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Duff-Phelps Healthcare IT Insights
1. Duff & Phelps
Healthcare Services:
Healthcare IT Services Insights
Healthcare M&A Post-Affordable Care Act:
Front-Row Insights from California to Inside
the Beltway
February 2014
Inside
1 Healthcare MA Post-
Affordable Care Act:
Front-Row Insights
from California to Inside
the Beltway
4 2013 MA Activity
7 Selected Publicly Traded
HCIT Companies
8 Contacts
On October 3, 2013, Duff Phelps
hosted an interactive discussion on the
healthcare MA environment post-initial
implementation of the Affordable Care
Act (ACA), drawing perspectives from top
leadership across the healthcare industry.
The diverse panel included experts from
the healthcare information technology
sector (HCIT); a view from inside the
Beltway; and insights from a prominent
practicing physician who administers a
medical enterprise at the forefront of what
many believe will become a new model for
healthcare delivery – an entity that serves
as both provider and payor.
Led by Duff Phelps’ Managing Director
Brooks Dexter, panelists included:
yy Paul Holt, Chief Financial Officer of
Quality Systems, Inc., which provides
EHR solutions to approximately 85,000
physicians, with over 4,000 group
practice customers nationwide;
yy Darin LeGrange, Chief Executive Officer
of Aldera, a leading provider of cloud-
based and on-premise core
administration solutions for healthcare
payors and administrators;
yy John Kelliher, Senior Managing Director
of the Marwood Group, a healthcare-
focused strategic advisory and financial
services firm with offices in Washington,
D.C., New York and London; and
yy Dr. Howard Fullman, Area Medical
Director of Kaiser Permanente West
Los Angeles.
Panelists discussed a number of
important issues related to healthcare
implementation in the post-ACA era, the
highlights of which are summarized below.
The Real-time Landscape and
Tangible Drivers of Change
While opinions of the ACA vary widely and
are considered a cause of unprecedented
political discord, the one point most
everyone will agree on is that technology
can – and will – play a tremendous role in
reshaping our nation’s healthcare system.
Since passage of the Health Information
Technology for Economic and Clinical
Health Act (HITECH) as part of the 2009
Stimulus Bill, healthcare providers and
eligible physicians have been working
diligently toward implementation of full
Electronic Health Records (EHR) and the
Centers for Medicare Medicaid Services’
(CMS) Meaningful Use (MU) Rule.
With implementation of MU’s Stage I data
capture and sharing requirements well
underway, most providers have shifted
their focus to Stage II’s advanced clinical
processes, including the exchange of more
rigorous health information; increased
requirements for e-prescribing and
incorporation of lab results; electronic
transmission of patient care summaries
across multiple settings; and more
patient-controlled data. These Stage II
requirements, along with conversion to
2. Healthcare Services: Healthcare IT Services Insights – February 2014
Healthcare MA Post-Affordable Care Act: Front-Row Insights (cont.)
Duff Phelps   2
ICD-10 protocols, have set the stage for
increased reliance on information technology
and are a source of increased MA activity
across the healthcare services industry.
Structural issues such as scale, efficiency
and costs also are driving change. Many
expect consolidation, especially in the acute
care setting, to continue in the post-ACA
environment. In just the last 12 months,
the median market value of the acute care
hospital sector has risen 49.0 percent (Duff
Phelps Healthcare Update, December 2013).
Our panelists believe these changes in our
healthcare system are being driven by a
number of intangible – but very real – shifts
in the industry, including aging of the US
population; cyclical reform tied to future
election cycles and federal budget cuts;
the convergence of financial and clinical
risks across the continuum of care; and an
increasingly robust demand from consumers
for greater access to information from and
integration among healthcare payors and
providers – all giving rise to an increase in
mergers, acquisitions and other transactions.
Marwood Group Senior Managing Director
John Kelliher believes the first of these
shifts represents significant uncertainty
for the healthcare industry, with both the
2017 and 2021 post-election cycles having
major potential to disrupt the system as
cost savings are pursued and changes to
the healthcare system are incorporated.
