MSPs – Weathering the COVID-19 Storm and Positioned for Growth

According to two recent industry surveys, the managed service provider (MSP) industry is holding up better than most during the pandemic-induced economic slowdown, and MSPs are well positioned for growth in the coming years. ITGlue and Datto surveyed thousands of MSPs before and after the onset of the COVID-19 pandemic. The findings from the surveys were similar and reflect the strength and resiliency of the MSP industry:

MSPs experienced solid growth prior to the pandemic.
According to Datto, nearly 80% of MSPs experienced average annual revenue growth of 5% or more over the past three years and approximately 20% of MSPs reported growth of more than 20% per year, on average.

Among ITGlue survey participants, the top third of MSPs had revenue growth and net margins over 20%.

MSPs have been impacted by the slowdown but are likely performing better than other segments of the economy.
Responses to Datto’s post-pandemic survey showed MSPs still expect to grow in 2020 but at a much slower pace than they originally forecasted. As expected, most respondents said they expect to reduce their growth plan following the onset of the pandemic, however, 11% said they are revising their growth projections upward as they expect to beat their original pre-pandemic plan.

ITGlue found that approximately half of MSPs saw their monthly revenue decrease in April as the result of the coronavirus shut down, though some MSPs reported an increase in revenue. In addition, ITGlue found responses about economic outlook didn’t change much between the pre- and post-pandemic surveys, with approximately 85% of respondents being neutral to bullish on the MSP market’s ability to recover from the pandemic. ITGlue concluded “this lack of change would seem to reflect a view of the pandemic as a short-lived economic phenomenon, one that would come with a V-shaped recovery, rather than a slower return to normal economic activity.”

Despite current turmoil, growth opportunities exist for MSPs
Although the COVID-19 pandemic has created a challenging environment for MSPs, it has also produced new opportunities. Many MSPs are observing an acceleration of cloud mitigation projects and greater demand for security, continuity, and compliance services.

Other areas expected to drive revenue in 2020 include improvement of remote access solutions, VoIP, Azure migrations, business resilience solutions, and hardware sales.

Interest in M&A waned a bit but remains strong
Prior to the pandemic, ITGlue found just over half of MSPs were either interested in acquiring or merging with another MSP (the question measured interest from both potential buyers and sellers). In the follow-up survey, interest in M&A diminished a bit but remained strong. Over 1/3 of respondents remained interested in M&A with 13% indicating an active interest (down from 17%), and an additional 24% responding they are open to an opportunity (down from 35%).

When only looking at potential sellers, ITGlue’s survey found seller interest was also somewhat diminished compared to pre-pandemic levels. The results showed MSPs that are actively considering a sale decreased from 6% to 4% of respondents, and those that are open to an opportunity decreased from 21% to 11%.

The decreased interest in M&A among MSPs is not surprising and is likely due to the high level of uncertainty caused by the onset of the pandemic. MHT expects interest in M&A among MSPs will rebound to pre-pandemic levels as the economy starts to recover and MSPs adjust to new market conditions.
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It’s too early to tell what lasting impact the pandemic will have on the MSP industry, but the surveys indicate the MSP industry seems to be doing well in comparison to most other industries, with good growth opportunities in front of them.

MHT Partners, a leading technology investment bank, believes MSPs that continue to perform well in the current environment will draw a lot of attention in the M&A market. Both financial and strategic buyers are flush with cash and looking for acquisitions, particularly those involving resilient businesses serving attractive markets.

If you would like to learn more about MHT and our Technology practice, please contact Kevin Jolley (kjolley@mhtpartners.com) or Mike McGill (mmcgill@mhtpartners.com).

Sources:
Datto’s Global State of the MSP Report (https://www.datto.com/resources/dattos-global-state-of-the-msp-report-na)
ITGlue’s 2020 Global MSP Benchmark Report (https://www.itglue.com/resource/global-benchmark-2020/)

The Connected History and Popular Regrowth of Roller Skating

Hundreds of people lined up on July 16th in Long Beach, CA, and no, it was not for a COVID-19 test. Instead, crowds assembled (hopefully socially distancing, of course!) in hopes of buying a new pair of roller skates from Pigeon’s Roller Skate Shop during its flash sale.(1) With shelter-in-place and work-from-home initiatives, many Americans have more free time than ever. As people have begun picking up hobbies new and old, specially those involving the outdoors, it is only natural that many have turned to one of America’s most beloved pastimes from earlier decades: roller skating.

