The world of healthcare mergers and acquisitions (M&A) has experienced a significant rollercoaster these past two years, primarily due to the events of COVID-19. Before the pandemic locked down our communities, M&A, particularly in the health and human services space, was experiencing a significant increase in activity. This was caused by several factors. Among them: Existing organizations — or strategic buyers — were witnessing the benefits of growth through acquisition to compete with larger businesses and prepare for managed care, while private equity investors saw this field as one worth investing in. With an excess of cash reserves (i.e., "dry powder"), these private equity investors started spending.

Does this sound familiar: The phone rings. You answer, and on the other end is someone who tells you that they represent a company eager to purchase your healthcare business.
These kinds of calls are happening every day, with some businesses receiving multiple calls a week. On the surface, these might seem like good calls to receive. After all, if someone is interested in buying your business, you must be running a good operation. And if you've been considering whether it's the right time to sell your business, such a call might be an avenue forward for you.
But seller beware: While it's good to answer the phone and hear what's presented to you, moving ahead on a transaction with a cold caller could be fraught with risk. Let me explain why.

Prior to the pandemic, the retail pharmacy industry was experiencing significant disruption. We were witnessing a steady increase in transactions and consolidation, Amazon's entry into the market, significant changes to strategic alliances between major payers and pharmacy benefit managers (PBMs), and the introduction of a wide array of new technologies, just to name a few noteworthy trends and developments. It's safe to say that COVID-19 not only disrupted some of these disruptors, but it also brought with it new disruptors.

TBI Duluth is a remarkable story. The company is comprised of two companies headquartered in Duluth, Minn.: TBI Residential and Community Services and Pathways to Achievement. TBI Residential and Community Services provides residential foster care services, operating 29 licensed homes for adults ages 18 and up. Pathways to Achievement provides high-quality home healthcare and support services. The business serves clients with complex physical and emotional needs, providing care involving medical, behavioral, and everyday living skills.

There is a struggle these days to find reliable and competent leadership. In many ways, the human services industry exemplifies the challenge. Despite an abundance of books, speeches, and guides that focus on the creation of good leaders, their absence persists.

This persistence, however, is not a result of our inability to pull good leadership from thin air. Rather, it's about our inability to simply look at the colleagues around us. Good management is cultivated, not found. This isn't a radical claim and is a concept I'm sure many are familiar with. But few, it seems, have managed to successfully cultivate new leaders. A complex reason why this challenge exists within the human services industry: gender disparity, especially for women of color. Human services is an industry that should, above all things, champion equity and equality for its clients/consumers — no question. Yet, if those same principles are not reflected in management, a company may find itself ill-equipped to champion anything. 

Owners of healthcare companies, practices, and agencies often ask us how they can increase their businesses' market value. Buyers determine the value of a business based on return on investment and riskiness of the investment. Business owners create value by increasing the return on investment and decreasing the riskiness of ownership.

A silver lining of the public health emergency is that it has forced many healthcare businesses to reevaluate their operations and refocus on what truly drives their success. For those businesses planning for a transition or future diversification, this has become even more important. One thing we have learned from the past year is that not everything we think is important really is necessary. In addition, we now have a greater understanding of and appreciation for the marriage of virtual care and transparency and how they, when combined, represent a powerful relationship.

As you may or may not know, I have been an advisor to owners of provider agencies supporting individuals affected by an intellectual and/or developmental disability (I/DD) for more than 30 years. I am fortunate in that I love this work. It is enormously gratifying to earn a living by helping others reach their goals. I am able to help business owners reach their financial goals and buyers achieve their growth and value-creation goals while improving the lives of employees and clients alike through the right transaction.

Each year typically brings at least some unforeseen developments that influence healthcare transactions. Oftentimes, these occurrences affect a single sector or just a few sectors. Rarely, if ever, is there an unexpected event that touches numerous marketplaces, let alone all of them, and does so in a dramatic way.

I was recently speaking with one of the sellers I represented about the sale of his provider agency. I asked him what he thought was my most significant value during his long selling process. Without skipping a beat, he said, "'The emotional support you provided to me." He explained that it was helpful to talk with me when things got stressful or even a bit scary since I had been through the process of selling my own company.

The only constant for home healthcare agencies is change. For many owners of agencies, change is both demanding and fatiguing. At some point, owners start thinking about exiting their company. Some owners elect to pass ownership down to their adult children. Some stop taking on new clients/patients and simply close their doors. Others seek to sell their company in the marketplace. This column is written for those owners considering selling in the marketplace.

As human services business owners and operators, we should not apologize when our businesses earn a profit. Rather, it's time to stop shielding our staff from the important discussion of budgets and bottom lines. They should have some exposure to the budgeting process and understand the need for a healthy bottom line.