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M&A dynamics in healthcare

July 11, 2022

Caspar van der Geest 's motto is "Without trust, no deal! He has over 15 years of experience in M&A transactions in the Healthcare sector. As of 2020, JBR has guided 14 sale and purchase transactions in the healthcare sector.

The team recently published the Healthcare Collaboration Monitor. It contains the most complete overview of mergers and acquisitions/participations in the Dutch healthcare sector over the years. Since 2012 JBR has been meticulously keeping the monitor up to date and providing it to healthcare institutions, directors, supervisors and employees in the healthcare sector.

We speak with Caspar about the transactions, trends and developments.

 

You and your team have researched the transactions of the past 4 years in the healthcare industry. What is the overall conclusion?

After the dip in 2020, a strong recovery occurred in 2021. One could argue that the pandemic caused a slowdown in the beginning and an acceleration thereafter. The increased focus on healthcare has also led to increased M&A momentum.

Whereas private equity was the rule rather than the exception in oral care, the increase in PE can also be seen in the other segments of the health care industry. In transactions subject to the NZA healthcare merger test, the share of PE overall is around 60%. The share in the other segments excluding oral care has increased from 17% in 2018 to above 40% in 2021.

Some of the leading transactions are of course the sale of Bergman Clinics to Triton and the sale of Equipe Zorgbedrijven to Nordic Capital. But the entry of foreign parties into the Dutch healthcare market started earlier. This includes not only PE, but also large strategists and listed institutions such as Korian, Orpea and DomusVi. These parties are mainly active in nursing home care and in recent years have bought several residential care companies such as Stepping Stones, Compartijn and Martha Flora.

The corona pandemic has also caused an increased focus on mental health care. There is a consolidation going on within the GGZ, triggered in particular by Mentaal Beter. I expect a lot of dynamism in that segment in the coming years, although the emphasis will increasingly lie on innovative care concepts and digitalization. This will shift the focus from traditional providers to newcomers offering e-health solutions who are looking for a market.

M&A dynamics in healthcare 1
Totaal aantal zorgtransacties ingedeeld per NZa zorgsegment. Klik op de afbeelding voor de leesbaarheid

 

What trends and developments are affecting transactions?

The trend of aging manifests itself in many forms. The shortages in the labor market are one example. The healthcare sector is also struggling with structural shortages. The promise that e-health can meet the increased demand has not yet been fulfilled and at best only partly compensates for it. We are only at the beginning of the aging wave when it comes to the demand for care. A large group will reach the age of 75+ in the coming years and the demand for care will increase accordingly. Living at home for longer is the trend, but the size of the elderly group and increased illnesses such as dementia also increase the demand for new residential care concepts and nursing home care.

Providers that offer innovative solutions in these segments that increase efficiency and quality of care can expect significant interest from an M&A perspective.

The digitization of care pathways is currently done by many small parties. Many transactions in this segment remain off the radar of the NZA, as these parties are often not subject to reporting requirements. In this corner I expect more M&A dynamics in the coming years. This also applies to ICT providers in healthcare.

 

Is there a specific segment(s) in which there were many transactions?

Oral care has been the segment with the largest number of transactions for years. Also in 2021, this segment was clearly the largest with 89 transactions out of a total number of 213. Followed by long-term care with 32 transactions. And medical specialist care and GGZ, both with 22 transactions in 2021. Within intramural care I expect a lower number of transactions in the coming years. On the one hand because several larger private providers have already joined a strategist, and on the other because a few large strategists have held off on acquisitions.

M&A dynamics in healthcare

 

Are healthcare transactions about consolidation? And are there other reasons/values (softer) for a transaction?

The drivers behind M&A activity are diverse and vary by segment. Volume aggregation and economies of scale are relevant in every segment. A central platform with fixed costs that becomes more efficient by adding more volume. Unfortunately, this promise is not always fulfilled.

Smaller organizations find it difficult to continue functioning independently due to increased regulatory pressures and tightening of purchasing criteria at health insurers, care offices and municipalities. Joining a larger party often offers a solution.

In addition, the reasons mentioned above, such as digitalization and the classic reason such as reaching retirement age for care entrepreneurs also play a role.

 

Can you comment on the forecast for the next 3 (or 5) years? What transactions has JBR done in the healthcare industry in recent years that fit the trends?

JBR has executed several transactions in most healthcare segments in recent years and has been involved in the strategic growth or contraction agenda of public and private healthcare providers.

JBR can boast at least 15 years of healthcare experience. Various developments have repeatedly provided the impetus for new dynamics in the market, such as:

  • the transition of domestic help to the WMO
  • the introduction of the ZBCs
  • the redesign of the AWBZ
  • Shifting third-line and second-line care to the lines below
  • new funding rules for e-health
  • The reform of the mental health care system, etc.

 

Examples of these pathways are:

  • Sales of various healthcare providers and suppliers to the healthcare industry
  • multi-year acquisition guidance with a large foreign healthcare provider
  • restructuring of a VVT and WMO organization
  • portfolio issues and strategy guidance at public and private healthcare providers
  • for a complete overview see: jbr.co.uk/references.

 

Can you say that the internationalization of healthcare is in full swing?

In many of the countries around us, international consolidation had already taken place earlier. In recent years, the Netherlands has increasingly come into the picture of international private equity and major strategists. For example, the largest ZBC (Bergman Clinics) and the largest private GGZ provider (Mentaal Beter) have come into foreign hands. The largest childcare organization, after a period of foreign shareholding at Onex, is back in Dutch hands (Waterland Private Equity). The question is, by the way, whether that really makes a difference.

I don't expect the internationalization of the healthcare market to decline in the coming years.

In fact, the innovative strength in the Netherlands also offers opportunities for the rollout abroad of new concepts developed here. Therefore, I expect that the focus will increasingly shift to providers of innovative care concepts such as digitalized care pathways, telehealth and monitoring, diagnostics, etc. Classic providers who mainly have a lot of care capacity to offer will still be in demand. Although I think the heyday will weaken after the uncertain start to this year with rising inflation, high absenteeism and increasing pressure on payment and financeability. All the more reason, especially in these times, to set a clear strategic course, whether or not translated into a concrete M&A agenda.

 

Can you tell us more about the JBR Healthcare sector survey?

The Healthcare Collaboration Monitor contains the most complete overview of mergers, acquisitions and participations in the Dutch healthcare sector. By adding sub-segments and scoring on additional criteria, this overview offers more insight (down to each individual transaction) than other overviews and publications.

Since 2010, JBR has been closely tracking results and providing them to healthcare institutions, administrators, supervisors and healthcare industry employees.

The starting point for the research report is the healthcare transactions announced by healthcare institutions and approved by the NZa (Dutch Healthcare Authority).

 

Download the healthcare collaboration monitor

Do you have any questions about:
Collaborations, mergers or acquisitions that are or may be occurring at your organization, such as;

  • Expanding or downsizing your portfolio of activities in the healthcare sector;
  • A complete list of all healthcare transactions analyzed;
  • consulting work of JBR in the healthcare industry and what JBR can do for you;

Then contact me without obligation:

 

Caspar van der Geest 1

 

Caspar van der Geest

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