Healthcare M&A and Finance Summit September 25, 2008 Partners - - PowerPoint PPT Presentation
Nelson Mullins Riley & Scarborough LLP Healthcare M&A and Finance Summit September 25, 2008 Partners in the Business of Healthcare Welcome and Introduction Glenn Sturm, Partner Glenn Sturm, Partner Nelson Mullins Riley &
Partners in the Business of Healthcare
Nelson Mullins Riley & Scarborough LLP
Healthcare M&A and Finance Summit
September 25, 2008
Nelson Mullins Riley & Scarborough, LLP Nelson Mullins Riley & Scarborough, LLP
Nelson Mullins Riley & Scarborough, LLP Nelson Mullins Riley & Scarborough, LLP
Full Service Firm Founded in 1897 More than 400 lawyers in 2007 Benefits from the continued growth of SE region Ten offices (Atlanta, Boston, Washington, D.C. and
throughout the Carolinas)
Large firm pedigrees and experience Small firm focus and attention Top tier clients Hundreds of transactions Focus on private and public middle-market
companies, sponsors and transactions
Large Firm Expertise Large Firm Expertise Focus on Business Focus on Business-
Oriented Solutions Active Partner Involvement and Supervision Active Partner Involvement and Supervision Leaner Staffing Leaner Staffing Lower Cost Infrastructure Lower Cost Infrastructure Superior, Cost Superior, Cost-
Effective Execution
54 lawyers recognized in The Best
Lawyers in America (2007)
Corporate M&A, health care and general
litigation practices "among best in the region" - Chambers & Partners
"Go-to firm" for corporate governance -
BellSouth
Products liability practice "among best in
the nation" - Chambers & Partners
"Go-to firm" for litigation - Wyeth, Georgia-
Pacific and Whirlpool
Partners in the Business of Healthcare
How to Finance a Healthcare Deal in a Challenging Market: Back to the Basics
Nelson Mullins Riley & Scarborough LLP
Healthcare M&A and Finance Summit
September 25, 2008
Helen E. Quick, Moderator
Nelson Mullins Riley & Scarborough, LLP Nelson Mullins Riley & Scarborough, LLP
Hector Calzada Calzada
Deloitte Financial Advisory Service Deloitte Financial Advisory Service
John Valentine
Hyde Park Capital Partners, LLC Hyde Park Capital Partners, LLC
David Yates
ORIX Healthcare Finance ORIX Healthcare Finance
Helen E. Quick is a partner in the firm's Washington, DC office and serves as is a partner in the firm's Washington, DC office and serves as a vice a vice-
chair the firm's National Healthcare Practice Group.
house general counsel for two companies where she managed the business development, human resource and l where she managed the business development, human resource and legal egal departments of each company. departments of each company.
ring, negotiating and documenting private financing transactions, incl negotiating and documenting private financing transactions, including asset uding asset-
based, cash flow and real estate loans, purchase and sale transactions, joint actions, joint ventures and mergers and acquisitions. ventures and mergers and acquisitions.
, including hospitals, healthcare systems, ambulatory surgery centers, pharm hospitals, healthcare systems, ambulatory surgery centers, pharmacies and acies and physical therapy practices regarding general contracting, licens physical therapy practices regarding general contracting, licensing and ing and strategic planning. strategic planning.
Nelson Mullins Riley & Scarborough LLP is a national law firm with almost is a national law firm with almost 450 attorneys and a strong reputation in meeting the complex lit 450 attorneys and a strong reputation in meeting the complex litigation, igation, corporate, securities, regulatory, and other legal needs of a wi corporate, securities, regulatory, and other legal needs of a wide range of de range of companies and individuals, offering solutions that complement ou companies and individuals, offering solutions that complement our clients' r clients' values and objectives for more than 100 years. values and objectives for more than 100 years.
Who has the capital?
