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AHLA's Speaking of Health Law
Recent Trends Related to Behavioral Health Transactions
Jordan Zoeller, Senior Vice President, Stout, speaks with Julie Sullivan, Shareholder, Greenberg Traurig LLP, about recent trends in the regulation of transactions related to behavioral health providers. They discuss current federal and state oversight trends, state laws impacting behavioral health providers both at the hospital and outpatient levels, and tips for navigating this increasingly scrutinized landscape. Sponsored by HealthCare Appraisers, now part of Stout.
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Speaker 2:Hello, my name is Jordan Zaller , and I'm joined today , uh, by Julie Sullivan to discuss recent trends in the regulation of behavioral healthcare providers. Uh, I'll quickly introduce myself and then I'll turn it over to Julie to do the same. Uh , I'm a Senior Vice President with Healthcare Appraisers , um, which is now a part of Stout Stouts, the Global Advisory firm, specializing in corporate finance, accounting, and transaction advisory and financial disputes claims and litigations. Uh , my practice is centered specifically on business valuation and transaction advisory services within the healthcare space. Julie, thanks for being with us today.
Speaker 3:Thank you, Jordan. And , um, as Jordan mentioned, I'm Julie Sullivan. I'm a shareholder , uh, with the International Law Firm of Greenburg Toric out of their Denver, Colorado office, and I specialize in healthcare law, predominantly provider side law with an emphasis on the behavioral healthcare space.
Speaker 2:Well, great. Well, let's set the table a little bit, Julie. Um, let's talk about kind of the, the state of of play as it is right now , um, with respect to, you know, federal oversight , uh, of healthcare transactions. Um, what are we seeing in the, the market currently?
Speaker 3:Yeah, so there's been a couple of longstanding , um, oversight mechanisms by a couple of the federal agencies, namely the Federal Trade Commission , um, via the Harsco Rodino Antitrust Improvements Act. Um, which originally upon enactment had a $50 million threshold for reviews and kind of pre-merger approval processes. Um, that also, it goes well beyond the healthcare , um, space, but did implicate the healthcare space as well. Um, and it's adjusted by inflation every year. It's now standing at just shy of, of $120 million as a threshold before your HSR filing requirements to the FTC are implicated. So obviously that's, you know, always been at play in this or always, you know, since the HSR ACT was imple implemented, but kind of a longstanding oversight mechanism really for those larger material transactions , um, where we're talking big dollar providers , um, and transactions. The Centers for Medicare and Medicaid services are CMS has also , um, kind of thrown their hat in the ring. Um, again, they've always had mechanisms via their change of ownership and change of information processes associated with Medicare enrollment. Um, but in recent years, they're , they've sought greater transparency , um, on transactions that do not constitute changes of ownership, but rather are just changes of information. Um, for example, when you have a stock deal of a healthcare provider , um, that technically is considered a CHO and not a chow . Um, and , and that's was really aimed at skilled nursing facilities. So not necessarily aimed at the behavioral health space, but , um, you know, there's been long rumblings that that may get expanded , um, beyond just the skilled nursing facilities that really kind of bubbled up during the pandemic , um, as they saw some, some quality concerns and staffing concerns , um, unique to, to private equity backed , um, facilities in that, in the long-term care space.
Speaker 2:That's great. And I know you've mentioned the FTC , uh, filings as well, and certainly in the first half of this year , uh, along with the FTC, we saw the Department of Justice , uh, department of Health and Human Services , um, buying some of this activity in the healthcare consolidation space and requesting public comments. Um, and, you know, we, we saw that they were interested in activity, not just from financial buyers like, you know, private equity or venture capital , uh, but also strategic buyers, whether they be, you know, large national for-profit operators or, or even just regional hospital systems. Uh , they received over 6,000 public comments or so , um, mm-Hmm , <affirmative> , which, you know, broadly asserted , um, that they were concerned by either monopolistic , um, issues from either those strategic buyers , uh, or possibly other negative effects , um, from some of the, the financial buyers as well. Mm-Hmm. <affirmative>. Um , so that's, you know, certainly some interest on the federal agency side. Is there anything that congresses currently considering or looking at?
