25 April 2013

Are HMOs back?

As the ramifications of the Affordable Care Act comes more into focus, I can’t help but wonder if the days of the HMOs are back.  As I wrote in a recent piece on the rise of ACO's, closed medical network systems are expanding at rapid rates.  What is different this time around is that the payors aren't the only ones leading the charge -  hospital systems, universities, and provider networks are all scrambling to acquire assets, build paywalls around services, and capture consumer lives.  And they are doing so at a very local level.  It was bad enough that we had few insurance companies attempt to rationalize medicine during the HMO days; are we now hoping that hundreds of localized efforts will be successful this time around?
A physician employed by a regional medical hospital system recently told me that their employee benefits changed such that visit to any provider or facility outside their controlled system would now be charged out-of network rates.  It took me by surprise not only because of the overtly limited directive, but also the fact that this system doesn't administer an insurance plan per se.  To be sure, this system has been heavily acquisitive and expansive lately (surgical facilities, urgent care, providers), but the reach is still limited.  Certainly they are testing this option with their employees first, but no doubt they plan to roll this out through the health exchanges.  I'm no expert, but this seems to be one of the smallest network footprints I have ever seen.  At least in HMO world, you couldn’t see every doctor, but had many more choices. 
The argument for closed networks is that it facilitates better outcomes and lower costs.  In other words, if a medical system keeps care within their system, they can leverage knowledge, IT, and service offerings to maximize quality and minimize cost. A patient can be guided more efficiently and effectively, focus more on prevention, and limit extraneous testing and procedures.  This theory is great on paper, but the premise relies on inefficient, for-profit entities to lead the transformation.  Remember – some of these hospital systems, for example, are the same ones that operate under the guise of a “non-profit” banner have played a leading role in our current state of out of control health care costs.
Also, how much influence can an individual ACO have? Kaiser might be the perfect model, but how scalable is it?  It has been around for years and has had little reach outside California.  And where is the optimal tradeoff between choice and cost?  These local systems may provide an option for many specialties, but how can that be enough to adequately serve individual needs of all patients?  Wouldn’t we almost be better off with a national led system with a larger reach and ability to protect choice?  These microcosms of local ACOs all seem to come at it differently with different capabilities -  there is no focus on common efficiencies or even offerings to impact the system at large.  
It’s certainly too early to tell where we're headed as implementation doesn’t really hit until 2014.  However, I don't think ownership of small health care systems are the way to cut costs and improve outcomes, rather it might merely shift market share to bigger hands at a local level.  I would rather see better use of technology and new approaches such as telemed, EMR based efforts, and home health that actually expands coverage and availability of health care.   Almost all experts agree that optimal reform would find the right balance between costs, profit, and choice that can be scaled on a national basis.  I worry, however, whether the consolidation trend at a local level is leading us astray out of the gates.  Perhaps out of this local competition will emerge better models that can be used on a more national basis.  But let's hope that the result won't leave us longing for the days of the Aetna HMO plan. 

05 April 2013

Should You Take the Money Now?

With the reported record $100B of dry powder that private equity funds must deploy in 2013, it seems logical for a growing company to partner with a financial investor right now.  While the surplus cash can lead to favorable terms,  is it better for an entrepreneur to wait ?   Or does the current frothy investment appetite make it an ideal time take the private equity plunge?
Generally speaking, delaying a sale is better.  From a financial standpoint, valuations tend to accelerate as a company grows.  In a good market, a $1M bottom line may yield a $4M valuation (4x); but doubling the bottom line might yield a three times better valuation ($12M).  Thanks to "multiple expansion," a dollar of cash flow is worth more as an enterprise grows.  There are many factors as to why, but the primary reason is an increased supply of money available for larger deals.  There are also other critical factors that tend to work in your favor as a bigger concern, such as negotiations around corporate governance and control issues.

However, outside of price, there might be business reasons why it's better to bring in financial sponsors now.  PE firms are very well connected and good at scaling businesses.   They also can help mitigate risks such as competitive threats or large capital investments that an entrepreneur may not want stomach on his or her own.  PE shops are also good at building seasoned management teams and helping to grow company infrastructure.  If any of these areas are critical to the success in the near term, than it might be the right time for a partnership.
Of course, the timing alone is not the only consideration for taking institutional equity.  According to that same Bloomberg article, over 1/4 of PE firms are expected to fail.  Diligence around the track record of a firm is key; If the firm is not around for the second bite of the apple, then the lofty valuation on the front end doesn't mean as much.  Also, goal alignment is also important.  For example, private equity is not "patient capital."  Your business will be sold to the highest bidder at some point in time.  There's no emotional ties to the business and the clock starts on day one.
Current private equity valuations certainly offer an attractive way to deepen your company's coffers (and your personal one).  But an entrepreneur must balance taking chips off the table with avoiding giving too much away too soon.  Working from the perspective of the long-term needs of the business is probably the best thing an entrepreneur can do to decide.  It's more important to gauge whether a financial partner can help grow the your business rather than whether or not you are getting a great price.  Even though the macro environment may change, a good business will always have a buyer.  But then again, if November rolls around and there's still money on the sidelines, they may just force the island vacation on you.