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Four predictions for the smart money in 2024

Updated: Apr 10

As any casual reader here will surmise, Union Healthcare Insight neither provides investment recommendations, nor endorses companies, providers, or anyone else. So, in talking about “where the smart money is going in 2024” I’m in no way suggesting that if you are smart, you’ll imitate the trends I’m describing. Instead, my focus in today’s post is on analyzing institutional investment, i.e., where financial services or other major healthcare investors are placing their bets—in particular Wall Street, private equity, venture capital—plus the big insurers, drugmakers, and providers.

 

Why? Because it’s always a good idea to know where the markets are betting big. What do they see for this year and the next several that may not be as clear to the casual observer?

 

Based on our recent interviews with investors, attendance at healthcare investment conferences and retreats, and scouring the financial literature, here is our take—starting with a fast recap of the recent past, followed by four predictions for the rest of 2024.

 

Fast recap of 2023

 

The bottom line, as we predicted a year ago, was that healthcare deal volume and value were both down almost across the board in 2023. Almost (more on that in a moment).


That unused capital did not dry up, nor was it deployed elsewhere.  Quite the contrary. The story we heard over and over is the phenomenon of “dry powder” as investors and startups alike waited on a more favorable interest rate environment. If you’re reading this, you’re probably familiar with the reasons why. But for those who need a refresher:

 

  • A rising interest-rate environment made investors/buyers hesitant to price deals, and sellers were loath to cash out at a discount.

  • The upshot was a lot of patient capital and a lot of startups accessing lifeline financing and inking creative partnership deals to stay afloat in 2023.

  • Nearly everyone is expecting the Fed to slightly cut rates by mid-2024, even if the market’s history of predicting such moves is pitifully poor.

 

Buyers want to buy, and sellers need to sell. The big open question is if/when rates start to come down, and whether or not startups have the cash to keep going till then. It’s a precarious situation, to say the least, but the prevailing mood is optimism all around. Which is a terribly odd thing to write in 2024. For so many reasons.

 

So with that, four predictions on where the smart money will flow across the rest of 2024:

 

Prediction #1: Expect to see continued deal activity in the provider space—the notable exception to 2023’s overall decline in deal volume—among some not-so-usual suspects

 

Hospitals and health systems were the one sector to see increases in deal volume in 2023—driven in part by interest-rate drama. Not-for-profit health systems have special exposure to this, because though they typically borrow at extremely favorable rates relative to for-profit companies, that debt needs to get refinanced on regular schedules. Financial engineering can cushion some of that, but the combination of massive margin pressure coupled with higher rates (and wider spreads between credit ratings) forced a number of shotgun marriages.

 

Hospital and health system margin pressure was nearly universal, but the gulf between the haves and have-nots widened further in 2023. The haves benefitted from healthy investment portfolios, robust cash reserves, and strong financial stewardship. In other words, finance, not operations, made all the difference. In such an environment, which has only modestly moderated this year, consolidation is all but inevitable. And even some orgs that didn’t feel exactly compelled to sell have explored for-profit conversion. (See here for my analysis of the Summa Health-General Catalyst tie-up.)


On the non-hospital front, physicians continue to be a hot acquisition ticket, but deals here increasingly have skewed away from the PE-backed rollups of specialty groups (and even health-system acquisitions of primary care) and toward strategic buyers such as retailers and insurers, who are most interested in groups with a value-based care or consumer-market angle.

On the surface, this seems odd—given the track record of failure from countless companies focused predominantly on consumer-oriented care or value-based innovation. What’s different now vs., say, five years ago? The answer is that, as we predicted this time last year, value-based care and consumerism will increasingly be used to sustain legacy business models as their historical economics face new pressures. To wit:

 

Prediction #2: Demand for value-based care enablement will continue to be strong—and the cracks appearing in the Medicare Advantage profit structure will only strengthen investment on this front

 

All the major MA insurers struggled with utilization spikes in 2023—most of which were, troublingly, unexpected. Reasons ranged from short-term seasonal issues (respiratory illnesses, RSV vaccine deployment, and care prompted by it), and more structural problems such as continued uptick in deferred care from the pandemic, plus increased use of supplemental benefits offered as a competitive differentiator between plans.

