CDPQ and OTPP Acquire Healthcare Companies in Their PE Portfolios
ABOUT MEDICAL SOLUTIONS
Medical Solutions specializes in placing quality travel nurses, allied healthcare professionals, interim clinical leaders and non-clinical professionals, in contingent as well as permanent positions, for hospitals, clinics, and long-term care facilities throughout the U.S. The Company’s workforce solutions include a managed services program, which offers hospitals and healthcare systems a streamlined approach to contingent workforce processes, helping facilities gain efficiencies, control labor costs, and enhance patient care standards. Medical Solutions is headquartered in Omaha, Neb., with company locations in San Diego, Cincinnati, Denver, Tampa, Jacksonville, and Tupelo, Miss. In 2018, the Company acquired PPR Talent Management Group in Jacksonville, Fla., and in 2019, acquired Omaha-based C&A Industries, parent company to workforce solution firms Aureus Medical Group, Aureus Group, AurStaff, Celebrity Staff, and FocusOne Solutions. Medical Solutions was one of the first travel nursing and allied healthcare staffing companies to be certified by the Joint Commission and has been continuously certified since January 2005. For more information, visit medicalsolutions.com.
ABOUT CENTERBRIDGE PARTNERS
Centerbridge Partners, L.P. is a private investment management firm employing a flexible approach across investment disciplines — private equity, private credit and real estate — in an effort to develop the most attractive opportunities for its investors. The Firm was founded in 2005 and as of July 1, 2021 has approximately $31 billion in capital under management with offices in New York and London. Centerbridge is dedicated to partnering with world-class management teams across targeted industry sectors and geographies. For more information, please visit www.centerbridge.com.
At Caisse de dépôt et placement du Québec (CDPQ), we invest constructively to generate sustainable returns over the long term. As a global investment group managing funds for public retirement and insurance plans, we work alongside our partners to build enterprises that drive performance and progress. We are active in the major financial markets, private equity, infrastructure, real estate and private debt. As at June 30, 2021 CDPQ’s net assets total CAD 390 billion. For more information, visit cdpq.com, follow us on Twitter or consult our Facebook or LinkedIn pages.
Even though details of the transaction were not released, earlier today. The Middle Market carried a Bloomberg News article stating the deal would value the company at about $2.3 billion including debt:
Centerbridge Partners and Caisse de dépôt et placement du Quebec are nearing a deal to buy Medical Solutions, a travel nurse staffing firm backed by TPG, according to people familiar with the matter.
The deal could be announced within days and would value the company at about $2.3 billion including debt, the people said, asking not to be identified discussing confidential information. No final decision has been made and the deal could still fall apart, they said.
TPG Growth acquired Medical Solutions in 2017 for about $500 million, according to media reports at the time, and the private equity firm had hired advisers earlier this year to explore a sale of the Omaha, Nebraska-based company.
Medical Solutions places temporary medical staff like travel nurses at more than 2,200 healthcare facilities around the U.S. Demand for its services is expected to grow with staffing needs related to the pandemic, as well as an aging population.
Representatives for Centerbridge, CDPQ and TPG declined to comment. A spokesman for Medical Solutions, also known as Medsol, didn’t immediately respond to requests for comment outside of normal business hours.
Health systems are seeing higher turnover and attrition, and more vacant positions that take longer to fill in some cases due to worker burnout, which was high among healthcare workers even before the pandemic.
Demand is highest for nurses, who make up the largest part of the clinical workforce. Hospitals in rural areas are particularly reliant on travel workers, like the ones staffed by Medsol. So are understaffed hospitals that have relied on traveling healthcare workers to fill gaps during the pandemic.
Did you catch the last paragraph about the high turnover and attrition rates among nurses and how understaffed hospitals and ones in rural areas are particularly reliant on travel workers like the ones staffed by Medsol?
I mention this because people think Medsol's explosive growth is only due to the pandemic.
It's not, the pandemic undoubtedly increased demand for travel nurses and allied healthcare professionals all over the US but there is a shortage of workers and this company is filling in the gaps.
In other words, even if the pandemic ends tomorrow, there will still be a high demand for travel nurses at understaffed and rural hospitals all over the US.
However, the pandemic is exacerbating shortages of nurses and demand for Covid-19 nurses is exploding, putting pressure on Medsol to find solutions for its clients:
The point I'm making is that even though the pandemic has raised the demand for travel nurses, it's silly to claim that Medsol will not grow once the pandemic ends and that CDPQ and Centerbridge bought it "at the top" from TPG.
That's rubbish! TPG and its clients made more than 4X on this deal which is why they're selling to move on to other investments (see TPG's healthcare investments here).
