Dec
21

The Ametros deal – details and perspective

Ametros just sold for $350 million in cash, a rather stunning haul for the MSA administrators’ owners.  There’s a lot detail on how and why Ametros’ value was that high in the interview below,

Along with the Carisk recap, this was one of the (very) few recently-attempted sales in the industry that came to fruition. In the parlance of private equity Ametros may be a unicorn – from here it looks like its valuation wasn’t based on an earnings multiple, rather the company’s massive bank deposits and growth potential.

I spoke with CEO Porter Leslie earlier this week – he was refreshingly open and candid; I didn’t have to dig through gobs of corporate-speak to get to the real stuff.  Here’s our conversation.

Questions for Porter Leslie

MCM – Talk about how Ametros has grown to over $800 million in [bank] deposits.

Leslie – It has been a long grind, we identified something that the market needed, to take care of Injured Workers [IW] after settlements, over time a lot of large payers and attorneys came around… CMS highly recommends it, it helps IWs, and helps settlements happen – it all makes sense – it took time to scale and to get story out there, nothing fancy, just focused on building strong relationships

MCM – One aspect of Ametros I’ve been consistently impressed with is your marketing – talk about how leadership thinks about marketing and investing in brand.

Leslie – what we do is pretty complicated, no one understands WC or MSAs or professional admin of MSA – [so we’re at a] third level of complication – thrust has been to make it simple – mission is to make healthcare easy for IW, everything we do is thru lens of making it simple and practical – if IW can get it, then the expert that advises them can understand it

[we have] great people on the marketing side – Melissa [Coleman] works well with Helen [Knight of KingKnight]– we give them room to run, there are a lot of ideas and creativity across social media, websites, wherever they see opportunity to connect. We focus a lot on telling the stories of IWs that go through a settlement and how we can alleviate burden for them.

We do play in a lot of traditional publications, if you go to our website we highlight members. Few organizations really emphasize the human element and story around it – that’s what people care about – our people understand the space, we don’t spend on conferences so much as getting to people that matter to them and share story – message is around why do they give a darn about this and why should they – service is beneficial to all involved.

MCM – Has CMS done anything recently to increase payer interest in MSAs and professional administration?

Leslie – [recently there’s been a] Steady drumbeat from CMS on tightening up oversight and MSAs and professional admin…for instance, a few years ago with CMS’ electronic portal to submit reporting – we worked hard with CMS to make it work. Last year CMS put out messaging re MSAs in an attempt to move the market towards submitting MSAs for CMS’ approval– CMS did a webinar last month saying that in 2025, CMS will mandate that when you settle a case you have to put a $ figure for moneys that were set aside to protect Medicare …now the payer has to tell CMS when they settled the case, even if the MSA was not formally submitted to CMS for approval, the payer has to tell CMS [explicitly] the amount that was set aside to protect them. All this effort to drive extra visibility shows CMS is watching settlements and wants to make sure the injured workers’ medical funds are properly set aside and administered after settlement.

MCM – Unusual for a bank to acquire a workers’ comp services entity; talk about the rationale.

Leslie – Don’t think of ourselves as WC services business – receive business from WC but once injured workers land with us, the individual is a cash pay member of the healthcare system – in the [sale] process we did not want to be typecast into WC business – we do fair number of general liability and accident claims as well

Webster is top 25 bank and the largest bank-run administrator of HSA [Health Savings Accounts]. Webster acquired an HSA admin company that was tiny, now it is close to $13 billion in deposits…Webster held majority of Ametros’ deposits and made a loan to the business, knew Ametros well and was accustomed to investing and growing this type of business. The deal really was the natural evolution of a partnership that was years in the making.

MCM – While there haven’t been many transactions of late, in general valuations have declined from those a few years ago…this transaction bucks that trend. Valuation of $350MM was quite impressive, as was the all-cash purchase.

Context is Webster is a [recent] combination of Sterling Bank and Webster [which] doubled its size…they have been pretty active looking for differentiated source of deposits…Webster is not trying to be expert in WC…know Ametros has a team of experts that do that know that.