 

But fat chance of any of this discouraging continued growth in the MA space. The upside is just too great, and the starting point for profitability is too high, to expect any real pullback—especially given that boomers will continue to age into Medicare for the rest of this decade. But it does mean that insurers and providers alike will need to focus not only on absolute growth but also profitability per patient. This means better utilization management, investment in analytics to better predict future utilization, and partnership with VBC enablement companies. And there’s an emerging focus on dual-eligibles (patients with access to both Medicare and Medicaid), which have historically been among the costliest patients (often because their health needs have been underserved for most of their lives).


And what’s the most popular enabler of this consumer-based, value-oriented future? No points for guessing artificial intelligence, because you knew it was going to be on this list. But here it’s important to separate the signal from the noise, because the biggest investment trends will not necessarily focus on the areas that tend to pull the most headlines in the mainstream or even healthcare trade press.

 

Prediction #3: AI is an obvious industrywide hotspot, but smart investors are going to be quite deliberate; favored near-term applications will be more administrative (and less clinical) in nature

 

I, for one, welcome our new AI overlords (and if you got that reference, email me because we’re gonna be buds). And it’s kind of a bummer to write that AI’s biggest near-term impact is not going to be robot physicians, but instead more behind-the-scenes areas such as helping to smooth utilization (for MA in particular), manage authorizations and denials, and increase cash acceleration via AR management. In other words: great news for revenue cycle nerds—it’s your time to shine once again! (That’s not sarcasm, though I know it’s hard to tell me with sometimes. The first research study I ever wrote was on reducing revenue cycle cost to collect.) The fact that administrative and rev cycle applications are by far the lowest-hanging fruit (compared to most clinical applications) means that the rev cycle part of healthcare is in real danger of yet another technological arms race. I’ll briefly explain.

 

We saw the last rev cycle arms race in the mid-2000s, as orgs started adopting new staffing models and automation technologies to help process claims and denials. The upshot was, paradoxically, a massive increase in initial denials combined with a steep drop in hospital AR days—in other words, a win-win for everyone, unless you count the even more massive increase in annual costs all this investment generated. Are we in for another round of rearmament? Probably. And one big enough to contribute to a new spike in healthcare as a share of America’s GDP.  This would be one of lots of things we see as potentially contributing to such a spike.


We can also expect an uptick in AI investment in the clinical trial space. With pharma feeling more pricing pressure—from both regulatory and competitive dynamics—clinical trial efficiency will be key to bringing more drugs to market, and faster. Will it lead to an increase in costs? Again, probably. And speaking of drugs:

 

Prediction #4: Big investments in life sciences will continue—fueled by the converging forces of high-priced rare-disease therapies and exploding growth in the weight-loss market

 

The pharma world has seen big leaps before in the chronic-care space (think statins). And it’s seen eras of massive growth in enormously expensive drugs serving small populations. Rarely has it seen both at the same time, and we are definitely seeing that now. Genomics, biologics, and precision medicine are producing an unprecedented wave in specialty drugs—particularly in cancer. And GLP-1 drugs have the potential to upend the chronic care market.

 

Pharma deal volume/value were down in 2023, and many of the big pharma companies saw stock market performance dip (Novo Nordisk and Eli Lilly—i.e. the two companies that already have weight loss drugs in the market—being notable exceptions). But again, this was more a reflection of the broader economic climate than a meaningful decline in investor interest in this space. And with spending continuing to trend upward in a big way, we predict investor interest here will continue be strong, for all of the reasons above. But this is an issue that requires much more discussion. If you’d like to learn more, see our recent post on innovation, or contact us for our latest study on the topic. In the meantime, see below for our synthesis of current deal targets, with knock-on winners and losers from across the healthcare marketplace.


Where are these investments taking us?


It's often lamented that prices in the healthcare world only go up, but most of us know that's not remotely true. Technological advances have drastically reduced the cost of surgeries (inpatient to outpatient, invasive to MIS), diagnostics, and countless administrative functions. But overall spending never decreases because efficiencies gained in one area free up resources to spend on newer innovations. Today's healthcare investment climate points strongly at a new cycle of innovation that is far likelier to drive up spending in the short-to-medium term rather than realize new cost savings. That's not an indictment of where the smart money is going; simply an observation. And it's quite possible that investments in chronic care treatments and AI-powered rev-cycle improvements will drive long-term savings. But I doubt they'll be curbing aggregate spending anytime soon.


The research and analysis that went into this post are part of our upcoming State of Healthcare 2024. If you'd like be part of that research or would like it brought to your organization, contact us. And for regular updates, sign up for our monthly Board Briefing webinar series. We'd love to hear from you!

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