Speaker 3:Yeah, you know, kind of along those same lines of just, you know, looking for further avenues to , um, you know, keep an eye on, on the healthcare consolidation. Um , front is just recently, a couple weeks ago here , um, the Congressional Research Service, which is a non-partisan shared staff to congressional committees and members of Congress. They just issued a report on August 8th of this year , um, suggesting that congress that consider additional oversight and enforcement , um, mechanisms really focused on that private equity and, and real estate investment trust or reap , um, investment in healthcare. So some of the issues that they were floating were, you know, kind of an analysis of the limited liability and kind of corporate veil principles and, and having more reach beyond those via the False Claims Act and otherwise to reach those , um, those corporate sponsors where they, they're directly involved in the operations or decision making of the Port Co or the, you know, the provider entity. Um, they also suggested to Congress in that report of , um, considering lowering those HSR thresholds , um, to capture more of, of the healthcare provider transactions , um, in this space. Again, just in kind of furtherance of that transparency and visibility into who owns what, who's controlling what , um, in the, the healthcare space. So, and actually in that report , um, they highlighted a False Claims Act case that , um, was squarely in the behavioral health , um, space with , uh, in Massachusetts. It was the Martino Fleming versus South Bay Mental Health Center's case that , um, where a private equity firm was sued for the alleged fraudulent business dealings of its portfolio company, south Bay Mental Health Centers , um, that the South Bay Mental Health Centers is a for-profit mental health clinic , um, that was purchased by a PE shop back in 2012. Um, and the PE firm appointed , um, and actually filled with, its with its own , um, employees, majority of the seats on South Bay board of directors. And so a prior employer , um, or employee rather filed a keam action under the False Claims Act alleging violations of the False Claims Act, namely by submitting Medicaid claims for services by unlicensed, unqualified, and unsupervised social workers and counselors at the center. Um, the state of Massachusetts, or the Commonwealth of Massachusetts, I should say, intervened in the suit in, in 2017. And the crux of the case there was really about that, you know, piercing of the corporate veil and whether that PE sponsor , um, ought to be held accountable for its portfolio company's actions, given that it effectively controlled , um, or was alleged to have controlled the board of directors. Um, ultimately the , the parties, you know, settled the matter in 2000 , um, 22 prior to any, you know, formal disposition, but , um, in basically pretrial motions, they , it was looking like it was gonna survive, and there was gonna be that issue of material fact ultimately of whether the PE sponsor was involved and did control , um, the court post such that that corporate fail should be pierced and, and , um, the PE sponsor be held accountable for , um, for the, the billing, you know, the alleged billing liabilities at play there. So it's, you know, certainly , um, you know , the con, the CSR there or the CRS rather is, is , um, certainly putting that bug in the ear of Congress , um, of finding other avenues for further oversight. Again, whether or not any of that will materialize is, is obviously to be determined, but , um, certainly continuing to explore avenues for further oversight , um, and visibility into , um, the PE-backed healthcare space, including that behavioral health law space.
Speaker 2:Yeah, I think that's important to point out , um, you know, why there's certainly this increased level of oversight and , and why it's happening now. Um, and you, you touched on some of the examples I think from , um, the case you just referenced, where, you know, where either seeing, you know, poor poorer staffing ratios or working conditions , um, with some of these private equity linked , um, operations and, and how that's impacting, you know, the quality of patient care. Um, some of the other things I think that are important to note, you know, there's obviously been this topic of, of burnout in the healthcare space that's become more prevalent since covid . Um, certainly any, you know, degradation to, to staffing ratios is , um, only contributing to that. And some of those public comments even from , um, you know, the, the healthcare consolidation, you know, requests that we mentioned earlier , um, are along those same lines. And , um, hearing how, you know, it's gotten worse over time. Um, certainly other , I think other factors, you know , it's not just limited to the staffing ratios, but , um, you know, on the clinical side, but maybe on the, the nonclinical side, you know, there's these , uh, you know, individuals that can help make the delivery of healthcare otherwise more efficient, whether it's, you know, billing or other , uh, operational tasks that are being, you know, shifted to a , a smaller pool of people , uh, or even in some cases just limitations in, you know, available medical supplies needed to, you know, render surgeries or, or other healthcare. Um, so, you know, one of the other probably key concerns is , um, even when some of these healthcare providers just outright fail , um, then there's obviously a, a big gap in, you know, a patient's ability to access , um, medical care where it's needed. You know, probably one of the most public examples currently , um, relates to Steward Healthcare. Mm-Hmm . <affirmative> , which had over 30 hospitals , uh, before it filed for chapter 11 bankruptcy , um, in May of, of this year. So, you know, I think in a nutshell , um, we're seeing increased oversight on healthcare consolidation , um, as, you know, as it relates to both the quality and the access , uh, of healthcare services for, you know, patients in a, in a given market.