MCM – How will Ametros operate going forward?

Leslie – No team changes or system changes or tech changes – vision from W is to remain independent similar to HSABank – questions Webster is asking [of management] are how to grow faster; need people, systems, etc? – Ametros administers 8-9% of MSAs that are settled today, and we should be handling 80-90%…[expect we will] put forth budgets to really propel the business.

 

MCM – What changes will customers see?

Leslie – Keep same brand, same products, invest in making them better, no changes to staff

[There is] Not a workers’ comp dedicated bank out there, so may be other opportunities for Webster in WC.

[There are] Other entities [in MSA administration] that are 1/5th the size of them that could be acquisition candidates

What does this mean for you?

Great business ideas with great marketing executed very well can be very lucrative. 

You need all three.

 

 

 


Dec
18

Provider consolidation = Higher workers’ comp costs, longer disability

Healthcare provider vertical integration increases work comp medical costs, increases disability duration, and does not deliver better outcomes.

And, provider consolidation continues to increase.

The lede is the one-line summary of WCRI’s latest – and quite useful – research.

Olesya Fomenko and Bogdan Savich collaborated on a very well done study of vertical integration of providers’ impact on work comp, and their research bodes ill indeed.

Summarizing the experts’ findings, vertically integrated providers had: 

Some detail…courtesy WCRI

And if you think that’s bad…here’s the impact on disability duration…

These conclusions generally align with what we’re seeing from other payer types…consolidation leads to higher prices and negative to neutral impact on outcomes.

That isn’t stopping consolidation  – far from it.

What does this mean for you?

Find out how consolidated provider markets are where your business is. And watch for more consolidation, as that will predict higher costs.


Dec
15

Well that was a GREAT Thursday.

The FED announced that not only is it not raising rates, it plans on cutting interest rates next year. While that’s great news indeed, what drove the FED decision shows the economy is doing well – and will get better.

From Reuters quoting FED Chair Jerome Powell:

  • “We are seeing strong growth that … appears to be moderating.
  • We are seeing a labor market that is coming back into balance …
  • We’re seeing inflation making real progress,” [emphasis added]

In fact, personal consumption expenditures inflation is seen ending 2023 at 2.8% and falling further to 2.4% by the end of next year

And, betting markets predict the FED rate will drop 1.5 points – below 4% – over the next 12 months.

Stock markets boomed, with the DOW hitting an all-time high and the S&P close behind.

And home mortgage rates are back below 7%, and headed down from there.

What does this mean for you? 

  • Lower credit card interest rates so consumers will spend more,
  • cheaper mortgages will mean construction will increase,
  • which means more jobs.

 


Dec
14

Electric grids, infrastructure, jobs and payroll

In which we briefly discuss the power grid, jobs and what it means for you.

The good news is the Inflation Reduction Act (IRA) and bipartisan Infrastructure Investment and Jobs Act invest billions of dollars to upgrade the nation’s electrical grid.

courtesy Carbon Collective

(a connected grid enables operators to send power from places where there is plenty of electricity – say Arizona – to places where demand is super high – say Oklahoma during a deep freeze)

Dollars going to infrastructure are a major reason construction spending has jumped..it’s now more than a third higher than pre-COVID

Paralleling investment, construction employment has dramatically increased and is well above pre-pandemic rates..

source – FRED

What does this mean for you?

More investment = reliable infrastructure + more jobs = higher payrolls = higher premiums.

A very good explanation of the grid, transmission, and electricity production is here.


Dec
13

Optum employs(?) more doctors than any other organization

The giant subsidiary of United Healthcare employs [>]90,000 MDs and 40,000 more advanced practice clinicians – far more than any other entity.

That’s more than one out of every ten physicians, and a far higher percentage of practicing MDs.

While that’s pretty amazing, its just one of the many investors, healthplans, private equity firms, large healthcare systems, and insurers snapping up all manner of healthcare providers.