Economic Policy vs. Healthcare Policy— — Impact of Presidential Election Impact of Presidential Election
Ever-
evolving Landscape— —Bear Stearns, Bear Stearns, Fannie Mae, Freddie Mac, Lehman Bros., Fannie Mae, Freddie Mac, Lehman Bros., Merrill Lynch, AIG, Goldman Sachs Merrill Lynch, AIG, Goldman Sachs… …
Volume of deals— —Small vs. Large Small vs. Large Companies Companies
Changes in EBITDA Sale Multiples vs. Financing Leverage Multiples Financing Leverage Multiples
Adjustment of Expected Rates of Return for Private Equity Investors Private Equity Investors
Deal Volume (No. of Transactions)
Sector YTD 2008 2007 2006 2005 Behavioral Health 48 13 24 26 E-Health 81 59 74 61 Home Health 20 48 55 73 Hospitals 31 57 56 50 Labs, MRI, Dialysis 28 52 46 39 Long-Term Care 23 125 146 129 Managed Care 8 28 28 30 Physician Groups 6 41 32 35 Rehabilitation 12 14 9 10 Other 62 104 136 135 Subtotal Services 319 541 606 588 Biotechnology 93 142 115 113 Medical Devices 79 191 150 141 Pharmaceuticals 35 177 138 128 Subtotal Life Sciences 207 510 403 382 Grand Total 526 1,051 1,009 970
Source: Irving Levin Associates, Inc.
(continued)
Deal Value ($mm)
Sector YTD 2008 2007 2006 2005 Behavioral Health $ 140 $ 58 $ 1,771 $ 1,200 E-Health 5,845 1,505 4,863 4,100 Home Health 2,804 1,485 842 498 Hospitals 1,814 8,416 35,738 2,880 Laboratories, MRI, Dialysis 364 5,303 2,537 6,500 Long-Term Care 1,429 14,719 22,629 6,900 Managed Care 845 8,804 1,254 19,100 Physician Medical Groups 222 98 237 1,100 Rehabilitation 14 432 153 96 Other 8,386 14,245 30,888 8,000 Services Subtotal $ 21,863 $ 55,065 $ 100,912 $ 50,374 Biotechnology $ 76,358 $ 40,632 $ 36,407 $ 23,100 Medical Devices 62,215 57,936 53,268 42,200 Pharmaceuticals 34,122 72,862 77,851 46,600 Life Sciences Subtotal $ 172,694 $ 171,430 $ 167,526 $ 111,900 Grand Total $ 194,557 $ 226,495 $ 268,438 $ 162,274
Source: Irving Levin Associates, Inc.
(continued)
Senior/Mezz/Equity
Tumultuous Times— —LIBOR Floors, Best LIBOR Floors, Best Efforts Underwriting, the Demise of the Efforts Underwriting, the Demise of the Second Lien Market, and End of "Covenant Second Lien Market, and End of "Covenant-
Lite" Era
Cost of Capital— —Fees, OID, and Warrants Fees, OID, and Warrants
Government Reimbursement Environment
Industry Fragmentation— —Consolidation Consolidation Opportunities Opportunities
Effective Management and Cost Containment Containment
Regulatory Barriers to Entry
Restrictions in Physician Referrals and Ownership Ownership
Moratoriums
Impact of Medicare Advantage/Part D
Distressed Debt— —Finding the Good in the Finding the Good in the Bad Bad
War Stories— —"Do you feel lucky punk? Well, "Do you feel lucky punk? Well, do you?" do you?"
Partners in the Business of Healthcare
Top 10 Deal Issues That Keep You Up At Night (And How To Put Them To Bed)
Nelson Mullins Riley & Scarborough LLP
Healthcare M&A and Finance Summit
September 25, 2008
Michael Hollingsworth, Partner
Nelson Mullins Riley & Scarborough, LLP Nelson Mullins Riley & Scarborough, LLP
Ed Croft, Founder and Managing Director
Croft & Bender, LLC Croft & Bender, LLC
Chris Joyce, Executive Vice President, Mergers and Acquisitions Mergers and Acquisitions
Alliance Imaging, Inc. Alliance Imaging, Inc.
Background
Major Deal Issues
Unique Issues Because of Current Market Market
Dislocated Assets
Private Equity Exits
Good Time for Strategic Buyers
Geographic Footprint
By Asset Category and Size
Fraud and Abuse/Carve-
Financing Outs
More Sign and Close Deals?
Material Adverse Change Provisions
Definition of MAC
For Benefit of Buyer or its Lenders?
Due Diligence Outs
Reverse Break Fee as Seller's Exclusive Remedy Exclusive Remedy
Survival of Representations and Warranties Warranties
Longer Survival in Current Market?
Larger Basket Instead of Pervasive Qualifiers in Reps and Warranties? in Reps and Warranties?