Centerbridge and CDPQ are buying Medsol, a leader and one of the largest providers of total workforce solutions in the healthcare industry, so they can nurture this company during its next growth phase.
And I wouldn't be surprised if they too make 4X or more on this company if they decide to sell in five years (at that point, CDPQ might just buy the entire company and keep it in its portfolio for longer).
The important thing to remember is that there are secular reasons as to why the healthcare sector remains a great place to invest.
Martin Laguerre, Executive Vice-President and Head of Private Equity and Capital Solutions at CDPQ, said it best:
"For two decades, Medical Solutions has served as a true staffing partner for its clients, providing for the efficient placement of dedicated and highly-qualified professionals to offer exceptional care. A mission-driven culture, comprehensive workforce solutions and strong relationships with skilled nurses and health professionals are at the core of the Company’s success. We are pleased to support the next phase of its expansion and help Medical Solutions meet the evolving needs of healthcare facilities across the United States.”
This deal also underpins why the "Canadian model" is so successful in private equity:
- Great long-term relationships with great partners: All of Canada's large pensions have developed their fund investing and co-investing programs with great private equity funds to lower fee drag and maintain a healthy allocation in private equity.
- Great governance leads to competitive compensation: To do co-investments properly, Canada's large pensions operate at arm's length from governments and hire highly trained staff which are able to analyze co-investment deals thoroughly and quickly. This form of direct investing is the key to long-term success in any private equity program but you need to hire the right staff and pay them properly to do co-investments properly.
Also worth noting, I recently discussed CDPQ's mid-year results with their CEO, Charles Emond, and over a six month period ending in June, the Private Equity portfolio posted a 13.5% return on the strength of the excellent operational performance of its assets, including support by CDPQ’s teams for the growth through acquisition strategies of portfolio companies.
In other healthcare related news, the Ontario Teachers' Pension Plan (OTPP) acquired a majority interest in Acorn Health:
Ontario Teachers' Pension Plan Board (Ontario Teachers'), today announced the acquisition of a majority stake in Acorn Health, a leading national provider of Applied Behavior Analysis (ABA) therapy for children diagnosed with Autism Spectrum Disorder (ASD).
As part of the transaction, Acorn Health founder and Chief Executive Officer, Vicki Kroviak, as well as other senior management, will retain a meaningful ownership stake in the company. MBF Healthcare Partners II, L.P., who have supported Acorn Health since its founding in 2018, will sell its ownership stake and fully exit the business. Terms of the transaction are not being disclosed.
Acorn Health’s mission is to provide life-changing ABA therapy services to children diagnosed with autism. They operate a network of 51 clinics across seven U.S. states and provide both center-based and in-home services.
"We are excited to partner with Acorn Health and grow our portfolio of leading healthcare platforms. The company provides tailored and high-quality care to young individuals with autism, allowing them to live fuller, more independent lives ," said Karen Frank, Senior Managing Director, Equities at Ontario Teachers’. "We look forward to working with Vicki and the management team as they grow the business further and continue having a positive impact on the lives of these children and their families."
“Our new partnership with Ontario Teachers’ gives Acorn Health additional capabilities to invest in our people, our systems and our clinical infrastructure. We see a substantial need and will continue building a sustainable company offering a highly important service to children with ASD so that they may live their most independent and meaningful lives,” said Vicki Kroviak, Chief Executive Officer at Acorn Health. “We are appreciative of MBF’s guidance and support over the last several years in helping us build a leading ABA therapy company with a national reach.”
Acorn Health is the latest investment to complement Ontario Teachers’ long history of global healthcare investing including building leading physician practice management platforms in dental, veterinary, ophthalmology, and dermatology. Recent investments include US-based NVISION Eye Centers, and New Zealand and Australia-based dental clinic operator, Abano Healthcare.
Calex Partners served as financial advisor to Acorn Health on this transaction.
About Ontario Teachers’
Ontario Teachers' Pension Plan Board (Ontario Teachers') is the administrator of Canada's largest single-profession pension plan, with C$227.7 billion in net assets (all figures at June 30, 2021 unless noted). It holds a diverse global portfolio of assets, approximately 80% of which is managed in-house, and has earned an annual total-fund net return of 9.6% since the plan's founding in 1990. Ontario Teachers' is an independent organization headquartered in Toronto. Its Asia-Pacific region offices are located in Hong Kong and Singapore, and its Europe, Middle East & Africa region office is in London. The defined-benefit plan, which is fully funded as at January 1, 2021, invests and administers the pensions of the province of Ontario's 331,000 active and retired teachers. For more information, visit otpp.com and follow us on Twitter @OtppInfo.