Social media platforms, such as Instagram and TikTok, have been dominated with roller skating posts, accelerating the trend even further.(2)

Roller skating became popular in the 1930s and experienced surging popularity at various times, including in the ’60s through the ’90s. However, roller skating was more than an erratic trend in mainstream culture. United Skates, a 2019 documentary film highlighting the history of black roller skating rinks, tells a narrative deeply entrenched in the civil rights movement. Ledger Smith, known as “Roller Man,” skated 685 miles from Chicago to D.C. to attend the March on Washington, wearing a placard that read “FREEDOM” around his neck.(3) Popular actress Ana Octo has spent time in the recent past protesting (in roller skates) in support of Black Lives Matter and posting historical information about Ledger Smith to her 65,000 followers. (Her Instagram bio reads, “Don’t hate, roller-skate.”).(4)

Roller skating finally peaked in mainstream popularity in 2000 when 22 million Americans reported they skated at least once a year. In comparison, only 17 million people reported playing baseball.(5) Roller skates and skateboards led the U.S. alternative sports market in 2017 with $11 billion in revenue, which is expected to continue growing steadily over the next few years.(6) Bauer, a leading performance sports manufacturer, reported a 723% year-over-year online search traffic increase for inline skates.(5) Many retailers cannot keep skates in stock due to limited production, factory shutdowns, and sudden increased demand. Is 2020 the renaissance of roller skates?

As consumer investment bankers with significant experience working with clients in the outdoor and enthusiast products’ sectors, we are eager to watch this trend unfold, as well as the recent increase in biking, and see whether ”wheeled activity” will remain popular post-COVID or take a back seat to other activities once restrictions lift. Meanwhile, you can find us dusting off our old skates until we can get our hands on some new handmade Moxi skates, which currently take a whopping 10-14 weeks to ship due to factory shutdowns.

Sources:
1) https://abc7.com/community-events/hundreds-line-up-for-roller-skates-in-long-beach/6329421/
2) https://www.nytimes.com/2020/06/24/style/roller-skating-is-back-baby-taylor-lorenz.html
3) https://www.businessinsider.com/roller-man-skates-for-freedom-2015-8
4) https://www.thedailybeast.com/the-rich-history-of-black-roller-skating-rinks-and-their-civil-rights-legacy?ref=scroll
5) https://www.insidehook.com/article/health-and-fitness/rollerblading-comeback-coronavirus
6) https://www.techsciresearch.com/news/2645-roller-skates-skateboards-leads-11-billion-alternative-sports-equipment-market-in-us.html

EMS Technology Companies Are Showing Promise and Grabbing Investors’ Attention

In recent months, companies providing technology solutions for ambulance and emergency medical services (“EMS”) agencies have gained steam. Accelerated by the impact of COVID-19, stress on existing healthcare services’ infrastructure has forced change. Regulatory barriers to innovation are being demolished. As a result, a number of high-profile EMS technology (“tech”) companies have successfully raised capital from investors in recent months, and promising new technologies are poised to continue to attract investor attention.

The funding boom for EMS tech companies stems from a few dynamics at play within the industry.

