The Home Health Value-Based Purchasing (HHVBP) Model is set to roll out nationwide on Jan. 1, 2023. While its demonstration pilot had been live in nine states beginning in 2016, that pilot ended abruptly before 2021 due to COVID-19. Under HHVBP, home health agencies will be subject to a 0-5% upward or downward reimbursement adjustment based on various performance measures. While 2023 is the first performance (measurement) year subject to these changes, reimbursement won’t be affected until 2025. Under the model, agencies will be grouped with their cohorts based on size – but not geography. In contrast, in the demonstration, agencies were judged against only other agencies in their respective states. After the nationwide rollout, competition will be determined based on agency size. Specifically, agencies with fewer than 60 unique survey-eligible beneficiaries in the calendar year before the performance year will be assigned to smaller-volume cohorts, while agencies with 60 or more will form part of the large-volume cohorts. The Total Performance Score (TPS) an agency receives under HHVBP will be based on their performance in multiple areas. These performance markers include: Five based on OASIS Two based on claims Five based on HHCAHPS survey quality measures An agency’s TPS will then be weighed against the TPS of other agencies in an organization’s respective cohort, and then the corresponding payment adjustment percentage will be computed. Impact on agency value Once HHVBP is implemented, it will change the reimbursement landscape to some extent. While there’s not any more money coming in from Medicare, per se, worse-performing agencies will in essence pay for better-performing agencies’ adjustments. “What some owners don’t realize is that a 5% change in revenue will have a significant impact on cashflow, or EBITDA,” said Mertz Taggart Managing Partner, Cory Mertz, “Those dollars flow straight to the bottom line, in the absence of changes to the agency’s cost structure.” Valuation impact illustration To display HHVBP’s potential impact on a given agency, consider the following assumptions: The model agency will be 100% Medicare revenue Visit volume and cost of sales will not change from performance year to payment year General and administrative (G&A) expenses will stay fixed from year to year Using the industry standard “multiple of EBITDA” methodology to determine value, performance year valuation may be follows: 1 – For illustration purposes only. Multiples are a function of, among other things, agency risk and marketplace. Without the HHVBP impact, the agency’s enterprise value is $11.2 million. Let’s look at the same agency, in the first Payment Year, with a 5% upward adjustment: Note that, in addition to the improved EBITDA, the multiple has changed slightly, as agencies with better quality scores tend to sell at higher multiples. The benefit to the agency goes beyond a $500,000 increase in revenue. In this case, the enterprise value increased by just over $4 million, or 36%. If an agency performed poorly enough warrant a 5% decrease, the change in valuation may look something like the following: Here, the agency's enterprise value dropped by $3.77 million in comparison to its pre-HHVBP implementation numbers. The swing in value is fully illustrated when comparing the best performing agency ($15.23M enterprise value) with the worst performing agency ($7.43M enterprise value). What agencies can do to prepare for HHVBP As explained above, an agency’s TPS, which will determine its rate adjustment, is based on relative performance on OASIS-based, claims-based and HHCAHPS Survey-based quality outcomes. Therefore, that’s what agencies should home in on in order to get the best result and the best possible change to enterprise value. “The agency should review and correct — if needed — internal processes and protocols to boost performance,” Mertz says. “Additionally, the agency should consider investing in the right tools and software to track outcomes data, and understand which outcomes are having the largest impact on the TPS.” Given that the first performance year is not until 2025, many agencies are comforted by the thought that HHVBP impact is still far away. That is not the case when it comes to valuation, as we expect home health acquirers will begin to price in the potential adjustments to their target acquisitions much sooner, perhaps as early as late-2023.

