For Immediate Release January 03, 2023 - Mertz Taggart, a healthcare mergers & acquisitions firm that focuses exclusively on at-home care and behavioral health, has announced that Michael Lloyd has joined the firm as an M&A Associate. Michael has dedicated his career to the post-acute industry and brings a wealth of knowledge to Mertz Taggart. His career began as a Patient Care Representative for a large national provider, where he learned how home care agencies operated daily. His passion for patient care led him to the vendor side of the industry, where he was the first employee of a start-up of a data company where CMS data was utilized to drive agency growth and improve outcomes. Before joining Mertz Taggart as the lead M&A Associate for at-home care, Michael covered the Southeast U.S. for clinical and financial services to clients at McBee, an industry-leading consulting firm. Cory Mertz, Managing Partner and co-founder of Mertz Taggart said, “Michael’s unique, well-rounded background and experience create value for the firm and the clients that Mertz Taggart serves as we continue to grow our presence in the industry.” “I couldn’t be more excited to begin the next step of my career with Mertz Taggart,” said Lloyd, “I have been familiar with the firm since its inception and have always admired their reputation in the industry. I look forward to bringing my passion and consultative approach to the firm and the clients we represent during the entire exit planning process. It is my hope that through this role I can also continue to bring value to the post-acute industry that I am very passionate about.”

From a recent industry webinar, Managing Partner, Cory Mertz shares insight on maximizing the value of your home health, hospice, or home care agency. Cory discusses both the value drivers and their impacts on the value or your agency. He then dives into the M&A process for selling your home health, hospice, or home care agency, including running a competitive confidential bid process with the best buyers in the industry. Chapters: 0:00 About Mertz Taggart 1:38 About Cory 2:34 Objectives 3:52 Maximizing Value = Building AND Capturing Value 5:20 Valuation Equation and Construct 11:37 Types and Discounts of Financial Consideration 14:54 Six Common Ways to Build Value of Your Agency 22:37 Capturing Value - Find Your Ideal Buyer and Compel Them to Make Their Best Offer - The Process 34:18 Capturing Value - Getting to the Close, Without Re-Negotiating Are you contemplating an eventual sale or purchase of a home health, hospice or behavioral health company? Contact us to arrange a confidential discussion today.

Home care M&A is in the midst of a growth spurt. When it comes to dealmaking, non-medical home care long seemed like the younger sibling compared to its home health and hospice counterparts. That’s changing though, as the home care value proposition is more apparent amid the COVID-19 emergency. The results are clear: for the second straight quarter, non-medical home care led the home-based care pack with the most transactions. The segment saw 10 transactions in the second quarter of 2022, followed by eight for Medicare-certified home health and seven for hospice. Note: Total industry transactions does not necessarily equal the sum of the sub-industries, as many transactions include more than one sub-industry. Home care leads the pack For the year, home care has seen 23 transactions compared to 17 apiece for both hospice and home health. Home care’s lead this quarter was largely driven by Help at Home Inc., the Chicago-based home- and community-based services company that completed three acquisitions during Q2. Help at home is backed by PE firms Vistria Group and Centerbridge Partners. Help at Home was particularly active in April, purchasing New York-based home care agencies Edison Home Health Care and Preferred Home Care. The acquisitions gave Help at Home an additional 10,500 clients and 12,000 employees. Two months later, Help at Home expanded its southwest Michigan footprint by acquiring Alliance Home Health Care Services and its six Michigan locations. And don’t expect Help at Home to slow down anytime soon. The company will likely remain aggressive for the remainder of the year, acquiring accretive companies with their eyes set on an exit. Last year, rumors swirled that the company was considering going public, but with the softening of the equity markets, including home care stocks, they seem to have delayed IPO plans for now. Other home care-related transactions during Q2 include Personal Touch Home Care’s acquisition of Neighbors Home Care in April. Parentis Health, a California-based senior care company, also bought home care provider Pop-in Care that same month. In June, PE-backed home health and hospice company Excelin Health acquired On My Care. Along with offering personal care, On My Care also provides skilled nursing, physical, occupational and speech therapy, as well as social worker services. The uptick in home care dealmaking is especially notable because, overall, transactions were down year over year from the first half of 2021 to the first half of 2022. The first half of last year saw 69 combined home health, home care and hospice transactions reported compared with just 48 in the first half of 2022. Yet the home care segment’s share of transactions has increased from 42% in the first half of last year to 48% in the first half of this year. Home health still riding high The home health industry was hit hard in June when CMS released its new proposed payment rule with a 4.2% decrease to payment rates. Even though the rule is still in the proposal stage, the cut sent waves of concern