In fact, almost three-quarters of all physicians are employees of companies or healthcare systems/hospitals – not members of physician-owned practices.

As with everything in healthcare, location makes a big difference.

One of the biggest drivers has been Optum’s acquisitions, which included Kelsey Seybold, a very large practice in Texas…Optum reportedly paid $2.2 billion for the business.  And, that happened AFTER the time period in the graph.

What does this mean for you?

Your healthcare will be driven by investors’ goals.

note – Optum’s communications folks asked me to publish a correction, because not all of the 90k docs are “employees”…I asked how many of those 90k docs are “employees”; Optum’s reply was “We don’t break out the numbers because we focus on the total number who serve our risk-based patients.”

I’m quite sure Optum knows the number. why they won’t release it is a mystery.

I also asked – twice – whether the “physicians who contract directly with Optum” (which make up some/part of the 90k docs):

  • exclusively contract with Optum,
  • are allowed to contract directly with other payers, and/or
  • is Optum the contracting intermediary?.

I didn’t get an answer.

So, all I can tell you, dear reader, is Optum directly employs ≤ 89,999 physicians, and may or may not allow those “non-employed” physicians to contract with other payers.


Dec
11

Healthcare regains the political stage

Healthcare has not been on the political landscape since the last attempt to overturn the Affordable Care Act aka ObamaCare failed…and then-candidate Trump talked up his very-hard-and-actually-impossible-to-locate HealthPlan.

Just-released polling indicates several healthcare issues are top-of-mind for voters across the political spectrum.

  • 4 out of 5 voters say it is “very important” for candidates to talk about healthcare affordability...making healthcare the second most important topic among respondents.
  • The ACA is back in voters’ minds with almost half of poll respondents stating the ACA’s future is “very important issue”.
  • Medicare and Medicaid are also top of mind for voters as is access to mental healthcare with 75% and 70% of respondents respectively stating these issues
  • Related, about a quarter of voters (24%) say they would only vote for a candidate who shares their views on abortion.

What does this mean for you?

As America ages and healthcare becomes increasingly unaffordable, more voters are more about healthcare. 

 


Dec
8

Facts for this weekend’s chats!

Whether you’re chatting around the grill, conversing at a swim meet or hockey game, or between quarters of a football game, here’s the real scoop on the economy, with immediate responses to show you’re the one with the real story.

hint…the “everything sucks” narrative is flat out wrong.

  1. No one wants to work these days! 

Surprise…

Net is the percentage of everyone 16 and older working today is within a half point of pre-COVID participation rates.

No, there is NOT some huge number of Gen Zs, millennials, or whatever that’s said “screw it, we’re outta here, and I’m gonna live with/off my parents forever!”

 

And…for the core group – folks 25-54 – labor force participation is near an all-time high at 83.5%!

 

2. Well…there just aren’t that many people working!

Hmmm…There are more people employed now than ever, and employment has been increasingly steadily for the last three years.

credit FRED.

3. Okayyyyy…but inflation’s higher than wages, so we’re falling behind!!

Well, no – since way back in March – 9 months ago – earnings are growing faster and more than inflation, so you can buy MORE with your weekly paycheck today than you could a few months ago.

source Statista

What does this mean for you?

You are gonna be soooo smart.


Dec
7

Work comp services – another deal is done

Private equity firms Lee Equity Partners and Elements Health Investors completed a recap of Carisk Partners last week, marking one of the very few deals to be done over the last many months.

While this may be an indication that things may be moving, there are several reasons we aren’t likely to see a return to the halcyon days of a decade ago.

First, over the last two years Carisk is one of the very few companies to actually get a deal done. Several others tried and failed, mostly because:

a) sellers’ expectations were out of whack with what buyers would pay;

b) due diligence revealed softness in numbers &/or growth plans &/or management depth;

c) current debt service costs made a deal too costly; and/or

d) the property is/was too large (more at the mercy of industry trends than smaller entities, very hard to grow share when you are already huge)

Carisk has very experienced and quite effective management, terrific marketing, some of the best sales people in the industry, a strong culture and a coherent strategy for growth and expansion.