After the final three months of 2021 saw a surge in merger and acquisition activity across all sectors that was fueled by a wave of sellers eager to exit the market, deal volume in general for the first quarter of 2022 returned to more modest levels, with at least 41 behavioral health transactions closed. However, there is one notable exception. The mental health sector remains hot, with 26 transactions announced in Q1, shattering the previous record of 16 set in the fourth quarter of 2021. Note: Total industry transactions does not necessarily equal the sum of the sub-industries, as many transactions include more than one sub-industry. The success of LifeStance and Refresh Mental Health in recent years has piqued buyers’ interest in the mental health sector, said Mertz Taggart Managing Partner Kevin Taggart, CM&AP. “Both of those companies have been wildly successful with multiple sales over the last couple of years, including LifeStance going public in 2021,” Taggart commented. “Private equity started seeing the success of both of those groups in 2020 and 2021. There is a lag between the time they decide to get into the market and when they start making acquisitions, which I believe was reflected in the Q1 numbers.”. Refresh itself was one of Q1’s most notable acquisition targets. In March, the company was acquired by Optum, the UnitedHealth Group subsidiary that provides pharmacy benefit management and healthcare services. While not necessarily reflected across all of behavioral health in Q1, demand for provider organizations remains robust. Bankers and buyers are now rebuilding their pipelines, and Taggart said he expects to see a strong back half of 2022, barring any unforeseen developments on the macroeconomic level. “There is a strong demand for mental health companies,” he observed. “The rest of behavioral healthcare will also be attractive, although perhaps not quite to the same level.” Addiction Treatment A total of 14 addiction treatment deals were announced in Q1—a figure in line with most quarters dating back to late 2019, but down from the 31 deals announced in the fourth quarter of 2021. Both financial institutions and potential buyers appear to be rebuilding their pipelines to start 2022 with one notable exception. BayMark Health Services, backed by the private equity firm Webster Capital, has remained active, completing three deals: In January, BayMark acquired the online addiction treatment platform Kaden Health. A month later, the company expanded into Indiana and grew its AppleGate Recovery brand with a deal for Lucina Treatment Centers, a group of five office-based opioid treatment programs. In March, BayMark added Pathfinders Recovery Centers, which operates programs in Scottsdale, Arizona, and Aurora, Colorado, as well as Emerald Isle Health and Recovery in Surprise, Arizona. Webster Capital also announced a new partnership in February with Oceans Healthcare, a behavioral healthcare company with 33 locations, including 23 inpatient hospital campuses, across the Southeast. Meanwhile, after completing three transactions in nearly six years previously, Acadia announced two addiction treatment/mental health deals in Q1, acquiring Centerpointe Behavioral Health Kansas City and Orlando Health. Other deals in the addiction treatment space announced in the first quarter include: Amulet Capital Partners, a middle-market private equity firm, announced it has recapitalized Lighthouse Behavioral Health in Columbus, Ohio. Burrell Behavioral Health and Preferred Family Healthcare announced a partnership to create a newly named not-for-profit behavioral health and addiction treatment provider known as Brightli. Royal Life Centers, an addiction treatment provider with 8 locations, has been added to the portfolio of CMJ Health Services. Heritage CARES, a virtual behavioral health, substance misuse, and suicide prevention company, merged with YouTurn, a platform for therapist-led video content for stress, behavioral health, and substance misuse. Retro Capital Group announced a platform deal for Resurgence Behavioral Health. Summit BHC acquired seven psychiatric hospitals in six states from Strategic Behavioral Health. Mental Health As noted above, while activity in other subcategories slowed in the first quarter, mental health transactions surged, with a record 26 deals announced, surpassing the previous high of 16 in the fourth quarter of 2021. In the most notable deal of the first quarter, UnitedHealth Group subsidiary Optum acquired Refresh Mental Health from the private equity group Kelso & Co., according to media reports. While terms of the deal were not disclosed, Kelso acquired Refresh at a valuation of about $700 million in December 2020. “Optum and Refresh Mental Health are excited to expand effective behavioral care to patients through a more