across the sector. “The entire home health community is in a bit of a tailspin, given the release of the rule,” Joanne Cunningham, the CEO of the Partnership for Quality Home Healthcare, told Home Health Care News. “We are continuing to peel back the analysis and get a full understanding of all of the components of it, but it certainly has been a real stemwinder of a reaction from urban, rural, big and small home health agencies across the country.” Despite industry backlash to the proposal, demand and valuations for home health agencies remain at an all-time high. Still, the 4.2% proposed cut could impact deals down the road. “It will impact deals and deal volume as some would-be sellers will be in a wait and see mode,” Mertz says. “For deals in the works, it can certainly create a valuation gap between the buyer and seller that will need to be worked through. Any time there is uncertainty — 4.2% is significant but far from certain — in the marketplace, valuation gaps occur.” Home health giant Amedisys Inc. (Nasdaq: AMED) was responsible for some of the more notable deals this quarter. The company closed on both its AssistedCare and Evolution Health deals, building on their presence in North Carolina and Texas. The former was completed for a price tag of $25 million, the latter for $70 million. Another big story this quarter, perhaps the biggest, was Humana Inc. (NYSE: HUM)’s announcement in April that it would sell 60% of its hospice and personal care assets from Kindred at Home to the private equity firm Clayton Dubilier & Rice (CDR). “What is nice about this transaction is that it allows Kindred to free up some cash, while still maintaining a strong connection with the hospice and personal care division,” Mertz says. “This will allow them to wait and see how value-based purchasing evolves over the next few years. If hospice and personal care services become a bigger part of the value-based ecosystem, though I’m not privy to details, I would imagine Humana has an option of some sort in place to acquire CDR’s interest at some point in time.” Hospice M&A demand still strong On its end, hospice remains active. The sector is still seeing high demand, as well as sky-high valuations. In June, Vistria-backed St. Croix Hospice of Minnesota acquired Illinois-based Lexington Hospice Care. Over the last couple of years, the company has been bullish when it comes to its expansion efforts. Hospice of the Chesapeake agreed to buy fellow non-profit Calvert Hospice in April. Other deals included Webster Equity-backed Bristol Hospice’s acquisition of Hospice Select in April, and Ridgemont Equity-owned Agape Care’s purchase of Hospice of the Carolina Foothills in May. Sector-wide, the slow-down in dealmaking activity is largely seller driven. “We have not seen any softening in values across the care-at-home sector,” Mertz Taggart Managing Partner Cory Mertz says. “Private equity loves the industry, especially since COVID. U.S. private equity firms are still sitting on roughly $1 billion in dry powder with a mandate to invest. Interest rates are going up, but in the lower middle market, it hasn’t had a meaningful negative impact on values.”

Total transaction volume across the behavioral health care sector saw a modest decrease in the second quarter of 2022, dipping to 30 deals announced from the 44 that were reported in the first three months of the year. The decline, however, is not necessarily a product of surging interest rates or the equity market, said Mertz Taggart Managing Partner Kevin Taggart. Instead, Taggart said, the volume of behavioral healthcare transactions has been—and continues to be—seller-driven. “There has been a lot of talk about financial markets and their impact on mergers and acquisitions,” Taggart said. “While I agree a few additional points in interest rates can have a huge impact on a large transaction, we’ve been somewhat insulated both in the behavioral health industry and lower middle market.” Note: Total industry transactions does not necessarily equal the sum of the sub-industries, as many transactions include more than one sub-industry. Private equity and venture capital accounted for 24 of 30 (80%) transactions in the second quarter. Notably, the sector saw several significant venture capital rounds, all of which had some level of technology that provided scalable accessibility to patients. While the appetite for larger M&A transactions outside of behavioral health seems to be slowing this year given some of the current macroeconomic trends, the lower middle market is expected to still be a seller’s market in behavioral health, Taggart said. “Even though transaction volume is down, Mertz Taggart is still very bullish on behavioral health and expects multiples and demand for quality companies to remain strong through the remainder of 2022,” he said. Addiction Treatment M&A The addiction treatment subsector saw its transaction volume continue to decline, with eight deals announced in the second quarter, which was down from 15 in Q1 and 31 in the fourth quarter of 2021. With just eight deals reported, Q2 had the lowest volume of addiction treatment transactions dating back to mid-2018. The quarter did see a pair of provider organizations complete significant venture capital-backed funding rounds. Bicycle Health raised $50 million in series B funding. The funding round was led by InterAlpern Partners and also included Questa Capital, City Light Capital and First Cressey Ventures. Bicycle Health said the funding will be used to expand the organization’s virtual telehealth opioid use disorder treatment services. Meanwhile, Boulder Care, a Portland, Oregon-based startup, announced that it raised $35.73 million through a combination of series B1 and B2 venture funding from Qiming Venture Partners, Goodwater Capital and Laerdal Million Live Fund, as well as investors from previous rounds including Tusk Ventures, Greycroft Partners, First Round Capital and Gaingels. Other deals in the addiction treatment category that were announced in the second quarter include: The Sylvia Brafman Mental Health Center expanded its treatment offerings with its acquisition of Through the Archway, a spiritual immersion addiction treatment program. Thrive Capital Management announced a platform deal for Harmony Recovery Group. Three provider organizations announced private equity-backed strategic deals: Community-based drug and alcohol addiction treatment provider Pinnacle Treatment Centers acquired Stepping Stone of North Carolina, a private, outpatient opioid addiction treatment program. Monument purchased fellow digital alcohol recovery program Tempest. And Bradford Health Services expanded its addiction treatment offerings into Mississippi with its acquisition of The Estate at River Bend. Modern Recovery acquired SpringBoard Recovery, creating a new Arizona-based umbrella organization known as Modern Recovery Network. Mental Health M&A Although down from the record high number of transactions reported in Q1, deal volume in the mental health subsector remained strong in the second quarter, with 17 transactions announced. Venture capital and private equity accounted for all but three deals in the mental health space. Five provider organizations announced venture capital funding rounds in the second quarter: Digital emotional support startup Circles raised $16.5 million in series A funding. The round was led by Zeev Ventures; Lior Ron, head of Uber Freight, NFX and Flint Capital, and Sir Ronald Cohen also participated. Parallel Learning announced plans to expand from the current six states in which it operates to between 18 and 23 by the end of the year after securing a $20 million series A funding round led by Tiger Global Management. Family mental health services provider Handspring Health closed a $6.2 million seed round that was co-led by Newark Ventures and NextView Ventures, along with participation from 25madison Ventures, Arkitekt Ventures, Quantum Angels and several health care operators. Concert Health raised $42 million in series B funding for its collaborative care treatment model. The round was led by Healthy Ventures. Iris Telehealth announced a $40 million series B funding round that will support the company’s plans for national expansion. The round was led by Concord Health Partners and Columbia Pacific Advisors. The following private equity-backed strategic acquisitions were reported: Mindpath Health acquired Acacia Counseling and Wellness, a telehealth and outpatient mental health provider that specializes in treating college students. Spring Health expanded its family mental health service offerings with a deal to acquire the family wellness platform Weldon. CM Counsel acquired Karner Psychological Associates, an outpatient mental health services provider in Albany, New York. Transformations Care Network expanded into Washington state with its acquisition of LightHeart Psychological Associates. Three private equity platform transactions were announced: Havencrest Capital Management invested in Deep Eddy Psychotherapy, a psychology practice with three locations in central Austin, Texas. Ellie Mental Health, an outpatient mental health clinic operator and franchisor, received an investment from Princeton Equity Group. Bay Area Clinical Associates, a mental health services provider for children, entered into a partnership with private investment firm Frontline Healthcare Partners. An additional three deals in the mental health sector were also reported: Irwin Naturals completed its acquisition of KHC Capital Group and its portfolio of five Ketamine Health Centers facilities in Florida. Kelly Services acquired Pediatric Therapeutic Services, a specialty firm that provides state and federally mandated in-school therapy services. Moriah Behavioral Health acquired Ignite Teen Treatment and Eden Center for Eating Disorders in a deal involving three provider organizations based in Nevada. Autism Services and I/DD M&A The autism services and intellectual/developmental disabilities (I/DD) subsector saw seven deals announced in the second quarter, a slight increase from Q1, but still below average for the category. With the exception of Constellations Behavioral Services being sold to its 150 employees and restructuring as an employee stock ownership plan, all other deals announced by autism and I/DD service providers involved private equity firms. Four private equity platform deals were announced: Graham Healthcare Capital made an investment in an undisclosed applied behavior analysis therapy provider. Private equity firm Enhanced Healthcare Partners added autism therapy provider Howard J. Chudler & Associates as a platform investment. Frontline Healthcare Partners announced a recapitalization and growth investment in ABA therapy provider JoyBridge Kids. Health Enterprise Partners made a strategic investment in autism spectrum disorder treatment company Proven Behavior Solutions. Meanwhile, Stepping Stones Group made a private equity-backed acquisition of therapeutic and behavioral company HM Therapy, and private investment firm Atar Capital announced a sixth acquisition through its portfolio company Pathways Health and Community Support, closing a deal for Psychological Assessment & Intervention Services.

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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