Indemnification Rights
Caps
Baskets and Mini-
baskets
Carve-
Escrows or Holdbacks
Working Capital
Indemnity
Getting What You Paid For
Financial and Operational Due Diligence
Divisional Purchases with no Separate Financials Financials
Purchase Price Adjustments
Working Capital
Balance Sheet
Other Metric
Earnouts to Bridge Valuation Gap to Bridge Valuation Gap
Disputes Common
Hard to Define on Front End
Information Technology
Cultural Integration
Mediation or Arbitration
Court Proceeding
Partners in the Business of Healthcare
Latest Trends in Healthcare: Key Drivers in Deal Activity and Hot Sectors for Investment
Nelson Mullins Riley & Scarborough LLP
Healthcare M&A and Finance Summit
September 25, 2008
Nelson Mullins Riley & Scarborough, LLP Nelson Mullins Riley & Scarborough, LLP
FOCUS, LLC FOCUS, LLC
Genesis Capital, LLC Genesis Capital, LLC
Barry D. Alexander is a partner in the firm's Raleigh office and is a partner in the firm's Raleigh office and chairs the firm's National Healthcare Practice Group. chairs the firm's National Healthcare Practice Group.
reimbursement and compliance issues arising under Medicare reimbursement and compliance issues arising under Medicare Parts A, B, & D, the Federal healthcare program's anti Parts A, B, & D, the Federal healthcare program's anti-
kickback statute, the physician Federal self statute, the physician Federal self-
referral or Stark law, and the Federal Civil False Claims Act. Federal Civil False Claims Act.
finance matters and frequently represents clients before the finance matters and frequently represents clients before the Centers for Medicare and Medicaid Services on healthcare policy, Centers for Medicare and Medicaid Services on healthcare policy, coverage, coding and reimbursement matters. He lectures and coverage, coding and reimbursement matters. He lectures and writes on Medicare payment issues frequently. writes on Medicare payment issues frequently.
Nelson Mullins Riley & Scarborough LLP is a national law firm is a national law firm with almost 450 attorneys and a strong reputation in meeting the with almost 450 attorneys and a strong reputation in meeting the complex litigation, corporate, securities, regulatory and other complex litigation, corporate, securities, regulatory and other legal legal needs of a wide range of companies and individuals, offering needs of a wide range of companies and individuals, offering solutions that complement our clients' values and objectives for solutions that complement our clients' values and objectives for more than 100 years. more than 100 years.
Jim Millar, a FOCUS Managing Director, has over 20 years , a FOCUS Managing Director, has over 20 years
management and business development experience as a management and business development experience as a senior executive with both large and earlier senior executive with both large and earlier-
stage companies.
with an aggregate value of over $1 billion. His expertise with an aggregate value of over $1 billion. His expertise includes private placement of debt and equity, mergers, includes private placement of debt and equity, mergers, acquisitions and divestitures, valuation services, business acquisitions and divestitures, valuation services, business formation, strategic planning and corporate finance. formation, strategic planning and corporate finance.
Before joining FOCUS, Mr. Millar was founder and Managing Principal of The Vine Group, a business advisory firm focused Principal of The Vine Group, a business advisory firm focused
stage and middle market healthcare and medical device industry. There he led private placement activities device industry. There he led private placement activities totaling more than $150 million as well as both buy totaling more than $150 million as well as both buy-
side and sell sell-
side transactions.
Headquartered in Washington, D.C., with offices in Atlanta, Chicago, San Francisco and Los Angeles Atlanta, Chicago, San Francisco and Los Angeles
International investment bank serving the "middle market" market"
Generalists with specific industry experience
We specialize in M&A, corporate finance and direct investments in entities with $5 investments in entities with $5-
300 million in revenues
We deliver a unique blend of operational experience and investment banking services, with an emphasis on and investment banking services, with an emphasis on M&A M&A
Rapidly growing due to repeat business, banker growth and referrals growth and referrals
Healthcare Services and Medical Devices
Technology: Hardware, Software and IT Services
Business Services and BPO
Telecommunications and Satellite Communications
Manufacturing
Energy, Oil & Gas
Retail
Food and Beverage
International
Government Contracting
Security Products and Services
Transportation
Jeff Villwock Villwock is a nationally known investment banking is a nationally known investment banking professional specializing in healthcare services. His career sp professional specializing in healthcare services. His career spans ans
Villwock currently is a Managing Partner with Genesis Capital, currently is a Managing Partner with Genesis Capital,
time Wall Street Journal All-
Star Analyst in Healthcare Services, Mr. Healthcare Services, Mr. Villwock Villwock came to Atlanta in 1997 to lead came to Atlanta in 1997 to lead the healthcare research group of The Robinson the healthcare research group of The Robinson-
Humphrey
Caymus Caymus Partners, LLC, a middle Partners, LLC, a middle-
market investment bank, which was formed in 2001 to provide high quality investment banking was formed in 2001 to provide high quality investment banking services to healthcare service companies. That firm was sold in services to healthcare service companies. That firm was sold in 2006 as Mr. 2006 as Mr. Villwock Villwock rejoined a former Robinson rejoined a former Robinson-
Humphrey colleague to build and operate Genesis Capital. colleague to build and operate Genesis Capital.