Speaker 3:Um , yeah, I think that's, it's a great point , um, that, especially even on the state side and, and I think we're gonna kind of turn to that next, so beyond the federal level states are, are kind of jumping on this bandwagon as well of, of getting more and more involved in approval or notification requirements, whether they be aimed at private equity, venture capital, REIT investors, or just more broadly across the healthcare space , regardless of, of who the investor owner is. Um, and again, I think, I think , um, that most of these states, you know, namely a lot of the hospital transfer acts that are out there on the books that, that extend to psychiatric hospitals as well as, you know, acute care general hospitals , um, but, you know, they're really focused on ensuring , um, that the public retains access, you know, in these providers changing hands , um, arguably more frequently than, than they had in the past , um, that the, the array of hospital and healthcare services being offered there does not skinny down to say, only the most profitable of, of services and, and ensuring that continued access of care in those underserved markets. So, you know, with that, those state regulations, they can take a whole slew of different forms, right? So some are provider specific, like those hospital transfer acts that are really aimed at hospital providers. Um, some have financial materiality thresholds akin to the, in the HSR type of threshold , um, where they're really only looking at kind of the bigger providers , um, in the state . Some are buyer specific, again, aimed at private equity, venture capital and REITs. Um, and, and many are surprisingly beyond salary acquisitions and, and reaching now into, you know, contractual arrangements, really management services arrangement, lease arrangements , um, wanting to understand sort of who owns the dirt , um, that the hospital , uh, operates on, and who's, who's performing those back office functions that are really intended , um, to create some of that efficiency and, and allow those clinicians to focus on the clinical aspects of operations. So , um, you know, lots of different forms, lots of different states , um, with those sort of transaction approval notification requirements. Um, not all will extend into the behavioral health provider space per se, but, but many do with their reach into physician organizations or , um, even just any healthcare licensed provider or specialty clinics. So there are going to be some , um, you know, last we , we looked a , a list of states that had 'em included, California, Colorado, Connecticut, Hawaii, Illinois, Indiana, Massachusetts, Minnesota, Nevada, New York, Oregon, Pennsylvania, Rhode Island, Vermont, and Washington. Um, so again, it's, it's becoming, you know, I wouldn't say necessarily the norm, but um, it is becoming a commonplace for states to also be engaging in these healthcare transaction review and oversights via these. Some of these are older laws and some of 'em are, are new.