  • Until recently there was little in the way of disruptive innovation in EMS. This persistent lack of innovation and entrepreneurship in EMS has created a significant tech debt among operators, resulting in embedded inefficiencies. Opportunities for technologists to create new solutions abound, leading to real cost savings and improved patient outcomes.
  • Complementary technologies in areas such as communications and geolocation have created new opportunities for innovation. Steps forward in adjacent industries have not trickled down quickly to EMS-specific applications. Technology has been stubbornly difficult to deploy in EMS, despite the significant outcomes-related benefits of doing so. More recently, however, the industry has been nudged in the right direction. Congress’ authorization of the First Responder Network Authority (“FirstNet”) represents a substantial step forward, leading to the expansion of high-quality broadband dedicated to first responders. Similarly, the Centers for Medicare and Medicaid Services’ Emergency Triage, Treat, and Transport (“ET3”) model leverages telehealth to enable treatment at the point of care, and companies like Allerio (allerio.com) are developing innovative products and solutions for first responders to fully realize the benefits of emerging technology. Going forward, industry-wide infrastructure investments will enable entrepreneurs to create more custom solutions for first responders.
  • The market for remote medical care is large, growing, and has never been stronger. The traditional EMS market is huge, with municipal agencies and private ambulance companies operating in tens of thousands of cities and towns nationwide. The traditional market is expanding as prehospital medicine becomes an ever more important stage in the continuum of care. Spurred on by telehealth and the ubiquity of urgent care, more healthcare is being delivered in the field. Companies such as Ready Responders, which leverages field medics to facilitate in-home telehealth, exemplify the trend. Most recently, contact tracing in the field has been a key initiative in the national response to COVID-19.

Recent investments in EMS tech companies include the $21 million raised by RapidSOS in June of this year, bringing its total funding to $107 million, and the more than $11 million raised by Pulsara, bringing its total funding to almost $30 million. Other emerging companies are sure to attract the attention of investors seeking to profit from growth in the space.

MHT Partners, a leading healthcare services investment bank, is an active advisor in the healthcare, technology, and medical transportation industries. If you would like to learn more about MHT’s practice, please e-mail Alex Sauter (asauter@mhtpartners.com) or Taylor Curtis (tcurtis@mhtpartners.com).

Venture Capital Investment in Education Technology

Global investment in education technology has grown rapidly over the past decade, benefitting from over $32 billion in venture capital funding. Education companies offering innovative digital content and services have proven to be attractive assets garnering ongoing competition by investors. In the last decade, these businesses traded on the promise that the traditional methods of learning would be at most, upended by new technologies, and at least, heavily complemented by them.

According to a report by Holon IQ, venture capital investments in education technology (“edtech”) totaled approximately $500 million in 2010. A decade later, edtech venture capital attracted nearly $4.6 billion in the first half of 2020, positioning the sector for a record-breaking investment year. No doubt, technology is accelerating across every industry, but especially in education as schools, colleges, students and families attempt to engage and maintain learning continuity in an isolating COVID-19 environment. Looking forward, Holon IQ projects the cumulative investment in the edtech sector to nearly triple to $87 billion by 2030.

Venture capital investment in the pre-K-12 to adult workforce education sector hit a peak in 2018, followed by over $7 billion in venture capital funding in 2019. China remains the top recipient of funding, with U.S.-headquartered companies attracting the majority of remaining capital.

Global spending in education is driven by a couple of factors:

  • Emerging markets such as Latin America, Southeast Asia and Africa are rapidly growing and looking to improve educational outcomes for large, underserved populations. By 2025, the primary-, secondary- and university-level student base is expected to grow by half a billion, driven primarily by population growth in developing countries. The scale, quality and speed required to deliver this instruction will undoubtedly involve technology.
  • In developed economies, technology is already used to support learners, teachers and school decision makers. Education technology has become especially important in the COVID-19 environment as schools implement newer asynchronous, remote and hybrid learning models.

The overwhelming demand for better communication tools and learning products should sustain a continued increase in investment over the back half of 2020. Beyond that, more advanced technology learning applications are expected to hit their strides by 2025 with augmented and virtual reality and artificial intelligence becoming more integrated into core education delivery and learning processes.

MHT Partners, a leading education investment bank welcomes further discussion: Rebecca Bell (rbell@mhtpartners.com), Shawn D. Terry (sterry@mhtpartners.com) or Alex Hicks (ahicks@mhtpartners.com).

Source: HolonIQ

Private Equity’s Emerging Interest in Psychology & Psychiatry Practices

Private equity investment in psychology and psychiatry practices has accelerated in recent years. Investors with a track record for partnering with behavioral healthcare companies, as well as generalist funds, have ramped interest up quickly in psych specialties. Numerous attributes of psychology and psychiatry practices align with private equity’s interests and experience, and recent M&A in the space suggests that market opportunities exist for the first-movers who can build large platforms for providing care nationwide. Furthermore, the ability to deliver care via telemedicine (telepsych) means psychology and psychiatry practices have been impacted far less than most specialties, and by some measures have even improved, during the COVID-19 pandemic.