Despite a concerted effort among providers
to eliminate unnecessary costs from the
system, the uncertainty remains strong,
as government analysts expect healthcare
spending as a percent of GDP will continue
to grow from the current 17.9% to 19.5%
by 2021 (CMS, Office of the Actuary,
September 2013).
With respect to the convergence of financial
and clinical risks, Kaiser Permanente Area
Medical Director Dr. Howard Fullman notes
that because healthcare has become so
expensive, government and commercial
payors can no longer afford the current
levels of payment and reimbursement
rates will shrink. As a result, payors are
increasingly moving away from volume-
oriented reimbursement and developing
reimbursement models based on improved
outcomes and quality of care. Similarly,
Aldera Chief Executive Officer Darin
LeGrange and Quality Systems, Inc. Chief
Financial Officer Paul Holt agree that
the lines between clinical and financial
risk will continue to blur through the
convergence of providers and payors, and
the establishment of Accountable Care
Organizations (ACOs). Like most, Fullman,
LeGrange and Holt believe that for payors,
the future of healthcare must extend
beyond simple transactions and claims
processing to actually tracking patients
through the continuum of care. With the
help of highly-functional and integrated
technology, adherence to a post-discharge
plan, for example, can be tracked through
a technology-enabled exchange with the
patient-centered medical home view, and
ultimately, help contain the future cost of
caring for that patient. Whether it’s through
the general shift from fee-for-service to
fee-for-performance, or through increased
integration across settings, technology and
consolidation will play a significant role in
reshaping the system.
Fullman attributes the third shift to rising
consumerism among the American public and
a demand for greater information, integration
and improved service and outcomes.
Though the marketplace has talked about
consumer-driven healthcare for the better
part of a decade, Fullman predicts greater
access to care will lead to a much-increased
awareness among consumers around
wellness and disease prevention as part
of the care continuum. Fullman and others
believe this higher level of engagement also
will contribute to containing costs.
Though each shift is uniquely powerful in
its own right, collectively (and alongside the
ACA’s legislative mandates), they are leading
industry players to seek unprecedented
solutions – and opportunities – through
increased transactional activity in both
healthcare IT and delivery.
Is This “New” Model of Healthcare
Delivery Really All That New?
LeGrange thinks Kaiser Permanente may
have had it right all along. The model they
began building more than 65 years ago is
more or less what we’re seeing emerge
as a result of the shifts described above,
especially in terms of managing clinical and
financial risk under a single umbrella. Benefits
of Kaiser’s “early ACO” laid the groundwork
for transforming the United States’ highly-
disparate healthcare system into a more
integrated one by bringing together hospitals,
payors and providers.
In addition to streamlining the process for
patients, this more-integrated approach
facilitates better preventative care and
management of patient populations – both
of which ultimately result in lower costs for
patients, payors and providers.
Having invested in technology early on,
Kaiser quickly learned that not all technology
automatically adds value, so it’s important
that the industry select carefully and
deliberately as it invests. In addition to the
high capital costs, users cannot overlook the
amount of time and human capital required to
fully leverage their investments in technology.
Moving forward, the enormous advantage
and long-sought ROI of a more integrated
healthcare delivery system – at Kaiser and
elsewhere – will come from convergence,
technology and analytics.
Post-ACA Sub-Sector Growth
and Consolidation
As the industry continues to evolve in
the post-ACA environment, the panelists
expect we will see a great deal of activity –
transactional and otherwise – in two distinct
sectors and for virtually opposing reasons.
Growth in the first sector, healthcare IT,
is being spurred by a number of demand
drivers (such as the implementation of MU
and conversion to ICD-10), prioritization
for efficiency and interoperability and
patient tracking. Aldera’s Le Grange
recently completed a roadshow with
private equity investors where 30 out of
3. Healthcare Services: Healthcare IT Services Insights – February 2014
Healthcare MA Post-Affordable Care Act: Front-Row Insights (cont.)
Duff Phelps   3
30 private equity groups approached were
interested in investing in this convergence
thesis. Ultimately, Aldera raised $14 million
from two investors in a placement that
was oversubscribed. He attributed this
investor interest in the company’s future
to the anticipated growing demand for
IT platforms – like Aldera’s – that have
unlimited configurability and are capable of
mass customization. Growth among HCIT
companies is – and, according to the above
panel of experts – will continue to be – strong.
