Global Healthcare Private Equity Report
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At a Glance
This article is part of Bain's 2023 Global Healthcare Private Equity and M&A Report. In prior downturns, healthcare private equity (HCPE) remained an attractive area for investment relative to private equity overall. After the 2000–01 downturn driven by the dot-com bubble, returns for healthcare deals that closed in the next two years averaged more than 30% (see Figure 1). Similarly, coming out of the global financial crisis in 2008–09, healthcare deals rebounded quickly; healthcare deals completed in 2009–10 had higher median returns than deals that closed the year heading into the financial crisis. This trend holds true for private equity broadly, but for healthcare private equity the returns were particularly attractive: For HCPE transactions in the first two years coming out of a recession, the top quartile earned internal rates of return of roughly 40% or greater.
Figure 1
Current macro challenges: Inflation and interest rates make this downturn differentWhile we remain confident in healthcare private equity’s relative attractiveness in a downturn, no two cycles are the same. If current trends continue, this downturn will have different implications for PE activity writ large and healthcare private equity specifically. Unlike the recessions in 2000-01 and 2008-09, current macro challenges are fueled by geopolitical uncertainty from Russia’s ongoing invasion of Ukraine and resulting energy supply insecurity, inflation at levels not seen in decades, and rising interest rates restricting credit access. Additionally, the recent stream of high-profile bank failures creates a host of other uncertainties for HCPE investors and their portfolio companies. Wage inflation has varied by geography but rose to elevated levels in 2022 (roughly 5% in the US and around 4% in the European Union). Healthcare wage inflation is driven by two factors: General goods inflation drives demand for higher compensation, and healthcare-specific labor shortages exacerbate the general trend. Provider businesses are markedly exposed to labor cost increases as workforce salaries and wages represent roughly 50% of operating expenses for hospitals; this can be even higher in more labor-intensive provider businesses such as home care, personal care services, and hospice. While costs are up, reimbursement is only modestly higher as rates are negotiated on a multiyear basis with payers or adjusted annually by governments. If these dynamics result in depressed 2022 EBITDA values for provider businesses, sponsors may look to hold their provider businesses through the downturn, reducing potential provider deal volumes further into 2023. Provider-based businesses (excluding related services and healthcare IT) typically represent around 20%–30% of HCPE buyout transactions. While we have not seen a disproportionate decline in provider activity on an annual basis, provider deals dropped nearly 50% from Q3 to Q4, and may continue to impact HCPE deal volumes in 2023. In parallel to the challenges presented by labor inflation, changes in central banks’ policies to temper price pressures in Europe and North America have restricted financing availability and driven up interest rates. Deal activity in the second half of 2022 reflects signs of these financing constraints, with fewer overall deals done compared with the first half of 2022 (see Figure 2).
Figure 2
Financing constraints are affecting two areas in particular—later-stage growth assets and small and midcap (SMID-cap) biopharma assets. Later-stage growth equity assets have seen multiples decline due to changes in the macro environment and far fewer deals announced. Some late-stage companies will be able to avoid fund-raising at a down round given strength in business and financial runway, but others will need to come back to the market to raise funds to survive. The focus of SMID-cap biopharma assets on earlier-stage drug development inherently creates a higher risk profile, making financing less available and more expensive for such deals. We expect the headwinds for SMID-cap biopharma to carry over to the service providers that focus on SMID-cap biopharma and early-stage drug development. Winning in a downturn: Investing in recession-resilient themesWhile the current macro context creates inherent challenges for investors, it also creates compelling pockets of opportunity. Sponsors are seeking out investment themes that play both to long-term trends and are poised to be resilient in a recession. Similarly, constraints on capital and inflationary pressures are causing PE sponsors to be more creative in how they get deals done. Recessionary and inflationary pressures will have different consequences across healthcare subsectors. At a high level, we expect provider businesses to be hit harder by a recession and inflation, while biopharma and life sciences tools businesses are likely to be more insulated (see Figure 3).
Figure 3
Within each subsector, however, assets face varying levels of exposure to the current macro challenges, including staffing shortages, rising labor costs, supply-chain constraints, and depressed consumer demand. Assets whose business models or broader end-market trends provide insulation from a downturn are well positioned as near-term investment opportunities; their fundamentals also position them to be attractive bets coming out of a recession.
Downturn dealmaking: Applying creative deal strategiesRelative to prior years, 2022 has already seen a mix shift in deal types as sponsors look to get deals done within the current macro constraints. For example, in North America, public-to-private deals have made a much larger contribution to total deal value than in the past three years (see Figure 4).
Figure 4
If tight credit continues into 2023, this may limit both the number of deals that come to market through traditional processes and the ability of sponsors to finance deals. In parallel, macro uncertainty may create concerns about near-term profitability negatively impacting deal quality. To get deals done, funds may need to continue to broaden the aperture on their deal strategy. For example:
2023 is likely to present new challenges for private equity investors—both in healthcare and beyond. Healthcare private equity’s resiliency in prior cycles and underlying market tailwinds suggest this sector should remain well positioned in a downturn once again. However, investors will need to fine-tune their investment theses and develop new playbooks to win good deals in this environment. If investors are able to place the right bets, they stand to benefit from the strong returns seen by top-quartile HCPE deals in prior downturns.
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