coordinated health system,” an Optum spokesperson told Axios. “Together, we will be able to drive deeper integration between medical and behavioral health care and advance personalized care to patients through value-based care.” Private equity drove most of the transaction volume in mental health, accounting for 16 of the 26 deals announced. This includes two acquisitions by Health Connect America, a behavioral health platform backed by Palladium Equity Partners. Health Connect America acquired Pinnacle Family Services in North Carolina and Healing Educational Alternatives for Deserving Students (HEADS), a Florida-based, trauma-focused provider. Among the other transactions in the mental health space that were announced in the first quarter: Digital provider Brightside Health raised $50 million in a Series B funding round led by ACME Capital and Mousse Partners. Mental wellness app Calm acquired health tech company Ripple Health Group, which provides services for older adults and their caregivers. Centene Corp. completed its acquisition of Magellan Health, increasing its members' access to behavioral health services. CloudMD Software & Services closed its acquisition of MindBeacon Health, a provider of digital healthcare services. CM Counsel announced a deal with James Levine & Associates. Discovery Behavioral Health, which operates a network of mental health, substance use, and eating disorder treatment centers, acquired Dan Med TMS Neuro Institute, a provider of transcranial magnetic stimulation (TMS) therapy for depression. Foresight Mental Health acquired Psychiatric Addictive Curative Therapies (PACT), which operates 14 mental health clinics in the Atlanta area. Digital mental health platform Headspace Health acquired Sayana, an AI-driven mental health and wellness company. Brightline, a youth telehealth-based behavioral health company, completed a $105 million Series C funding round led by investment firm KKR. Lightfully Behavioral Health announced a private equity-backed strategic acquisition of Resilience Treatment Center in Los Angeles. MindPath Care Centers made a private-equity backed strategic acquisition of Psychiatric Centers at San Diego. New Directions Behavioral Health acquired Tridiuum, a digital behavioral health company. Novamind, a mental health company that specializes in psychedelic medicine, closed its acquisition of Foundations for Change, an Arizona-based provider of ketamine-assisted psychotherapy. Pacific Clinics and Uplift Family Services announced a merger and plans to operate under the Pacific Clinics name. Comprehensive Behavioral Health and Psych Associates announced a merger to form Bloom Health Centers, a mental health treatment provider organization. The Recovery Ways Family of Programs expanded into Texas with its acquisition of Stuart J. Nathan, PhD, and Associates. Revitalist announced in January that it had executed a purchase agreement to acquire a ketamine clinic in Jacksonville, Florida. Digital eating disorder treatment company Equip Health closed a $58 million Series B funding round led by The Chernin Group, with Tiger Global Management and General Catalyst joining as new investors. Transformations Care Network has partnered with Columbia Associates in Psychiatry and New Directions Counseling Services. Legion Health closed a $150 million Series C investment round that included institutional investors UpHonest Capital and Soma Capital. Autism Services and Intellectual/Developmental Disabilities As with addiction treatment, transactions in the autism services and intellectual/developmental disabilities (I/DD) space were down, with six deals announced in the first quarter compared to eight in the final quarter of 2021. The six deals—all of which were backed by private equity firms—were the fewest in a quarter since the second quarter of 2020, which coincided with the start of the COVID-19 pandemic. The deals announced in the quarter included: Caregiver, a privately held, long-term care services and support provider for those with I/DD, acquired AbleLight, which operates two programs in Indiana, and Compass Residential & Consulting. Hopebridge announced a partnership with Autism in Motion (AIM) Clinics to increase access to pediatric autism services. Florida-based KNR Therapy, backed by Shields Capital, announced a merger with Autism Learning Center in Georgia. Ally Pediatric Therapy received an investment from Spanos Barber Jesse & Co. The Stepping Stones Group, a national provider of therapeutic, behavioral, autism, nursing and educational services, acquired the Southcoast Autism Center, based in Massachusetts. In March, the Chicago-based private equity firm Vistria Group began the process of acquiring I/DD services and housing provider Beacon Specialized Living.

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