2017 report, clandestine disinterestedness beforehand action grew in added specialty areas, including gastroenterology, orthopaedics, urology and oncology. For example, in September, clandestine disinterestedness abutting Accepted Atlantic invested $200 actor in OneOncology, a physician-centric technology-powered aggregation focused on association oncology practices that are adverse astronomic challenges, including added burden from hospital consolidation, bound assets to advance in innovation, and connected accouterment to addition acquittal models. OneOncology has partnered with three oncology practices to date. Flatiron Health’s oncology software admiral the OneOncology technology platform. Similarly, Frazier Healthcare Partners, acclaimed for its beforehand in dermatology and accepting additionally amorphous advance in orthopaedic practices (in January 2017, Frazier led an beforehand of The Core Institute, a 67-physician accumulation accouterment orthopaedic casework in Arizona), acquired Atlanta Gastroenterology Associates, one of the bigger GI practices in the United States with added than 60 locations in the accompaniment of Georgia and 95 board-certified physicians, via its administration company, United Digestive. Commentators agenda that beforehand in GI practices will no agnosticism abide to abound as the accident of abiding altitude such as diabetes, blubber and aerial claret burden continues to increase, and because of the favorable cardinal of GI procedures accustomed for outpatient affliction settings. The aforementioned holds accurate for beforehand in orthopedics, which is actuality apprenticed in ample allotment by the about-face of accepted procedures, like hip and knee replacements, to beneath big-ticket outpatient settings, and the accretion aggregate of such procedures (likely a aftereffect of the crumbling population). In October, KKR completed its accretion of Envision and its emergency medicine, anesthesiology and radiology casework businesses.

Gastroenterology, orthopaedics, urology and oncology — the new darlings of PE circles — are acceptable to accumulate added and added absorption — and beforehand dollars — over the advancing years.

Consolidation additionally connected in the burning affliction area in 2018, as consumers abide to attending to retail healthcare for lower-cost casework alfresco the hospital and ER settings. One of the bigger deals was FastMed Burning Care`s accretion of NextCare Holdings Inc., which was acquired by Alcentra Basic Corp. in 2016. 2018 additionally saw a clandestine disinterestedness barter as Freeman Spogli & Co. arbitrary CRH Healthcare, a patient-focused abettor of 38 burning affliction centers in Georgia, Florida and Alabama.

Conclusion

If 2017 was the year of cross-sector transactions, 2018 was the year that industry players doubled-down, and with companies such as Amazon breaking into the healthcare industry, there’s no cogent what array of avant-garde deals and commitment models 2019 will bring. All the while, clandestine disinterestedness investors will no agnosticism abide to beforehand boundaries and seek new, agitative opportunities for investment.

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