Investors have long been active acquirers of behavioral health companies and service providers, but financial sponsors have accelerated the pace of investment in psychology and psychiatry due to a number of converging factors:

  1. Private equity’s access to financial capital enables consolidation of the fragmented industry as it exists today. Many independent psychology and psychiatry companies are small, composed of fewer than a dozen professionals. Investors looking to acquire or “roll up” a number of small practices stand to benefit from significant increases in efficiencies that accompany greater scale, as well as lower costs. For providers, that often means more time focused on patient care and less time addressing the administrative minutiae of running an independent practice.
  2. There is an enormous market, as well as an unmet need, for mental health treatment in the U.S. Nearly every adult stands to benefit from some form of psychology or psychiatry treatment at some point in his/her life, and the industry has grown at a rate of more than 5% annually in recent years to over $18.9 billion in 2019. Significant growth in demand for services has outstripped supply, and in 2019 there was approximately only one licensed psychologist or board-certified psychiatrist for every 3,300 people in the U.S. Many psych professionals expect the COVID-19 pandemic to exacerbate this trend, as adverse effects on individuals’ social, economic, and physical wellbeing portend additional mental health diagnoses. (American Psychiatric Association, WHO.)
  3. Technological and regulatory improvements are rapidly expanding access to care. The ability to deliver care via telemedicine and fewer regulatory hurdles imposed by CMS and private insurers means that psychology and psychiatry services are available like never before to individuals that cannot travel to a provider’s office for medical or logistical reasons.

TPG Capital’s acquisition of LifeStance Health (joining existing investors’ Summit Partners and Silversmith Capital Partners) is illustrative of recent transaction activity in the sector, and Refresh Mental Health, backed by Lindsay Goldberg, has announced that it will be exploring transaction options as well. In the vast middle market, platforms such as New Harbor Capital’s Community Psychiatry Management represent regional platforms with significant opportunities for growth.

MHT Partners’ healthcare investment banking services represent founders, owners, and entrepreneurs undergoing M&A transactions. If you would like to learn more about MHT’s experience, please e-mail Taylor Curtis (tcurtis@mhtpartners.com) or Alex Sauter (asauter@mhtpartners.com).

Pandemic Shaping the Playing Field for Physician Group Acquisitions

Throughout the pandemic, private equity and strategic acquirers’ appetites for well-performing physician groups across a number of specialties have been resilient.  On the other side of the equation, physician groups that had desired to remain independent are now seeing the benefits of being part of a larger organization as they work to manage significant declines in patient volumes and related operational challenges attributable to COVID-19.  It’s reasonable to infer that as some groups start to emerge from the crisis, they will begin to explore partnerships with private equity-backed platforms seeking shelter from future storms.  This bodes well for both groups, as private equity platforms can add leading practices to their rolls, and physicians can benefit from increased scale, robust back-office services, and enhanced payor contracts.  Across the board, we foresee large waves of consolidation of independent groups and sponsor-backed platforms under the auspice of “we’re better positioned to address future challenges and on-going pandemic fallout together.”

One trend we expect to gain momentum will be commercial payors’ efforts to use the pandemic to drive consolidation of physician groups as part of the race to vertically integrate, provide more coordinated care, and narrow networks.  As an example, integrated payor / provider groups like United Healthcare’s Optum Division have been increasingly aggressive in their pursuit of physician group acquisitions, as well as technology-driven care models like those acquired in the purchase of remote behavioral health provider– AbleTo for $470mm.  We also think there is a meaningful play for sponsors interested in building out more integrated models, which can extend the continuum of care, improve outcomes, and reduce overall healthcare expenditures.   Enhanced Healthcare Partner’s recent combination of a surgicalist group and physician compensation services group to form EA-Synergy is a prime example of how value can be generated by providing more coordinated services to health systems.

Based on conversations with the sponsor community, we expect the first wave of pandemic-driven physician group M&A activity will largely consist of add-on acquisitions in specialties where private equity has already invested, specifically: dermatology, vision services, orthopedics, GI, dental,  physical therapy, and women’s health.  There is also meaningful interest in ENT practices, and interestingly, in some traditionally hospital-based specialties like cardiovascular care.  However, we think new, large sponsor-backed provider platforms will be the exception and opposed to the rule for now.