Villwock has completed assignments in the hospital has completed assignments in the hospital management, home healthcare, assisted living, surgery center, management, home healthcare, assisted living, surgery center, disease management, dialysis service, rehabilitation service and disease management, dialysis service, rehabilitation service and physician service industries. physician service industries.
Genesis Capital Provides Tailored Services Genesis Capital Provides Tailored Services
Securities products & services offered through representatives of G.C. Securities, LLC, member FINRA/SIPC in states where the firm & representatives are registered.
Restructurings
Debtor and creditor representations 363 sales Refinancings Negotiating plans of reorganization
Advisory Services
Capital and strategic planning Board of Director and Special Committee advisory work Valuations Fairness opinions Hostile defense
Mergers and Acquisitions
Exclusive sales & divestitures Buy-side acquisition programs Management buyouts
Financing
Private placements Majority / Minority equity Senior debt 2nd Lien / Term B Subordinated debt Strategic investments Joint ventures
Engagements have ranged from < $10mm to over $1 billion in transaction size Clients have ranged in size from < $25mm to over $30 billion in enterprise value
Private Companies Middle-Market Companies Fortune 500 and Large Companies
Genesis Capital Clients: Genesis Capital Clients: Driven by Need Driven by Need – – Not Size Not Size
Our relationships and resources help us to distinguish ourselves and maintain key advantages over other middle-market investment and merchant banks
Part A
Part B
Part C
Part D
Part A
Part B
Part C
Part D
Inpatient Hospital/ SNF/ HHA/ Hospice Services Physician/ Non- Physician Practitioner/ Ancillary Suppliers/ Outpatient Hospital Services Medicare Advantage Prescription Drug Coverage
Part A Part C Part D Part B
Parts of the Medicare Program & Coverage Parts of the Medicare Program & Coverage
Part A
Hospital inpatient services, hospice, SNF, home health
Part B
Physician services, Hospital outpatient services, durable medical equipment, prosthetics, orthotics and supplies medical equipment, prosthetics, orthotics and supplies ("DMEPOS"), Outpatient Surgical Services ("DMEPOS"), Outpatient Surgical Services
Part C
"Medicare Advantage" alternative to Parts A and B, f/k/a the "Medicare Choice" Program "Medicare Choice" Program
Part D
Prescription Drugs
"Beneficiaries"
Part A – – no premium payment if: no premium payment if:
65 years of age or older; paid Medicare taxes for at least 10 years; and receiving, or eligible to receive, retirement benefit years; and receiving, or eligible to receive, retirement benefits s from Social Security or the Railroad Retirement Board from Social Security or the Railroad Retirement Board
Permanent kidney failure requiring dialysis or transplant ("ESRD") (regardless of age) ("ESRD") (regardless of age)
Entitled to Social Security or Railroad Retirement Board disability benefits for 24 months (regardless of age) disability benefits for 24 months (regardless of age)
Government employee, or spouse of government employee
Part A – – with premium payment if: with premium payment if:
Did not pay Medicare taxes; age 65 or older; and a citizen or permanent resident of the United States permanent resident of the United States
Part B
Eligible for Part A and payment of monthly premium
Part C
Must be eligible for Part A
Must be enrolled in Part B
Must not have ESRD unless enrolling in an ESRD special needs plan needs plan
Must reside in plan service area or continuation area