About Acorn Health
Acorn Health is a national provider of applied behavior analysis (ABA) therapy for children diagnosed with Autism Spectrum Disorder with locations in Michigan, Illinois, Virginia, Florida, Maryland, Pennsylvania, and Tennessee. Acorn Health is deeply committed to industry-leading quality clinical care and is accredited as a Behavioral Health Center of Excellence® (BHCOE) offering both center-based and in-home services. Founded in October of 2018, our mission is to give children diagnosed with ASD the opportunity to live more independent and meaningful lives.
A little more background on this deal. MBF Healthcare Partners II, L.P. (“MBF”), a middle market healthcare focused private equity firm, sold Acorn Health to OTPP:
Acorn Health, based in Coral Gables, Florida and an accredited national provider of high-quality applied behavior analysis (“ABA”) therapy to children with autism spectrum disorder (“ASD”), was formed by MBF and Vicki Kroviak, CEO, in February 2018. Since its formation, Acorn Health successfully executed an organic and acquisition-focused growth strategy to expand service offerings to new markets. At the time of sale, the company employed approximately 1,200 individuals, served more than 1,300 families, and operated a network of 51 clinics across seven states, including Michigan, Illinois, Virginia, Florida, Maryland, Pennsylvania, and Tennessee.
“Bringing together a best-in-class team to rapidly scale a company represented both the opportunity and the challenge in the fragmented and evolving autism services space,” said Miguel (Mike) B. Fernandez, Chairman of MBF. “MBF’s operational experience and emphasis on growth coupled with Vicki’s cultural and clinical vision for the company led to a major win for all stakeholders.”
“We are appreciative of MBF’s guidance and support over the last several years in helping us build a leading ABA therapy company with a national reach,” said Acorn Health Chief Executive Officer, Vicki Kroviak. “Our new partnership with Ontario Teachers’ gives Acorn Health additional tools to access opportunities and continue to invest in our people, our systems and our clinical infrastructure. We see a substantial need and will continue building a sustainable company offering a highly important service to children with ASD so that they may live their most independent and meaningful lives.”
About MBF Healthcare Partners II, L.P.:
MBF Healthcare Partners II, L.P. is a leading middle market healthcare private equity fund based in Coral Gables, Florida. Our strategy is to partner with exceptional management teams while leveraging MBF's operating experience, domain segment knowledge, and tenured relationships to rapidly accelerate value creation. The partners of MBF have substantial operating experience in healthcare and have held senior management positions in both private and publicly traded healthcare companies. MBF principals have managed and helped build some of the nation’s most innovative and successful healthcare companies. The firm is headquartered in Coral Gables, Florida. For more information, please visit www.mbfhp.com.
If you go on Acorn Health's website, you'll be amazed at what they are doing to help children with autism and their families.
According to Canada's Chief Public Health Officer, approximately 1 in 66 children and youth are diagnosed with Autism Spectrum Disorder (ASD) in Canada. For families, an ASD diagnosis can involve significant emotional and financial challenges.
A (2020) study from the Centers for Disease Control and Prevention (CDC) estimated the prevalence of autism spectrum disorder (ASD) among adults aged 18 years and older in the United States in 2017*. This study fills a gap in data on adults living with ASD in the United States because there is not an existing surveillance system to collect this information:
An estimated 5,437,988 (2.21%) adults in the United States have ASD.
- The prevalence of US adults with ASD ranged from a low of 1.97% in Louisiana to a high of 2.42% in Massachusetts.
- The states with the greatest estimated number of adults living with ASD included California (701,669), Texas (449,631), New York (342,280), and Florida (329,131).
Consistent with estimates of ASD in US school-aged children, prevalence was found to be higher in men than in women.
- Approximately 4,357,667 (3.62%) male adults were estimated to have ASD, with state estimates ranging from 3.17% of men in South Dakota to 4.01% of men in Massachusetts.
- Approximately 1,080,322 (0.86%) female adults were estimated to have ASD, with state estimates ranging from 0.72% of women in Arkansas to 0.97% of women in Virginia.
ASD is a lifelong condition, and many adults with ASD need ongoing services and supports. The findings from this study can help states determine the need for diagnosing and providing services to adults in the United States who remain unidentified with ASD.
The point is that autism is prevalent in Canada, the US and around the world and companies like Acorn Health are doing their part to help children with ASD and their families.
There is a lot of research (and controversy) surrounding autism and its origins.
One recent study looking at four decades of data on millions of children is showing just how much the timing of a child’s birth influences their risk of developing autism:
The research published online this week in the journal Pediatrics finds that the prevalence of autism is four times higher in kids born extremely preterm. The risk level remains elevated in all children born early, but declines the closer a baby is to full term at birth.