On the other hand, while acute care hospitals
also are experiencing increased transactional
activity, it’s not because the sector is
growing – it’s because consolidation is a way
to enhance economies of scale, rationalize
capacity and manage reduced payor
reimbursements. In just the last 12 months,
the acute care hospital sector has seen more
than 45 MA deals (SP Capital IQ as of
December 31, 2013).
What Legacy Companies Need to
Consider Now
Our panelists agree that if legacy players
hope to survive the changing face of
healthcare, they must consider where, in
the reimbursement environment, they stand,
and then adjust accordingly regardless of
whether they’re a payor, provider or services
company. As Medicare dollars become
increasingly scarce, there will be clear
winners and losers.
Legacy players must also think about
their respective customer bases. Are their
customers being impacted similarly by
reimbursement risks? And if so, does that
provide more opportunity or risk for you?
Either way, it’s important to always think a
step ahead. In other words, it’s not too soon
to begin thinking about the implications of
MU Stage III.
Risk Insights
As investors look for opportunities within the
industry, Kelliher suggests they must first
determine their tolerance for risk. Kelliher has
observed investors with significant tolerance
focusing on the post-acute care space (home
health companies, inpatient rehab facilities,
long-term care hospitals and skilled nursing
facilities). Despite having the highest direct
reimbursement risks, the sector appears
to be providing value. Kelliher notes that
investors with a moderate tolerance for risk
are more apt to consider managed Medicare
plans or durable medical equipment, where
risks to reimbursements largely are behind
them (Medicare), or where competitive
bidding processes are already in place and
known (durable equipment). And finally, he
sees investors who want to avoid government
reimbursement risks altogether investing in
outsourced service providers such as HCIT
companies, or outsourced hospital services
or in payors, sectors somewhat removed from
direct reimbursement risk.
So whether it’s through an existing entity
or an emerging one (think ACOs), Kelliher
believes there is plenty of opportunity,
especially in the areas of case management,
cost management and population
management. The question for investors,
according to Kelliher, really becomes, “Who
can create the next-generation company
that’s going to provide a real material impact
in these areas?”
Healthcare IT Insights
With more than three-quarters of eligible
physicians having already adopted some
form of EHR, Holt believes many mid- to
large-sized practice groups are now looking
for technology solutions to help mine data
from all those health records. This next wave
of investment in healthcare IT will be around
ACOs and how you manage the analytics,
data sharing and interoperability to actually
deliver better healthcare – how a payor or
provider reaches out to patients, for example,
to remind them about taking their medicines,
coming in for appointments and doing all
the things that they need to do for their
healthcare. Meeting the population where
they are – including social media – may be
the future of increasing touches within the
healthcare system. Holt proposes the HCIT
companies that can support these efforts are
the ones set to benefit the most.
The pending conversion to ICD-10’s
expanded set of billing codes also provides
tremendous opportunity for HCIT companies.
Because conversion to ICD-10 presents a
monumental challenge to virtually everyone
across the healthcare spectrum, Holt
anticipates an increase in demand for
outsourced collections and revenue cycle
management services.
What’s Next?
Despite all the noise surrounding the ACA
and healthcare exchanges, our panelists
are confident that abundant transactional
opportunities lie ahead. The demand is there.
The money is there. And payors, providers
and health IT and services companies
see a need to be part of the “post-ACA”
solution. Technology and consolidation
were driving improvements in our nation’s
healthcare system before implementation
of the Affordable Care Act began and
they will continue driving opportunity
post-implementation (particularly as we
draw closer to the 2015 MU penalty). As
LeGrange deftly notes, “The proverbial cat
has been out of the bag for quite some time,
and there’s no way it’s going back.”
4. Healthcare Services: Healthcare IT Services Insights – February 2014
2013 MA Activity
Duff Phelps   4
Source: Capital IQ
2013 Healthcare IT MA Activity
107 HCIT transactions were announced
during the second half of 2013, in line with
the 108 transactions announced during the
second half of 2012. Strong transaction
activity in the sector was supported by
acquirers pursuing capabilities such as
interoperability and population health
management. Strategic buyers, including
portfolio companies of financial investors,
represented 88% of activity with new
platform acquisitions by financial investors
representing the remaining 12% of
announced deals.