Timing around the launch of new deals is a frequent topic of discussion.  Many well-capitalized businesses may opt to sit on the sidelines through the summer to see how the response to the pandemic unfolds and how the M&A market responds in kind.  However, for other groups, the relative lag in deal flow could place their process in the spotlight as opposed to competing for attention during headier times.  For those groups willing to dip a toe in the water, after seeing patient volumes swing back, a process launch in the late summer will give their advisors two or three months of “new normal” performance from which to baseline financial projections for the remainder of the year.  In this light, one could expect to see deals coming out beginning in Q3 2020. Pertaining to most things in life, timing is everything. There’s no right answer to the question of “when should I test the market,” but the demographic tailwinds which made physician groups compelling investments prior to the pandemic have not changed, and in fact may be amplified by pent-up demand that has been building for healthcare services over the past three months.

We continue to closely monitor the market for healthcare services businesses and remain optimistic that there will be attractive opportunities for well-run provider groups now and in the future.  To the extent that you would be interested in having further conversations on this topic, or others related to our healthcare services capabilities, please do not hesitate to contact members of the MHT Partners healthcare services team: Taylor Curtis (tcurtis@mhtpartners.com) or Alex Sauter (asauter@mhtpartners.com).

What is Social Impact Investment Banking?

To some, the terms “Social Impact” and “Investment Banking” may appear to conflict with one another. After all, aren’t investment bankers supposed to be “win-at-all-costs” dealmakers?

Well, like most things in life, it isn’t quite so black and white. The job of an investment banker is to facilitate transactions that achieve clients’ goals. In the past, that often meant focusing largely on one thing: maximizing value. Today, however, financial results are not the only measure of a successful business. To a growing cohort of entrepreneurs, business owners, and investors, companies that value the social impact of their operations are growing in influence and importance. As a result, partnering with an investment banker that can elevate the social or environmental impact of clients, while at the same time optimizing financial outcomes, is critical for a company vested in the impact of its business.

Given our expertise and deep experience with socially invested companies and “ESG” (environmental, social, and governance) investing, MHT Partners has launched a focused initiative to advise social impact and double bottom-line companies and investors as part of a Social Impact M&A Advisory program.

In recent years, impact and ESG investing has grown significantly, driving demand as investors look to partner with high-performing, impact-driven companies. The Global Impact Investing Network estimates that impact-specific assets under management (“AUM”) grew at an annual rate of 17% between 2014 and 2018. In the U.S., MHT Partners estimates that private equity impact investment AUM exceeds $30 billion[1]. Many of the largest and longest-standing financial sponsors are deploying impact funds, including KKR, which in February closed its $1.3 billion Global Impact Fund, and Bain Capital, which is currently raising its second fund under Bain Capital Double Impact. The growing community of impact investors and companies is creating a dynamic new market.

The growth in impact investing is not surprising, as there is ample evidence to suggest that companies that value social impact experience outsized returns and rates of growth. For years many marquee investors, often spurred on by powerful limited partners, have divested of interests in the munitions and fossil fuel industries. Now, real-world evidence from the Carlyle Group supports the case that socially conscious practices, such as increased board diversity and the incorporation of renewables into energy portfolios, yield more favorable economic outcomes for companies. Through the first four months of 2020 and the COVID-19 crisis, ESG funds have drawn more than $12.2 billion of capital and outperformed the market according to the Wall Street Journal. Impact investing is here to stay.

As investment bankers in the middle market, we seek to align ourselves with clients who share our values. The history of our firm reveals a long track record of advising high-performing companies in the consumer, healthcare, technology, and education segments that value social or ESG, as well as financial, outcomes. Our frequent dialogue with the most active and experienced funds that have an expressed mandate to invest in companies with a positive social impact gives us unique insight into the differentiating factors that are coveted by impact investors. We believe that companies that value social impact are poised to experience outsized growth in today’s economy, and we are excited to formalize our deep experience by moving forward as a leader for providing Social Impact M&A Advisory services.

If you would like to learn more about MHT’s Social Impact M&A Advisory practice, please e-mail Alex Sauter (asauter@mhtpartners.com).