Increased odds of autism persisted for children born early whether they were male or female and regardless of genetic or environmental risk factors, researchers with the Icahn School of Medicine at Mount Sinai said.
The study included data on more than 4 million people born in Sweden between 1973 and 2013 from the Swedish Medical Birth Register. Researchers looked at records through 2015 to determine if the individuals were diagnosed with autism and then cross-referenced that information with each person’s gestational age at birth. They also analyzed the data to identify siblings in order to determine if genetics played a role.
Autism prevalence was 6.1% for children born extremely preterm — between 22 and 27 weeks gestation — according to the findings. Meanwhile, the developmental disorder affected 2.6% of those born at 28 to 33 weeks, 1.9% of children born at 34 to 36 weeks, 1.6% who arrived at 37 to 38 weeks and 1.4% of babies considered full term who were born between 39 and 41 weeks.
Researchers said the findings suggest that “preterm and also early term birth should be recognized as independent risk factors for ASD.” And, they said that there should be early evaluation and long-term follow-up for children born premature — especially those born at the earliest stages — to ensure that kids with autism are identified and able to access treatment.
“Our findings provide further evidence that gestational age at birth should be routinely included in history taking and medical records for patients of all ages to help identify in clinical practice those born preterm or early term. Such information can provide additional valuable context for understanding patients’ health and may facilitate earlier evaluation for ASD and other neurodevelopmental conditions in those born prematurely,” the researchers wrote in their findings.
In another recent study, the Faculty of Medicine of The Chinese University of Hong Kong (CU Medicine) reported a ground breaking discovery that children with autism spectrum disorder (autism) showed delayed gut microbiome maturity compared with typically developing children.
They had an underdeveloped gut bacteria that is not related to their diet. The research team examined stool samples of children with autism and identified significantly fewer bacteria linked to neurotransmitter activities and five unique species of bacteria that are not typically found in the guts of children without the condition. These findings recently published in an international medical journal Gut highlights the potential of non-invasive bacteria markers for early diagnosis and treatment for children with autism.
Gut microbiome has a close connection with the pathogenesis of autism
Autism is a neurodevelopmental disorder characterised by the impairment of communication, the use of language and social interactions. Like most disorders that affect the brain, there is no one cause. It is believed that autism develops from a combination of genetic and environmental factors. Emerging research suggest that gut microbes communicate with the brain, dubbed the microbiome-gut-brain axis, and may account for the symptoms of autism. The prevalence of autism is approximately 1% in developed countries, hence based on this estimation, there will be over 70,000 people with this condition in Hong Kong, and incidence has been on the rise in recent years.
Dr. Sandra Sau Man CHAN, Clinical Associate Professor of the Department of Psychiatry at CU Medicine elaborated, "Apart from genetic factors, it has been suggested that the gut microbiome may have a part to play in autism spectrum disorders. The evidence suggests that the pathway between gut bacteria and the central nervous system, referred to as the gut-brain axis, has a profound effect on social behaviours. Physicians and researchers are working hard to identify modifiable factors such as the microbiome which shall bring hope to children with autism and their families."
Dr. Dorothy Fung Ying CHAN, Clinical Associate Professor (honorary) of the Department of Paediatrics at CU Medicine added, "Diagnosis of autism is currently carried out through regular developmental assessment for young children. Further clinical evaluation will only be offered to children when they show signs of atypical social and language development which is not satisfactory. The earlier autism is diagnosed and thus treated, the more effective and long-lasting the effects are. Research has shown that if children get early intervention, it's more likely that they won't need intensive support in elementary school and beyond."
Emerging studies suggest that the gut microbiome may have a significant part to play in autism. The evidence suggests that the pathway between gut bacteria and the central nervous system, referred to as the gut-brain axis, has a profound effect on social behaviours.
Children with autism had significantly fewer gut bugs linked to neurotransmitter activity
CU Medicine researchers tested whether children with autism harbour gut microbiome that differs significantly from that of typically developing children, which might facilitate early diagnosis or treatment. They compared the range, volume, and associated functions of bacteria in the stool samples of 128 Chinese children aged 3-6, half of whom had autism spectrum disorder. Below are the major findings:
The gut microbiome composition in children with autism differed substantially from that of children without the condition, with five bacterial species largely accounting for the difference. The sensitivity of these bacterial markers to identify autism is over 80%.
Several Clostridium species enriched in children with autism. Clostridia species have been linked with autism via the production of clostridial toxins which can damage the central nervous system.
Bacteria associated with neurotransmitter activities were substantially reduced in children with autism.