HCIT MA activity driven by buyers with
strategic ambitions.
The 2013 MA activity was largely driven
by purchasers seeking new technologies
to broaden their product portfolios and
expand their market presence. HCIT
vendors continued to target companies with
data analytic, practice management and
health information exchange capabilities.
Looking forward, 2014 MA activity should
be strong as providers and payors look
toward acquisitions to address challenges
including payment and cost pressures,
evolving regulatory standards, changing
demographics and quality of care measures.
Private equity portfolio companies
continue product expansion through
acquisitions.
In the second half of 2013, Vista Equity
Partners, Waud Capital, Thoma Bravo, ABRY
Partners and Altaris Capital were among the
private equity groups whose HCIT portfolio
companies completed add-on acquisitions.
The companies acquired operate across
a range of industry segments, including
receivables management outsourcing, practice
management software and integrated EHR
solutions. Several private equity sponsors
completed multiple add-on acquisitions during
the year – see below for details.
In September 2013, Vitera Healthcare
Solutions, LLC, a Vista Equity Partners
portfolio company that provides end-
to-end clinical and financial technology
solutions to physicians and medical
professionals, followed its earlier acquisition
of SuccessEHS, Inc. by acquiring Greenway
Medical Technologies, Inc. (NYSE:GWAY)
for an enterprise value of approximately
$632 million. Vitera expects the acquisition
to not only expand its market share in the
EHR space, but also enhance its product
platforms to support providers seeking
ways to navigate payment reform and meet
new regulatory requirements. According to
Matthew J. Hawkins, Vitera president and
CEO, the combined company will remain
“focused on growth and [its] commitment
to [providing] current and prospective
customers with proven, integrated and easy-
to-use solutions they need to grow profitably,
increase practice efficiencies and improve
patient outcomes in this ever-changing
healthcare environment.”
In August 2013, Adreima, Inc., a portfolio
company of Waud Capital Partners that
provides hospitals with Medicaid eligibility
and revenue cycle management services,
purchased Optimum Outcomes, Inc., a
national provider of patient-focused account
resolution services. This transaction followed
Adreima’s earlier acquisition of National
Healthcare Review and marked its fourth
add-on acquisition under Waud’s ownership.
Bob Wilhelm, CEO of Adreima, noted, “The
merger of Adreima and Optimum Outcomes
better positions the company to lead our
clients through the challenges presented
by the ever-increasing complexities of the
healthcare reimbursement landscape. Our
combined expertise, resources and capacity
will enable the company to better assist
providers to realize the full value of the
services they deliver.”
In July 2013, Mediware Information Systems,
Inc., a Thoma Bravo portfolio company that
designs and implements specialized software
solutions to automate complex healthcare
processes, acquired Definitive Homecare
Solutions Ltd., a provider of business and
patient management software solutions.
Mediware has been an active acquirer
and this acquisition marks its third under
Thoma Bravo’s ownership, second in 2013
5. Healthcare Services: Healthcare IT Services Insights – February 2014
2013 MA Activity (cont.)
Revenue Cycle Management Index
Quarterly LTM EBITDA Multiples (Q4 2010 - Q4 2013)
Duff Phelps   5
Source: Capital IQ
* Multiples calculated based on the average daily LTM EBITDA multiple of each
company for the fiscal quarter.
Note: Excludes Accretive Health, Inc. for the periods Q4’12-Q4’13 as the company is
in the process of restating its historical financial information. The above chart includes
multiples for all other selected companies in the RCM index and thus differs from the
multiples presented elsewhere in this report.
* Multiples calculated based on the average daily LTM EBITDA multiple of each
company for the fiscal quarter.
Information Services Index
Quarterly LTM EBITDA Multiples (Q4 2010 - Q4 2013)
and twelfth since 2008. Thomas Mann,
Mediware’s president and CEO, stated,
“Market conditions are ripe for consolidation
in the homecare technology sector… Health
reform, aging populations, prevalence
of chronic disease and other factors are
triggering rapid growth in homecare,
increasing the need for providers to access
software products and services that drive
down costs, maximize safety and efficiency
and support business growth.”