[1] Excludes real asset strategies

What Will Become of the Sharing Economy?

We had (and still have) “excess capacity” in personal assets – everything from office space to cars to restaurants to boats to houses to bikes…even apparel. It is physically impossible to use all of our “stuff” 100% of the time, and conversely, it is often inefficient to purchase all of these assets when you can’t afford them, can’t store them, or just want to use something once. Enter an explosion of entrepreneurs and their apps that virtually connected intermittent demand with intermittent supply. The sharing economy was born, and until a few months ago, society had developed a feeling of accomplishment (wasting less, saving money) while billions of dollars were being generated by property owners and app developers. Further, the sharing economy includes the “gig economy,” which shares all of the same network effects previously described. However gigs are personal and professional services performed remotely (e.g., legal services, graphic design) or in person (TaskRabbit, Uber, NetJets, Wag.com, etc.). The gig economy contributed to a dynamic transformation in our society, as millions of workers around the world pieced together multiple occupations, often lifestyle-oriented, to generate a desired level of income.

And then came the COVID-19 global pandemic in late 2019 and early 2020. The unprecedented shelter-in-place rules have had a crippling impact on the sharing economy, as much of the sharing economy depended on the transportation, hospitality, entertainment, and office space demand of people. Said another way, much of the sharing economy relies upon close human contact.

Perhaps the most notable impacted networks, so far, are Uber, Lyft, and Airbnb. The two dominant ride-sharing companies had not been publicly traded for a year when global ride-sharing demand evaporated in Q1. Millions of self-employed drivers around the world, and nearly 8,000 total full-time employees, are out of work. Airbnb was slated to go public this year and instead has laid off 1,900 employees and taken on $2bn of expensive debt. For some lucky drivers, the spike in grocery, parcel, and meal delivery has softened the blow.

The bottom line is that most of us are still not comfortable being in close contact with shared “stuff” without a sanitary guarantee. My family’s next trip was to involve an Uber ride to the airport, cross country flight, Turo car rental, Airbnb lake house rental, and probably peer-to-peer boat and bike rentals. Everything has been cancelled.

When will we, as frequent sharing economy customers, be comfortable with these arrangements again? When will the millions of drivers, property owners, office owners, dress owners, etc., find a proven and affordable disinfecting solution that we can all swear by? How will a customer receive validation that a bike or cubicle or car was properly sanitized? When a vaccine is rolled out, will we as customers need to prove our vaccination or is it the other way around?

As consumer investment bankers, we are keenly interested in how the evolution of the sharing economy will continue as COVID 19 continues to impact the world. To discuss this and any other consumer topics, please don’t hesitate to reach out to us.

A Bright Future for Telehealth Beyond COVID-19

Telehealth gained significant momentum in 2019. Nevertheless, on an absolute basis, flexible, widely available telehealth solutions were limited. COVID-19 has upended the status quo and charted a new growth trajectory for telehealth(1). In fact, the pandemic has created an opportunity to ingrain telehealth as a commonplace service in U.S. healthcare.

Once COVID-19 started spreading in the U.S., Medicare expanded telehealth coverage(2), Health and Human Services issued guidance to states in favor of relaxing interstate medical licensing rules(3), and 49 states waived or altered regulations on telehealth(4). Waivers included allowing physicians with out-of-state licenses to practice telemedicine within the state, allowing more mediums of communication during a telehealth appointment, and the reduction of regulations on making prescriptions through telehealth appointments. To protect vulnerable populations, elected officials have encouraged and passed legislation in favor of telehealth visits for the elderly and those at higher-risk for COVID-19(5). While many changes are temporary, convenience and increased patient use of the telehealth platforms following the changes has created pressure to permanently adopt the new rules.

