Private Equity Investment in Ambulance & Medical Transportation, Part 2: How Private Companies Are Positioned to Improve the Medical Transportation System

As private equity investment in healthcare services has boomed over the past decade, select funds have turned an eye toward one of the most important and challenging areas of healthcare services: ambulance and medical transportation. In part two of our series on private equity investment in medical transportation, we’ll examine how private companies, including those backed by private equity, can contribute to the improvement of care by reducing costs and augmenting quality.

First, it makes sense to take a moment to define what improvements look like in the context of medical transportation. As with all corners of the U.S. healthcare system, the structural makeup of the medical transportation industry makes optimizing the notoriously difficult tradeoff between cost and quality difficult to balance. A few of the complicating elements of the industry include the coexistence of municipal and private services, stubbornly low Medicare and Medicaid reimbursement rates in many regions, and a shortage of highly trained paramedics and EMTs. Solutions to reduce the cost to provide care, reduce the cost to patients and taxpayers, improve response times, or improve the quality of care delivered in transit are in the best interest of all stakeholders in the medical transportation value chain.

In that context, private medical transportation companies can often provide care at a lower cost than alternative services. As opposed to public or municipal ambulance services, which are less inclined to contract with commercial payors, private ambulance operators possess the negotiating power and financial incentive to form strong agreements with insurance companies. Public ambulances are also often more costly to operate because geographic boundaries, population density, and local politics commonly contribute to suboptimal scheduling and positioning in the field, impairing response times. Municipal services can rarely flex resources between emergency and non-emergency work effectively, augmenting the amount of costly idle time as well. Finally, government-adjacent ambulance agencies are protected by select safe-harbors regarding Office of the Inspector General (“OIG”) anti-kickback statutes, protecting public-sector ambulance services from what in the private sector would be considered fraud. Effective payor contracting, fewer geographic limitations on service areas, the ability to provide multiple levels of service, and robust regulations make private medical transportation companies with strong management a superior option in many cases than alternative modes.

On the quality side, private medical transportation companies are differentiated as well. Whereas many municipal ambulance services, particularly in rural and suburban areas, employ paramedics and EMTs that experience significant idle time in the field, private ambulance services are incentivized to optimize uptime and activity. Less idle time gives caregivers the routine experience that they need to stay sharp and maintain lifesaving skills, with the added benefit of giving paramedics and EMTs a fulfilling work experience. At the same time, private companies’ ability to move resources around between geographies means that they can serve the same regions more effectively than municipal services, while employing the same or fewer medical professionals. In an industry where staffing skilled medics is challenging due to labor shortages, increasing the probability that a skilled, experienced EMT or paramedic responds to a medical emergency is a key quality measure. Private medical transportation companies also are subject to oversight and competitive pressures that municipal services are not. Private companies must deliver high-quality services to the populations they serve, or else risk being replaced – an effective system of periodic checks and balances that dedicated, ingrained public services do not experience. Private equity excels in aggregating the expertise of professionals in multiple industries to apply best practices and implement operational improvements for companies of all types. The dynamics of the medical transportation industry force private equity sponsors to deploy that expertise in order to maintain and grow their business.

MHT Partners, a leading healthcare investment bank, believes that private investment can be a force for good in the ambulance and medical transportation industry, and that companies providing excellent care with an eye toward all stakeholders in the value chain are poised for success. While certain public services have excelled at addressing issues of cost and quality, many of the core challenges in the medical transportation system can be addressed by a competitive industry made up of private operators as well. If you would like to learn more about MHT’s healthcare services advisory practice, please e-mail Taylor Curtis (tcurtis@mhtpartners.com) or Alex Sauter (asauter@mhtpartners.com).

Soft Skills Dictate the Capabilities of Professional Development Services – Part 2

As a continuum to our last blog, we will discuss how corporations can effectively acquire, retain, and refurbish talent in order to remain competitive and meet increasing technological consumer demands. The good news is that solutions are in plain sight. In fact, Infosys, a global leader in next-generation digital services and consulting, has delineated strategy to help corporations address the talent needs of today and prepare for those of the future.  Now how to best implement and execute these strategies?