Annual beneficiary cost-
sharing cap for Medicare covered-
services ($3,250 for 2008)
Part D
Entitled to benefits under Part A or enrolled in Part B
Lives in a Part D plan service area
Guarantee issue
Special rules for employer plans
Dick & Lynne Cheney
Simon AND Garfunkel
Muhammed Ali
Barbra Streisand
Larry Flynt
Joe Namath
Pete Rose
Martha Stewart
Dick Butkus
Ann Margret
Calvin Klein
Harrison Ford
Medicare Benefit Outlays, by Account and Provider Type ($ in millions, based on President's Budget 2009/prior Treasury actuals) [benefits net of Medicare refunds]
FY 2000 FY 2005 FY 2006 FY 2007 FY 2008
Actual Actual Actual Actual Estimate Inpatient Hospital 86,477 121,562 119,122 122,000 132,899 Skilled Nursing Facility 10,626 18,128 19,236 22,198 22,645 Home Health Agency 4,608 5,963 5,922 6,350 6,348 Hospice 2,818 8,318 8,515 10,008 10,454 Managed Care (Part C or "Medicare Advantage") 21,463 27,001 28,688 39,305 48,926 Part A Benefits Subtotal 125,992 180,972 181,483 199,861 221,272 Physicians & Other Practitioners 35,946 57,282 58,226 66,433 61,048 Outpatient Hospital 8,438 19,604 22,119 20,735 21,597 Other Part B Carrier Services 1 7,164 15,183 15,269 16,003 17,108 Other Part B Intermediary Payments 2 6,013 11,767 13,291 12,092 13,015 Durable Medical Equipment 4,573 7,841 8,191 8,169 8,584 Home Health Agency 4,570 6,560 7,096 9,116 10,028 Laboratory 3,823 6,439 6,864 6,827 6,953 Managed Care (Part C or "Medicare Advantage") 3 18,348 24,110 27,489 38,150 46,002 Part B Benefits Subtotal 88,875 148,786 158,545 177,525 184,335 Transitional Drug Assistance (Drug Card) NA 1,125 229 10 NA Part D Prescription Drug Benefits 4 NA NA 31,718 49,103 45,087 TOTAL MEDICARE BENEFITS 214,867 330,883 371,975 426,499 450,694
1 Such as physician-administered drugs, free-standing ambulatory surgical centers (ASCs), and ambulance. 2 For institutional services, such as free-standing dialysis, outpatient rehabilitation, and rural health clinics. 3 Includes Part B transfers to Medicaid for low-income dual eligibles, to help pay Part B premium: $242 million
in FY 2005, $264 million in FY 2006, $359 million in FY 2007, and an estimated $100 million in FY 2008.
4 FY 2006 represents three-fourths of a year, as the Part D benefit became available on January 1, 2006.
1 Such as physician-administered drugs, free standing ambulatory surgical centers (ASCs), and ambulance. 2 For institutional services, such as free-standing dialysis, outpatient rehabilitation, and rural health clinics. 3 Includes Part B transfers to Medicaid for low-income dual eligibles, to help pay Part B premium: $242 million in FY 2005, $264 million in FY 2006, $359 million in FY
2007, and an estimated $100 million in FY 2008
1 Such as physician-administered drugs, free standing ambulatory surgical centers (ASCs), and ambulance. 2 For institutional services, such as free-standing dialysis, outpatient rehabilitation, and rural health clinics. 3 Includes Part B transfers to Medicaid for low-income dual eligibles, to help pay Part B premium: $242 million in FY 2005, $264 million in FY 2006, $359 million in
FY 2007, and an estimated $100 million in FY 2008
4 FY 2006 represents three-fourths of a year, as the Part D benefit became available on January 1, 2006.
1 Such as physician-administered drugs, free standing ambulatory surgical centers (ASCs), and ambulance. 2 For institutional services, such as free-standing dialysis, outpatient rehabilitation, and rural health clinics. 3 Includes Part B transfers to Medicaid for low-income dual eligibles, to help pay Part B premium: $242 million in FY 2005, $264 million in FY 2006, $359 million in FY