Speaker 2:Yeah, that's certainly a lot of , um, you know, state specific considerations, and it seems like things can vary widely from , uh, from one state to another and certainly to the extent that you have , um, a client that's operating in multiple jurisdictions. It , um, certainly, certainly seems to be a complicated matter. So
Speaker 3:Yeah, it definitely adds to , um, you know, the, the work associated with the transaction and the timeline. I mean, the reality is these, these approvals in that some of them are upwards of 180 days, you know, notice or , or pre-closing filings. Some require you to await regulatory , you know, regulator approval , um, which as we know can, can take many, many months, even more than a year. Um, so, you know, one here in, in my home state of Colorado, we've got the Hospital Transfer Act and, you know, it's, it applies to, for-profit and non-profit , um, hospital transfers. And it becomes, it's got a lot more nuances in public legislative hearing requirements and, and, and statutorily mandated steps that , um, the attorney general has to follow , um, with regard to certain hospital transfers of, of its assets. And it's indicated by 50% or more , um, of assets over the course or a series of transactions over the course of five years that, that in the aggregate reach that 50% transfer threshold. Um, and it, you know, it's, it's burdensome and it slows down the process. And, and a lot of these buyers, you know, or frankly distressed hospitals, I'm working on , um, you know, a distressed hospital deal and, and it's there , you know, it risks them running out of runway , um, where the buyer can't necessarily step in financially, you know, with that lifeboat until we know that the deal is gonna close. And so it's, it's, it's onerous on, on the parties and on , you know , again, I think the intentions upon enactment , um, were pure at really making sure that charitable assets, it kind of stemmed initially from , um, policing nonprofit hospital , um, asset transfers and really making sure that those charitable assets remain , um, you know, serving the general public that there's no private environment issues upon any sort of, you know, acquisition , um, by a for-profit operator. Um, but it's in operation, it's really become pretty burdensome. Um, and there's, you know, both providers, lawyers, and all the parties involved, evaluators, everybody really has , you know, struggled to figure out how, you know, the best way to, to expedite , um, those filings and approvals.
Speaker 2:I see. I see. So I know we've , uh, discussed, you know, some of the, when the beginning of this podcast , um, you know, this, this heightened interest in, you know, healthcare consolidation and in private equity , um, backed buyers. Uh, are there any, you know, state level laws , um, coming into play that kind of address, you know, that concern with the, the financial buyers specifically?
Speaker 3:Yeah, yeah. There's a couple of proposed laws out there that we're aware of that , um, if they become enacted, neither one is currently enacted. Um, but they would effectively amount to private equity bans , um, on, you know , certain types of arrangements or investments in the healthcare space. So one of those is, is , um, California assembly bill 31 29 , again proposed, but if it's enacted, it would effectively prohibit management service arrangements between , um, physician and psychiatric practices and any entity controlled by a private equity or hedge fund where the letter controls directs or manages any of the affairs of the former in exchange for a fee. Um, so again, there really, I mean, there are materiality thresholds , um, associated with, with what would be covered transactions in that space , um, of having, you know, the non-physician provider having an annual revenue of more than $4 million, or the pro or the provider having an annual revenue , um, of between 4 million and 10 million. So it's not a terribly high threshold relative to some other states or for example, at a HSR threshold of nearly 120 million. Um, and interestingly that California proposed bill , um, does allow the attorney general to hold public meetings , um, about the proposed transaction. So there's just public visibility and transparency into that, and the transaction cannot close , um, without that ag approval. So, you know, a significant shift should that go into your play and , and , um, you know, unclear whether the existing PE investments in MSO arrangements would effectively be grandfathered in, or whether some of those transactions would need to be unwound, which would frankly have a , you know, probably have a catastrophic effect on patient access to services, given just the big role that private equity and , and venture capital has played in recent years in the healthcare space. So a a second one is, is interestingly in the state of Minnesota where house file 42 0 6, again, a proposed bill , um, is proposing an outright ban on private equity or re ownership or control of a healthcare provider. Um, it would, it would prevent those parties from acquiring any direct or indirect ownership interest in a provider of healthcare or medical services, again , for , in exchange for a fee. Um, and so, you know, it's, it's not a submission or an approval requirement. It is truly just a, a proposed statutory ban on those types of investors in , um, the healthcare space. So, you know, again, I , I don't know the odds of, of those passing because I think they are highly controversial and, and incredibly disruptive to a path that the healthcare system , um, has been on for several years. Um, and, and whether they're evaluating , um, what that might actually look like and how , what the impact for the existing landscape of healthcare providers would be, should those laws take effect.
Speaker 2:Yeah, we'll have to, to keep an eye out for those. Julie. Um, so there's obviously been a lot of, you know, history with , um, you know, the scrutiny of, of hospitals and psychiatric hospitals . Um, are there other, you know, implications for, you know, behavioral healthcare that's, that's not in the hospital space , um, you know, outpatient providers, et cetera, that , um, you know, people should be aware of?