Cast a Wider Net for New Hires. The battle for new hires continues. It is well known and undeniable that Ivy League and other elite campuses are important targets for recruiters. Harvard University, Caltech and Stanford University produce the most employable graduates, according to the 2018 Global University Employability Ranking.[1] However, the demand for these graduates is highly competitive, so expanding the net for potential recruits is a must. This strategy has proven to yield excellent employee bases for some of the top companies. For example, Unilever, a transnational consumer goods company used machine learning algorithms to select its target number of 800 graduates from a wide net of over two million applicants. As a result, they were able to uncover an immense amount of data on the types of employees ultimately hired, which was then analyzed over time to reveal the most important attributes of a successful new hire. Those characteristics included learning agility, resilience and personal mastery. That is not to say that graduates from these top institutions are not equally qualified. Instead, the data points to the fact that companies who pigeonhole themselves to a narrow pipeline of graduates may miss out on a slew of capable and eager talent who will diversify capabilities, support digital initiatives and allow companies to “create the graduates they need.”[2]

Reskill and Redeploy In-House Talent. The idea that corporations can create the graduates they need is no myth. However, this requires continuous efforts from corporations to reskill and redevelop their existing talent. Nearly every company depends on traditional approaches such as instructor-led classroom training, onboarding programs and coaching. This requires corporations to actively transition away from the traditional route of hiring and firing and instead, train acquired talent as often as possible in unconventional ways. The most competitive companies are now adding digital campuses, boot camps and hackathons (a design, sprint-like event in which computer programmers collaborate).2 Most importantly, they are investing in soft skills that complement technical skills and help create a lifelong learning culture that fuels success. Below is a depiction of the variety of skill development techniques leading organizations are utilizing:

Engage Temporary Workers and Gig Economy Strategically. In addition to casting a wider net and reskilling, leading companies are leveraging temporary workers to fill the talent gaps. Although it requires strong internal processes to contract, integrate, manage and release these workers, they are proven to be highly useful and provide a different set of skills depending on the industry. For example, according to Infosys, technology companies use temporary staff for technical skills in 95% of digital initiatives. Manufacturers utilize temporary employees for design capabilities on 70% of their projects. Life sciences companies contract externally for business and industry expertise for 48% of their digital transformations.2 In all, these employees can be a great value add, allowing companies to expedite initiatives while catering to the changing needs of the consumer.

Align Organizational Structure to Evolving Business Needs.  Organizations must move away from hierarchal and matrixed organizational structures to team-based, self-managing ones for agile project needs.2 This allows for soft skills to be at the forefront of digital transformation, as the ability to collaborate and adapt are of upmost importance in advancing technical prowess and meeting the continuously evolving consumer demand.

Corporate strategy needs to be in perfect alignment with digital initiatives. This includes the development of a lifelong learning culture, the installation of an organizational structure that promotes cooperation, and, most importantly, the casting of a hiring net that captures talent with the soft skills that will ultimately drive initiatives. When corporations embrace this fact, they will realize movement. But, when they execute, they will realize growth

To learn more about MHT Partners, a leading education investment bank, please contact Alex Hicks (ahicks@mhtpartners.com) or Rebecca Bell (rbell@mhtpartners.com).

[1] https://www.timeshighereducation.com/student/best-universities/best-universities-graduate-jobs-global-university-employability-ranking
[2] Infosys Talent Radar 2019 Report

A Board Game Revival? Examination of Rising Popularity of Tabletop Gaming Among Millennials

In an ever-increasing digital world, board games are making a surprise comeback. The board game market encompasses packaged games typically set on hard surfaces, including boards, game pieces, figurines, cards, dice, and other accessories. In 2018, Value Market Research estimated the global board games market to be approximately $4.6 billion in revenue.  By 2025, this number is expected to nearly quadruple in size, to $16.3 billion, a compound annual growth rate of 20%.

People of all ages are growing fonder of tabletop gaming, but young adults are the driving force making this traditional style of gaming popular again. Millennials are turning to traditional cards, dice, and game boards, seeking in-person social experiences that their phones and laptops cannot provide. Interestingly, much of the rapid growth in the board game market is attributable to this young adult crowd rather than children, the traditional demographic target for most board game designers.

Desiring collaborative experiences with groups of friends, young adults tend to prefer games that emphasize strategy, social skills, and cooperation over games based on conflict or sheer luck. To this end, old-time board games like Monopoly do almost everything wrong. Monopoly has a very shallow strategy – players try to buy all the properties they can early on in the game, in order to gain an advantage that will snowball into a larger advantage later on.  Settlers of Catan, on the other hand, is a good example of the type of game millennials enjoy. The game forces players to strategize how best to devote limited resources over a period of time and encourages collaboration with other players through trade.