The amount and abundance of gut microbiota shall grow with age but that of children with autism is abnormally developed and lags that of age-matched peers.
Professor Siew Chien NG, Associate Director of the Centre for Gut Microbiota Research at CU Medicine remarked, "Our study shows for the first time that the gut microbiota of children with autism is abnormally developed and lags that of age-matched peers. As the development of microbial communities within the gastrointestinal tract during childhood represents a critical window of human growth and health, shifts in the gut microbiota during early life development may have important functional roles in the pathogenesis of autism and thus warrants extensive investigation."
Professor Francis KL CHAN, Dean of Medicine and Director of the Centre for Gut Microbiota Research at CU Medicine, concluded, "We are hopeful that our findings could resolve the unmet need of autism diagnosis. Our study supports the potential role of non-invasive prediction of autism based on faecal bacteria markers and age-related bacteria development profile. Future therapeutics targeting reconstitution of gut microbiota in early life and increasing abundance of neurotransmitter-synthesised bacteria should be explored for autism spectrum disorder."
The study was supported by the Health and Medical Research Fund of the Food and Health Bureau and InnoHK of the Innovation and Technology Commission of the HKSAR government.
 Sun, X., Allison, C., Matthews, F.E. et al. Prevalence of autism in mainland China, Hong Kong and Taiwan: a systematic review and meta-analysis. Molecular Autism 4, 7 (2013).
SOURCE The Faculty of Medicine of The Chinese University of Hong Kong
Interesting study, I remember three years ago, another study found that children born with low blood levels of vitamin D have 33 percent increased odds of autism compared with those born with high levels.
Researchers presented the unpublished results today at the 2018 International Society for Autism Research annual meeting in Rotterdam, the Netherlands.
The results come from the largest study yet to explore a link between vitamin D and autism. It involves an analysis of dried blood spots from 3,370 newborns in Sweden, 1,399 of whom now have an autism diagnosis.
The findings reinforce evidence of a link between vitamin D and autism risk. A 2017 study of 4,000 children in the Netherlands, including 68 who have autism, revealed that those born to vitamin D-deficient women have more than twice the autism risk of controls.
A link between vitamin D and autism is not surprising, because the nutrient is crucial for normal brain development. Newborns get vitamin D from their mothers, who get most of theirs from sunlight.
Why am I sharing this with you? Because there is a lot of new an exciting research going into autism but it remains largely a mystery as to why it is prevalent around the world (the prevalence of autism is approximately 1% in developed countries).
We need to learn more about this neurodevelopmental disorder characterized by the impairment of communication, the use of language and social interactions.
Still, there is hope and one thing is for sure, if children with ASD get early intervention, it's more likely that they won't need intensive support in elementary school and beyond.
This where a company like Acorn Health comes into play and I'm certain Teachers' Private Capital will help it grow its operations within and outside the US and that this will become a significant long-term investment.
Note, I also discussed OTPP's mid-year results with their CEO, Jo Taylor and he told me Private Equity is having another great year.
Lastly, it’s not lost on me that pensions are perhaps buying healthcare companies because they fear a slowdown ahead and these companies are fairly recession-proof.
Alright, let me wrap it up there, I just wanted to highlight two important healthcare investments made recently by two of Canada's top pensions.
Below, Medical Solutions is a thoughtful, consistent partner for its clients and their medical facilities— answering the call when they’re in need and not quitting until the job is done. "Whether it’s one placement or hundreds, we’re here for our clients every step of the way."
Second, CNBC’s Kate Rogers reports on the rise in demand for travel nurses as the Covid-19 pandemic continues to strain staffing at hospital networks across the United States. Arthur Caplan, professor of medical ethics at New York University, joins “The News with Shepard Smith” to discuss the burden the pandemic has placed on the nursing profession (December 2020).
Also, Laura Cutolo and Morgan Fitzsimmons are registered nurses and close friends who dropped everything at the height of the pandemic to jet to COVID-19 hot spots around the country. They join NBC's TODAY to discuss their experiences. “What keeps me motivated is, largely, that I hope there’s an end in sight,” Cutolo said.
These nurses are incredible and I commend them for their tireless dedication to their work helping all of us get through this pandemic (if only all the stubborn idiots would go get fully vaccinated!).
Lastly, walk through Acorn Health's clinic in Edwardsville, Illinois and find out why the company partnered with Dr. Greg Hanley to collaborate on clinical strategies, plans and priorities that benefit their clients and their goals for ABA therapy. Acorn Health and Dr. Hanley have a shared set of values that help guide our clinical principles, processes and procedures in the delivery of ABA therapy.
Great company doing meaningful work and I wish them a lot of success over the long run.