Strategic buyers look to HCIT to
fuel growth.
Leading public HCIT vendors including
The Advisory Board Company
(NasdaqGS:ABCO), WebMD Health
Corp. (NasdaqGS:WBMD) and Quality
Systems Inc. (NasdaqGS:QSII) were
among the strategic acquirers that made
acquisitions in the second half of 2013.
Additionally, companies such as Experian plc
(LSE:EXPN), Reed Elsevier plc (LSE:REL)
(through its subsidiary LexisNexis Risk
Solutions) and The Hearst Corporation made
acquisitions, believing the HCIT sector will
provide momentum and be a source of future
growth. Some of the key transactions from
the period are highlighted below.
In November 2013, Experian acquired
Passport Health Communications, Inc., a
provider of data analytics and software in
the U.S. healthcare payment market for
a reported $850 million. Since entering
the U.S. healthcare payment market in
2008, Experian has completed a series of
transactions to expand its product portfolio
and broaden its market reach. According to
Don Robert, Experian CEO, “We are now
taking the next step and the acquisition of
Passport Health will make us a clear leader
in this high-growth and attractive market.
With our newly combined product range, we
will offer our clients in the U.S. healthcare
industry a competitive one-stop shop to
manage risk and to satisfy their payments
requirements.”
In October 2013, WebMD acquired Avado,
Inc., a developer of cloud-based patient
relationship management tools allowing
patients and physicians to interact remotely.
The acquisition is expected to improve
WebMD’s current patient connectivity
platform, Medscape, and solidify its position
in the connected care space. David
Schlanger, WebMD’s CEO, noted, “Our
acquisition of Avado demonstrates WebMD’s
commitment to playing a leading role in the
emerging patient relationship management
space because we believe that connectivity
has the potential to make the delivery of
care more efficient and improve patient
outcomes.”
In October 2013, The Advisory Board
Company (“ABC”) acquired Care Team
Connect, Inc. (“CTC”), a web-based
software-as-a-service care management
workflow solutions company. ABC plans
to merge CTC’s product with its existing
software, Crimson, to analyze physician
behavior data and develop better care
management programs. Robert Musslewhite,
ABC CEO, stated, “We are excited to
add CTC’s outstanding care management
technology and exceptional talent to [ABC’s]
portfolio of solutions, particularly given our
members’ need for effective population
health capabilities in the current health
care environment… This provider-oriented
workflow tool for care management allows
[ABC] to offer a more comprehensive array
of research, technology and services to
help members with all aspects of population
health management.”
6. Healthcare Services: Healthcare IT Services Insights – February 2014
2013 MA Activity (cont.)
Duff Phelps   6
Source: Capital IQ
Stock Price Change
June 30, 2013 – December 31, 2013
Source: Selected companies as detailed on page 7. Data from Capital IQ.
Stock Price Index
January 1, 2013 - December 31, 2013
Selected Publicly Traded HCIT Companies
HCIT companies outperform the broader
market in 2013. In 2013, both the RCM and
Information Services indices outperformed
the SP500 index. The RCM index
outperformed the SP500 by 4%, while the
Information Services index outperformed
the SP500 by 35%. In 2013, athenahealth
(NasdaqGS:ATHN) was the leading
performer in the RCM index, gaining 84%,
and Medidata Solutions (NasdaqGS:MDSO)
led the way for the Information Services
index, gaining 209%.
EBITDA growth lags revenue growth.
In Q3 2013, 82% of the HCIT public
companies experienced year-over-year
revenue growth, averaging 9% across all
companies in the index; however, fewer
companies were able to generate EBITDA
growth over the same period. Nonetheless,
athenahealth (NasdaqGS:ATHN), Accelrys
(NasdaqGS:ACCL), Medidata Solutions
(NasdaqGS:MDSO) and WebMD
(NasdaqGS:WBMD) all generated year-over-
year EBITDA growth greater than 30%.