How are board game designers responding to these shifting demographics? There has been a clear pivot towards strategy-oriented games, not only in new releases in Europe, but also in North America. Furthermore, since millennials are attracted to games that require critical thought about decisions they make at each step, industry players are now designing more games with heightened complexity.  Designers are seeking more than ever to embed multifaceted, clever strategies into new games to hook the intellectual young adult crowd. Aside from complexity, millennials tend to care greatly about the aesthetics of board games.  Designers are creating sleek, contemporary board games that appeal to the tastes of younger demographics, and doing away with the juvenile, simplistic designs and flashy colors that characterized the board games of twenty years ago.

Board games are often a medium for millennials to spend a few hours socializing in groups, so pairing games with food and alcoholic beverages is popular. Catering to this trend, cafes and bars that offer dining and drinking experiences centered around board games are appearing across North America and Europe. In a recent survey, approximately 30% of millennials said they are interested in visiting one of these board game cafés or bars. With the rapid growth anticipated in the board games’ market, it should be expected that parallel industries, like these game cafes, should see quick growth as well.

As consumer investment bankers, MHT Partners will continue to monitor the rising popularity of board games with millennials, and we expect M&A opportunities to proliferate as new entrants looking to capitalize on trends in the fragmented games sector consolidate. We encourage those interested to keep up with our views on the board game market by subscribing to our consumer blog.

Private Equity Investment in Ambulance & Medical Transportation, Part 1: Why Investors See Opportunity

As private equity investment in healthcare services has boomed over the past decade, select funds have turned an eye toward one of the most important and challenging areas of healthcare services: ambulance and medical transportation. Private equity’s foray into medical transportation has not been without controversy, but MHT Partners believes that private investment can be an agent of positive change in the industry and create value for a wide array of stakeholders with a vested interest in a reliable, high-quality medical transportation system. Over a series of blog posts in the coming weeks, we’ll delve into why private equity is interested in medical transportation, how private equity can help improve care, and what the future holds for the industry.

Private investors’ interest in medical transportation is spurred by the industry’s shared characteristics with other attractive, investable areas of healthcare services:

  • First and foremost, the industry is growing. According to IBIS World, the U.S. ambulance services market is expected to grow at a rate of approximately 3% per year in the coming decade — at or above growth in the broader economy. Growth is driven by the aging population, as the oldest age groups disproportionately utilize ambulance services.
  • Second, the industry is tailor-made for operational improvements. The majority of the industry is composed of public providers or small private companies, most of whom have had difficulty implementing efficient operational processes to enhance utilization, expand reach, and manage cost. In an industry where seconds matter, mature operations are paramount for providing appropriate care.
  • Third, ambulance services are fragmented, with no clear market leaders even in major metropolitan areas. Fragmentation is a dynamic that plays well for private equity investors, who in many cases seek to acquire multiple businesses to create scale and efficiency in a targeted geography.

Despite some attractive attributes, the medical transportation industry possesses a multitude of unique challenges that face operators and investors:

  • Margins are razor thin, driven by reimbursement rates from government payors that haven’t kept pace with the cost of operations in recent years.
  • It is difficult to hire and retain high-quality paramedics and EMTs in many regions.
  • Private companies must coexist with municipal providers, who in many cases can afford to operate at a loss.
  • Owners must manage a universe of stakeholders that includes patients, populations, cities and towns, employees, hospitals, and nursing homes (to name a few).

As a result of these challenges, it is difficult to implement a successful strategy as a private medical transportation company. Nevertheless, experienced operators who can manage partnerships, costs, and logistics are poised to capture market share and create value. Influential private companies in the space include American Medical Response, by many measures the largest private ambulance company in the U.S., which is backed by KKR & Co., itself one of the largest private investors in the world. In the middle market, financial sponsors such as Alvarez & Marsal Capital Partners (Patient Care Logistics Solutions), Enhanced Healthcare Partners (Priority Ambulance), and New Heritage Capital (Covalent Health) have made investments in medical transportation successfully, in many cases expanding access and improving care for the populations they serve.

MHT Partners, a leading healthcare services investment bank, believes that private investment can be a force for good in the ambulance and medical transportation industry, and that companies providing excellent care with an eye toward all stakeholders in the value chain are poised for success. If you would like to learn more about MHT’s healthcare services advisory practice, please e-mail Taylor Curtis (tcurtis@mhtpartners.com) or Alex Sauter (asauter@mhtpartners.com).