Following the forced incorporation of more robust telehealth, the capability to utilize telehealth is growing for patients and providers alike. Patients will welcome the opportunity to see their physicians in person as soon as they’re allowed in order to address more complicated and urgent problems. However, quick health questions and routine consultations are positioned to remain virtual, freeing up patients’ schedules and adding an efficient option for providers. Ready Responders, a tech-enabled, on-demand health service that provides care in a patient’s home, continued serving its patients throughout COVID-19 and announced plans for further expansion(6). Telehealth’s role in companies like Ready Responders can help reduce unnecessary emergency department usage and direct patients more efficiently to proper providers when in-home care is inappropriate, creating promise for potential significant decreases in expenditures while improving care. Furthermore, with provider shortages nationally and in rural areas especially, increased telehealth resources, especially from physicians who might live elsewhere, help bolster access for populations who need healthcare the most.

With elective and non-essential care shut down in most of the U.S., many physician practices began experimenting with telehealth in order to continue to see patients and keep practices running. Largely using live video and audio, patients have discussed symptoms of respiratory infections with primary care physicians, showed dermatologists concerning skin conditions, walked through upcoming procedures with surgeons, and met with mental healthcare providers. Encounters with providers have led to diagnoses and prescriptions, expedited urgent or emergency treatments, and provided plenty of peace of mind. The experience both patients and practices have gained utilizing telehealth in the past few months has created comfort with telehealth that did not exist before the pandemic and lays a foundation for expanded use.

Major hurdles still exist for wider telehealth adoption following the first wave of COVID-19. On the reimbursement front, CMS released new guidelines for reimbursement of telehealth services(7); moreover, private insurance plans are following suit, rewriting policies on what telehealth services they cover and how much is reimbursed(5). Services covered, reimbursement amounts for telehealth vs. in-person services, and the new guidelines’ reimbursement and cost-sharing structures will all determine which services remain viable telehealth offerings for practices. Added time spent arranging telehealth appointments and technology gaps, specifically with patients lacking telecommunication device access or experience, can lower productivity and potentially dampen enthusiasm for future telemedicine use(9). Most importantly, maintaining the ability for physicians and other healthcare providers to practice across state lines following COVID-19 will strongly contribute to telehealth’s potential growth in the coming years(10).

MHT Partners, a leading healthcare services investment bank, believes continued regulatory evolution, demonstrated efficacy and increased efficiency, and consistent and straightforward reimbursement structures are paramount for telehealth to continue its growth and adoption by patients and providers. While telehealth still has plenty of room to grow, 2020 is seeing positive steps towards improving health outcomes, lowering healthcare costs, and increasing healthcare access through innovative telehealth offerings that will continue moving forward. Physician and healthcare practices will need to be increasingly aware of telehealth, know their state’s regulatory environment with regards to telehealth, and have an opinion on whether telehealth presents as an option to best serve their current and future patients.

Sources:
(1) American Telemedicine Association https://www.americantelemed.org/about-us/
(2) Medicare: Telehealth Coverage https://www.medicare.gov/coverage/telehealth
(3) mHealth Intelligence https://mhealthintelligence.com/news/feds-ok-interstate-licensing-paving-way-for-telehealth-expansion
(4) Federation of State Medical Boards https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf
(5) H.R. 6487 and S. 3548 https://s3.amazonaws.com/fn-document-service/file-by-sha384/fb7696e83acaf7ef91c5a397491226f01ae77205a458e462ecaa875fd31b2152083342720c7e7730e4b661aafa929313 https://s3.amazonaws.com/fn-document-service/file-by-sha384/902177abbfcf26c40e1e793ad5f52cca625fc2b900cdcdd95d8fb23dbc488b8e7898cf74c79592b1bc5ae61fa19898be
(6) Business Wire https://www.businesswire.com/news/home/20200320005540/en/Ready-Responders-Provide-At-Home-Care-Patients-Alleviate
(7) Centers for Medicare & Medicaid Services https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
(8) Kaiser Health News https://khn.org/news/telehealth-will-be-free-no-copays-they-said-but-angry-patients-are-getting-billed/
(9) Policy Med https://www.policymed.com/2020/04/covid-19-recent-changes-to-telehealth-regulations-and-reimbursement.html
(10) Interstate Medical Licensure Compact https://www.imlcc.org/a-faster-pathway-to-physician-licensure/

The Bicycle is Back in Black!

A simple mechanical contraption has surged in popularity over the past couple of months as people struggle with restlessness at home, public transportation unavailability, shuttered gyms, the temptation of all day work-from-home snacking and bulging waist lines – the bicycle is back in black!