Significant investor interest drives
valuation multiple expansion. The median
LTM EV/EBITDA multiple for the RCM
companies in the index increased from 9.9x
at 6/30/2013 to 13.3x at 12/31/2013. (Note:
The data for 12/31/2013 excludes Allscripts
(NasdaqGS:MDRX) and athenahealth
(NasdaqGS:ATHN). The data for 6/30/2013
and 12/31/2013 exclude Accretive Health
as it has not released financial information for
these periods.) The median LTM EV/EBITDA
multiple for Information Services companies
increased from 21.0x at 6/30/2013 to 22.7x
at 12/31/2013.
7. Healthcare Services: Healthcare IT Services Insights – February 2014
Selected Publicly Traded HCIT Companies
Duff Phelps   7
Source: SP Capital IQ
Note: Revenue multiples greater than 10.0x and EBITDA multiples greater than 100.0x are deemed not meaningful.
(1) Accretive Health, Inc. has not filed financial data since Q3 2012 and is currently in the process of restating historical financial data.
(2) LTM 6/30/2013 EBITDA multiples exclude Allscripts and athenahealth.
Company Name Ticker
Price
12/31/13
% Change
6/30/13
LTM Mulitples
(as of 12/31/2013)
Rev EBITDA
LTM Mulitples
(as of 6/30/2013)
Rev EBITDA
Change in Mulitples
Rev EBITDA
Revenue Cycle Management
Accretive Health, Inc.(1)
AH $9.16 (15.3%) NM NM NM NM NA NA
The Advisory Board Co. ABCO 63.67 16.5% 4.5x 39.1x 4.1x 33.2x 9.9% 17.6%
Allscripts Healthcare Solutions, Inc. MDRX 15.46 19.5% 2.3x NM 1.9x 26.1x 21.2% NA
athenahealth, Inc. ATHN 134.50 58.7% 9.6x NM 7.0x 76.8x 36.7% NA
MedAssets, Inc. MDAS 19.83 11.8% 3.0x 9.8x 2.9x 9.3x 2.5% 5.6%
Quality Systems Inc. QSII 21.06 12.6% 2.6x 13.3x 2.2x 9.9x 22.3% 34.5%
Mean(2) 17.3% 4.4x 20.7x 3.6x 17.4x 18.5% 19.2%
Median(2) 14.5% 3.0x 13.3x 2.9x 9.9x 21.2% 17.6%
Market Capitalization Weighted 25.5% 5.7x 9.5x 4.2x 40.3x 37.2% (76.5%)
Information Services
Accelrys Inc. ACCL $9.54 13.6% 2.6x 38.7x 2.2x 34.5x 14.8% 12.4%
Cerner Corporation CERN 55.74 16.0% 6.7x 22.7x 5.9x 21.0x 12.3% 7.7%
Computer Programs and Systems Inc. CPSI 61.81 25.8% 3.4x 13.5x 2.8x 11.6x 22.4% 16.9%
HealthStream Inc. HSTM 32.63 28.9% 6.4x 34.1x 5.3x 26.3x 20.9% 29.6%
Healthways Inc. HWAY 15.35 (11.7%) 1.2x 20.1x 1.3x 15.1x (6.6%) 32.7%
HMS Holdings Corp. HMSY 22.70 (2.6%) 4.3x 14.7x 4.6x 15.5x (7.8%) (5.2%)
Medidata Solutions, Inc. MDSO 60.50 56.2% NM 73.1x 8.4x 52.5x NA 39.3%
Merge Healthcare Incorporated MRGE 2.32 (35.6%) 1.8x 27.2x 2.2x 22.3x (14.9%) 21.9%
National Research Corp. NRCI.B 34.71 (0.7%) 5.5x 17.7x 5.6x 17.6x (2.0%) 0.4%
Omnicell, Inc. OMCL 25.53 24.2% 2.2x 15.6x 1.9x 13.4x 15.2% 16.2%
WebMD Health Corp. WBMD 39.50 34.5% 3.4x 27.7x 2.6x 36.5x 29.6% (24.3%)
Mean 13.5% 3.7x 27.7x 3.9x 24.2x 8.4% 13.4%
Median 16.0% 3.4x 22.7x 2.8x 21.0x 13.6% 16.2%
Market Capitalization Weighted 17.9% 5.2x 27.9x 5.4x 23.8x (4.6%) 17.4%