Speaker 3:Yeah, there are. Um, you know, just to, for a few examples, California, Massachusetts, and Oregon, for example, have , um, pretty substantial but broad scope applicability as far as what are the covered entities and covered transactions. So I'll , I'll talk a little bit about Oregon's law , um, but Oregon revised statute four 15.5 hundred , um, basically applies to all healthcare entities, which is defined super broadly to include healthcare professionals licensed in Oregon. So virtually any type of provider entity , um, is going to , uh, be required to submit a proposed transaction 180 days in advance of closing , um, to the Oregon Health Authority , um, for review and approval of the transaction. So , um, again, very broadly , um, applied covered transactions do include even transactions to form a new partnership. Joint Venture ACOs a new parent organization or a management service organization. Perhaps the saving grace is that they do have a slew of exemptions , um, under that, that statute as well as a fairly high materiality threshold. So under the Oregon statute, at least one party has to have an avenue average annual revenue of 25 million or more , um, and , sorry, not annual average revenue of 25 million or more in the preceding three fiscal years. And , um, the other entity has an average revenue of at least 10 million in the preceding three fiscal years. Um, or if it's a new entity, it's projected to have at least 10 million in revenue in its first full year at normal levels of utilization and operation. Um, but again, those exemptions will also come into play and , and a couple are , are particularly unique to certain other kind of non-hospital , um, behavioral health providers. So there's excluded , um, are those transactions involving residential facilities and communities. So, you know, that's particularly helpful to the , um, IDD space , um, that, that often operate a lot of residential facilities. Interestingly, they've also carved out , um, affiliations necessary to adopt advanced value-based payment methodologies , um, which is a kind of unique and, and forward-looking in as both federal and state , um, and commercial payers, frankly, you know, really look to , um, shifting away from fee for service and into a value-based , um, care payment model. So , um, there's another exemption for certain management services arrangements , um, where, you know , basically if, if the , um, management entity or the, the provider entity rather maintains responsibility, oversight, and control over the patient care and bills and receives reimbursement for patient care , patient care, as well as an exemption for health centers that serve medically underserved populations and will continue to do so after the transaction, so some light at the end of the tunnel. Um, so while it captures a, a , a broad scope of, of transaction types within its , um, applicability, I think that materiality threshold and some of those exemptions will , um, you know, kind of skirt out some of the non-hospital healthcare behavioral health provider transactions , um, from actually having to make those filings and, and obtain those approvals from the Oregon Health Authority. So, but it's interesting, I mean, to your point, Jordan, of, you know, what happens next with all this state , um, regulation , um, and I'd be curious to get your perspective , um, you know, on, on how this might actually impact in , in practice these types of transaction. Is it gonna be better? Are there gonna be buyer favorable, seller favorable? And I'd, I'd be curious to get your thoughts on that.
Speaker 2:Yeah, that's, that's an excellent question. Um, you know, some of these , uh, regulations have been in effect for at least a , a , a little bit. Um, but as you've identified, a lot of these are still kind of proposed and they represent, you know, somewhat of a , an unknown for the parties involved. Um, you know, I, I think generally speaking, we will see somewhat of a shrinkage in the willing buyer pool , um, you know, at least particularly from financial buyers that, you know, have a limited experience in healthcare . Um, it , I think you had, you know, you noted earlier that a significant proportion of , um, behavioral healthcare transactions involve a , a financial buyer or private equity. You know, it's over the past five years has probably been somewhere in the, you know, the half to two thirds , um, of those transactions, you know, in involves such a, such a buyer. So, you know, a reduction in any of those kind of buyers is likely to have a negative impact on, you know, both the number of deals , um, as we've seen over the past few years anyways, as well , as well as their valuations overall. Um, and financial buyers have had, you know, some recent difficulties outside kind of the bounds of, of the regulatory changes we've talked about just given the rise in interest rates. And , um, you know, there's been a bit of a gap in between what buyers are willing to pay and what , um, you know, selling prices , um, you know, sellers are asking for. And that, you know, tends to cause either delays or a kind of a decrease in deal volume , uh, from the peaks that we've seen in, in 2021. Um, so, you know, with these , um, behavioral healthcare , um, regulatory changes, yeah , I think we're going to expect to see some continued downward pressure on, on both the marketability , uh, and the valuations for these types of businesses. Um, and certainly, you know , um, strategic buyers are, are more often than not interested in , um, you know, investing in either a hospital or outpatient practice, you know, whatever it is for a more indefinite time period. But financial buyers, you know, typically have a, a shorter time span, whether it's, you know, five or seven or, you know, 10 plus years or so. Um, so from my perspective, I would say some of these state laws are, are likely to impact how these firms are ultimately able to divest their investments. Um , 'cause typically, you know, they're looking for either another larger financial buyer or a strategic buyer. Um, but if, you know, the, the proposed buyer , um, already wields too much control over their existing market is too large , um, you know, the, the , you know, from what we've heard, the state may, you know, step in and either causing delays or, you know, altogether blocking transactions Mm-hmm. <affirmative> , um, so
Speaker 3:Increasing the, the price of transacting it if nothing else.