2007, and an estimated $100 million in FY 2008
4 FY 2006 represents three-fourths of a year, as the Part D benefit became available on January 1, 2006.
1 Such as physician-administered drugs, free standing ambulatory surgical centers (ASCs), and ambulance. 2 For institutional services, such as free-standing dialysis, outpatient rehabilitation, and rural health clinics. 3 Includes Part B transfers to Medicaid for low-income dual eligibles, to help pay Part B premium: $242 million in FY 2005, $264 million in FY 2006, $359 million in FY
2007, and an estimated $100 million in FY 2008
4 FY 2006 represents three-fourths of a year, as the Part D benefit became available on January 1, 2006.
Troubles in hospital sector with low volume growth and higher bad debt has made sector growth and higher bad debt has made sector less attractive for investment less attractive for investment
Skilled nursing (nursing home) industry has done very well avoiding reimbursement done very well avoiding reimbursement reductions and continues to show good reductions and continues to show good growth growth
Home healthcare has seen a lot of transaction volume with operating results transaction volume with operating results better than expected in 2008 better than expected in 2008
Consumer-
directed health care options (e.g., Mini Mini-
clinics)
Despite continued concern in the financial and real estate markets, Healthcare M&A activity remained estate markets, Healthcare M&A activity remained robust in Q2 2008 robust in Q2 2008
With 100 deals in June alone, there were a total of 265 transactions in Q2 2008 265 transactions in Q2 2008, up from 223 deals in , up from 223 deals in Q1 2008 Q1 2008
The Healthcare Technology sector led the way with 58% of the total deal volume 58% of the total deal volume
The three most active sectors combined (Medical Devices, Pharmaceuticals and Biotech) saw 135 Devices, Pharmaceuticals and Biotech) saw 135 deals, or just over 50% deals, or just over 50%
The Healthcare Services sectors languished, reflecting some concern on behalf of investors reflecting some concern on behalf of investors
$85.6 billion was committed to fund the Q2 2008 Healthcare M&A activity 2008 Healthcare M&A activity
The Technology sector captured $80.7 billion, leaving $4.9 billion for the services sector leaving $4.9 billion for the services sector
This represents a 210% increase over Q1 2008, and a 40% increase over Q2 2007 2008, and a 40% increase over Q2 2007
The first six months of 2008 saw 488 transactions for a total of $113.3 billion transactions for a total of $113.3 billion committed committed
Healthcare M&A will continue to be robust, particularly in the Technology sector particularly in the Technology sector
M&A Volum e - Q2 2 0 0 8
Providers 25% Services 17% Devices, Equipment and Supplies 19% Informat ion Technology 8% Lifesciences, Biot ech and Pharma 31%
Transaction Value - Q2 2 0 0 8
Providers 3% Services 3% Devices, Equipment and Supplies 63% Informat ion Technology 3% Lifesciences, Biot ech and Pharma 28%
2.0 1.4 1.9 1.9 2.8 2.4 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Providers Services Product s
Mean Revenue Multiples
Q1 2008 Q2 2008
10.0 7.1 14.5 15.0 13.0 15.1 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 Providers Services Product s
Mean EBI TDA Multiples
Q1 2008 Q2 2008
Health Care Venture Capital Deal Volum e by Sector - Q2 2 0 0 8
Medical Devices 27% Biot echnology 24% Biopharmaceut icals 22% Pharmaceut icals 10% e- Healt h 9% Healt h Care Services 8%
Health Care Venture Capital I nvestm ent by Sector - Q2 2 0 0 8
Medical Devices 26% Biot echnology 29% Biopharmaceut icals 20% Pharmaceut icals 13% e- Healt h 3% Healt h Care Services 9%
Short term fix of the physicians' Medicare reimbursement cuts (SGR) could cause more reimbursement cuts (SGR) could cause more pain later pain later
CMS has attempted to reign in home healthcare reimbursement, yet companies healthcare reimbursement, yet companies seem to be seem to be upcoding upcoding (or managing (or managing documentation) to counteract cuts documentation) to counteract cuts
Uncertainty surrounds CMS' implementation
competitive bidding for DMEPOS and LTCH competitive bidding for DMEPOS and LTCH provisions) provisions)
Impact of potential decreased tax revenues and increased unemployment and increased unemployment
Republicans won't give Democrats a victory and vice versa and vice versa
Result = Stalemate
Expectation is that this bill eliminates profitability of providing healthcare services profitability of providing healthcare services to the Medicare population to the Medicare population
Commercial payors payors will emulate the will emulate the Medicare cuts, eliminating profitability from Medicare cuts, eliminating profitability from commercial business commercial business