Second the structural issues inherent in workers’ comp, namely it is a highly mature, consolidating/consolidated industry with very low to negative growth make it less attractive than, say, generative AI.

Third, debt – which makes up most of the purchase price of pretty much every sale – is still expensive compared to rates over the last decade or so. Investors will eventually get over mid-to-high single digit interest rates, but haven’t yet.

Lastly, reality is work comp is just not that interesting: many execs are highly risk-averse if not downright lazy; innovation is frowned upon if not actively avoided; and complacency is rampant as is chronic under-investment in IT and human capital.

The few transactions that have closed – HomeCare Connect and now Carisk most prominent- are really solid companies with great management teams, solid track records and a clear path to substantial growth. The ones that didn’t close were…not.

That’s not to say some companies won’t test the waters, but don’t get caught up in rumors about this or that company getting sold or preparing for a sale or going to market or talking to investment bankers.

Bankers are ALWAYS talking up potential deals…it is how they gin up business – and the work comp rumor mill loves to help ’em out.

What does this mean for you?

A great company will always be valuable. 

disclosure – I have a (very small) financial interest in Carisk.


Dec
5

Profit shifting aka work comp is funding the P&C industry’s losses.

Or, it is a GREAT time to be a monoline carrier.

The property & casualty insurance business is a tale of two extremes, with work comp profits offsetting losses across all other lines.

That’s one reason multi-line insurers are dragging their feet on cutting work comp and continuing to hoard billions of dollars in excess reserves.

Work comp is hugely profitable, with insurers raking in hundreds of millions in profits…with $10+ billion more in excess reserves, aka unrealized gains.

chart extract from S&P

Other insurance lines are the yang to WC’s yin.

S&P predicts all other lines will lose money on an underwriting basis again this year…

Here’s the money quote (pun intended):

➤ Dismal first-quarter 2023 direct incurred loss ratios in the homeowners and private auto business suggests a repeat of 2022, when highly favorable underwriting results in the commercial lines, aided in part by favorable prior-year workers’ compensation reserve development, were more than offset by the personal lines losses. [emphasis added]

and implications thereof:

The [2022] workers’ compensation combined ratio of 83.9% represented a decline of nearly 3.3 percentage points from the 2021 result. It ranks as the second-lowest such result in the last 25 years, owing to relatively benign trends in the current accident year and a fifth straight calendar year of favorable prior-year reserve development in excess of $5 billion. [emphasis added].

What does this mean for you?

Those who pay comp premiums are subsidizing insurers’ losses in personal and commercial lines – especially personal auto.


Dec
3

Good news…Monday. Rising wages + Lower inflation = Higher portfolios

About to head home after two weeks in Southeast Asia…off the grid for much of it.

Here’s the good stuff that happened whilst I was floating down the Mekong River.

Wages are up…

and have been rising steadily for the last 3 years…outpacing inflation.

And will keep going up…

From The Economist – “A blue-collar bonanza is under way…three forces that shape labour markets—demand, demography and digitisation—have each shifted in ways that benefit workers.”

If you’ve had to hire a plumber, carpenter, or electrician recently, you know what they’re talking about.

Implication – higher wages = higher premiums.

While inflation continues to drop…

One economist got this right, while many just endlessly caterwauled about the imminent rise in unemployment and drop in wages necessary to tame inflation.

Gotta love economists…or not.

Fuel prices continue to drop…leaving more dollars in our pockets

All this good economic news – consumers have more money to spend, employment remains very strong, and prices are moderating means there will be…

More dollars in your investment portfolio

You’ll likely see your investment portfolio rise in value…BofA, RBC, and Deutsche Bank are among the firms predicting record returns in 2024.

What does this mean for you?

As you start your week, don’t buy into the “economy is awful” nonsense. 

Finally – -one of the keenest observers of trends in business and the body politic is Scott Galloway of NYU. I highly recommend his weekly newsletter.