Speaker 2:Yes, exactly. Yes. And you know, those , um, those costs can be significant as well. So , uh, and as you mentioned, you know, if , uh, hospitals are already in financial distress distress that may be , um, you know, too much, too much to bear and may ultimately limit access to the healthcare services in a particular market. So , um, so yeah, so while, you know, some of the underlying demographics in demand for behavioral healthcare services may be favorable , um, you know, on the transaction front, yeah, they may be done at , um, somewhat of a, a decreased frequency and , and smaller valuations going forward. Mm-Hmm, <affirmative>. Um, so, you know, given, given all that, Julie, you know, do you have any, you know, tips or or guidance for our listeners who are faced with this , um, increasingly scrutinized landscape and behavioral healthcare?
Speaker 3:Yeah, you know, I mean, we're more frequently than not these days in , in markets with these types of , of state regulatory , um, issues and filing requirements. I mean, they can, they can be very political as , as really, you know, to cut to the chase the reality of the situation , um, both in terms of how quickly they move through the system as well as, you know, getting in front of the decision makers , um, and trying to obtain a favorable outcome . So, you know, we're often engaging local counsel with those regulator relationships to help kind of , um, bird dog it through the process. So, you know, engaging competent council and advisors to help navigate the process , um, is, is becoming more and more vital , um, to, to getting transactions done. I, I'd also say kind of along similar lines, really knowing your markets and prospective markets , um, and I , you know, we're seeing some clients just avoid certain jurisdictions , um, due to the approve approval constraints are just general scrutiny and , and arguably a distaste for certain investors in the healthcare space. Um, and so we're seeing not only exits from those markets, but also just a , a lack of willingness to , um, you know, entertain targets in , in certain of those markets. Again, I'd be curious your thoughts on that too, kind of more from that, that financial perspective or kind of deal strategy perspective of whether you have any additional tips kind of for navigating , um, some of this additional heightened regulation.
Speaker 2:Yeah, I think so. You know, it's, it's really going to be taking more of a, a long-term view for, you know, who either a financial or a , a strategic buyer. Um, you know, with respect to how , um, an , an investment in one of these behavioral healthcare companies is eventually going to, to terminate or , or be exited , um, you know, in being cognizant of the number of , uh, potential potential buyers in your market and whether or not they're large enough to , uh, to trigger some of these thresholds , um, you know, from, from what we've talked about earlier today , um, there is also , uh, and , and a possible alternative, you know , uh, strategic buyers in particular , um, could always consider the, the cost to build out a , a de novo version of a potential acquisition. You know, obviously there's , um, many times where it's, you know , uh, greatly preferred to just acquire an existing , um, healthcare operation, but , um, potentially might be an acceptable alternative to acquiring an entity that would , um, otherwise run into significantly more delays , um, you know, from a , from governmental scrutiny. So , um,
Speaker 3:Yeah, the inverse is certainly possible where because of some of those challenges, perhaps it's, it's really an opportunity for some of the more sophisticated , um, and savvy investors who know how to navigate the issues and, and are comfortable kind of taking on the challenge.
Speaker 2:Exactly. Exactly. Well, Julie, thank you so much for, for joining us today and talking about behavioral healthcare, and , um, thank you to our listeners as well, and , um, we, we appreciate you tuning in.
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