Whether it be road bikes, mountain bikes, e-bikes and the latest, gravel bikes, all have seen a surge in demand from “state of the art” versions to beginner varietals. While some of this mechanical mania will surely subside as “normalcy” returns to recreation, work and commuting – we believe a significant percentage of this change to consumer behavior will stick.

The National Association of City Transport Officials (NACTO) reports an “explosion in cycling” in numerous U.S. cities. While much of this is recreational, usage by essential workers commuting is up significantly and may portent the behavior of non-essential workers who return to the office in the coming months.

Domestically, an increasing number of cities have closed city streets to vehicles both in response to less cars on the road and increased demand from cyclists. Among notable cities:

  • Oakland has closed 74 miles of streets.
  • San Francisco just this week pledged to close another 20 miles of streets which brings the total to 34 miles.
  • NYC plans to close 100 miles (starting with 40 in May).
  • Seattle plans to permanently close 20 miles of streets.
  • Elsewhere in North America, Minneapolis, Philadelphia, Burlington, Denver, Boston, Charlotte, Calgary and Mexico City have all had street closures.
  • International cities ranging from Auckland to London, Berlin to Bogota, are doing the same.

Admittedly, not all road closings will be permanent, but it’s not a stretch to envision some permanency will continue.

Several considerations and factors contribute to cycling popularity:

  • Biking is fantastic exercise, and with public transportation in high density urban areas down 50% or more across the nation, biking is a logical alternative.
  • One can partake in this activity with the whole family.
  • It is lower impact versus some physical activities, and one can cycle late into their life.
  • Biking is an activity that can be both social and social distancing at the same time (unless you’re banging bike pedals, it’s difficult to be within 6 feet or so).
  • Importantly as well, biking is fantastic for the environment as it reduces reliance on cars.

More specifically with respect to some of the points above, according to the World Resources Institute, studies have shown regular cyclists can have a 50% less likely chance of heart disease among other ailments (the same can presumably be said for other acts of regular exercise). As relates to the environment, it’s estimated that each kilometer cycled avoids 250 grams of CO2 emissions. Cyclists in Copenhagen, one of the world’s most prodigious biking cities, by virtue of avoiding cars, keeps 20,000 tons of carbon emissions from entering the atmosphere.

All of this points to significant growth in the estimated $6B + bike market.

Anecdotal checks with numerous bike participants (vendors and independent shops) paint a picture of massive demand juxtaposed against limited supply. At the local bike shop I frequent just north of San Francisco, a simple mountain bike tune-up is taking 10 days (because of overwhelming demand), and the availability of a bike to demo in advance of a new purchase was exactly one (in contrast to probably 10 X that in less active times).

But a word of caution – America witnessed a significant bike boom in the 1970s, and at the time it appeared to be spurred on by high oil prices, a concern for the environment and a number of other “wellness“ dynamics also at play (sound familiar?). Bike sales boomed for a number of years and then they deflated just as quickly and alas, America didn’t become the Netherlands. That said, in hindsight, the 70s’ boom appears to have been fueled simply by baby boomers coming of age and buying “big people“ bikes. While bikes in the 70s were still viewed as somewhat of an odd accoutrement for an adult (rather than something shed with finality in one’s teenage years), bikes (and the quality and spectrum of them) have come a long way in the interim, and there is nothing “childish“ about them anymore.

In addition to the aforementioned dynamics, it remains to be seen how much consumer behavior will stick versus the alternative of bikes becoming glorified drying racks in one’s garage.

Additionally, with respect to worker commutes, the interplay of more people working from home (less need to commute) and convenience (dedicated bike lanes – perhaps less needed with more people working from home) remains to be seen.

As an avid mountain biker and believer in “a sound body makes for a sound mind,” I hope that this two-wheeled revolution continues!

MHT Partners, a leading consumer investment bank, welcomes further discussion. If you would like to learn more about MHT’s consumer advisory practice, please e-mail Craig Lawson, clawson@mhtpartners.com; Patrick Crocker, pcrocker@mhtpartners.com; Gavin Daniels, gdaniels@mhtpartners.com; Tara Smith, tsmith@mhtpartners.com or Tom Gotsch, tgotsch@mhtpartners.com.