Private equity investment in behavioral health has historically been limited to practices that cater to self-pay individuals or to the well-insured. Indeed, the term “treatment center,” to some, even conjures up images of spa-like facilities that cater to the rich and relapsing.
But we expect to see new interest growing in investing in practices that serve low-income individuals— and for good reason. The financial opportunities now inherent in providing such care could help spur improved access and outcomes for individuals of all incomes across the country.
Insurance and government payers now cover behavioral healthcare for more people, and more people who need care are seeking it out. As demand goes up, issues of revenue sustainability are slowly being ironed out, and new grant monies are coming available. The fragmented low-income behavioral market is ripe for consolidation as state-designated Medicaid managed care organizations seek to contract with strong providers that can successfully prove positive health outcomes; handle complex billing involving private, federal and state payers; and support care coordination across increasingly-complex healthcare networks.
Revenue sustainability has long fallen solidly in the “threat” quadrant of low-income behavioral health investment analyses. However, this concern has begun to dissipate with increasing implementation of the 2008 Mental Health Parity and Addictions Equity Act. And with Medicaid waivers, such as New York’s program that encourages the co-location of behavioral health services with primary care, state governments are not just changing payments and reimbursements, but actively promoting or requiring the provision of services.
The efficacy of the parity act has been of some debate, so new investors must proceed with their eyes wide open, understanding that for the time being, the sector will come with inherent and ongoing reimbursement battles. Not every insurance provider is following the rules to the letter, and patients are still being declined coverage for the behavioral healthcare they are now entitled to under law.
Further, when it comes to Medicaid reimbursement, state variation in reimbursement amounts is an important consideration.
Government support of financial, clinical success
Despite some recent fits and starts, regulators are starting to step in to ensure care is provided and providers are paid. In New York, for example, the attorney general has reached five mental health parity settlements with payers since last year. Other states may well follow suit, and quickly, as they shift more Medicaid enrollees to managed care plans.
Shifting toward managed care Medicaid also aims to improve care coordination and reduce costs. Such efforts will encourage the measurement of outcomes, and future reimbursement will depend on producing good outcomes.
Likewise, the managed care shift should also be a driver of consolidation. There will be opportunity for coordinated companies to weed out “bad actors” in the industry and create more consistent care by rolling up smaller organizations into larger, more efficient providers that rely on methods that produce proven outcomes. Behavioral health providers with scale will be able to win contracts from state-designated Medicaid managed-care businesses. Moreover, integrated care models will be better rewarded and will help realize better evidence-based outcomes along the continuum of care. This is a seminal moment for the promise of care integration.
Opportunities for scale
Most providers of behavioral healthcare services remain relatively small. For example, Centerstone has about $210 million in annual revenue and is one of the largest nonprofit providers, caring for about 142,000 patients in five states. By comparison, nearly 44 million people experienced a diagnosable mental illness in 2013, according to the most recent data from the Substance Abuse and Mental Health Services Administration. In July, Centerstone merged with WellSpring, a move that WellSpring says was calculated, in part, to improve its chances of winning acceptable contracts from Illinois’ designated managed-care companies, which are now responsible for half of the state’s Medicaid recipients.
Medicaid reimbursement won’t be the only factor evaluated by savvy private equity investors in behavioral health: The financial opportunities available to those who are able to coordinate care and create shared savings arrangements across healthcare networks are considerable, and an area in which investors experienced in roll-ups and in creating enterprise efficiencies stand to add value.Patrick D. Pilch is a managing director in BDO Consulting, LLC, with more than 25 years of healthcare, financial services, operational management, and restructuring experience. Patrick provides strategy, business transformation, interim management, M&A advisory, restructuring, turnaround, and performance improvement services to assist organizations and their stakeholders.
Karen Meador, MD, is a managing director in BDO Consulting, LLC, and part of The BDO Center for Healthcare Excellence & Innovation. A former physician executive with experience in clinical and administrative leadership roles, she now guides providers in developing innovative programs and services designed to transform clinical care, research and education in the ambulatory and outpatient, emergency and inpatient settings.