healthcare staffing m&a surges amid substantial …

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HEALTHCARE STAFFING M&A SURGES AMID SUBSTANTIAL LABOR SHORTAGEHEALTHCARE STAFFING INDUSTRY UPDATE | NOVEMBER 2021

TABLE OF CONTENTS

CONTACT OUR HEALTHCARE STAFFING INDUSTRY EXPERTS

Key Industry TakeawaysTravel Nursing and Allied Health See Strong Growth M&A Volume Continues at Rampant PaceRepeat Buyers Fuel M&A, Sponsors Build Sector PortfoliosHistoric M&A Trends and Public Company ValuationsSelect TransactionsPublic Company DataBuyer UniverseReport ContributorsFirm Track RecordEndnotes

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Eric WilliamsManaging Director

[email protected]

Mark SurowiakDirector

[email protected]

capstonepartners.com

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KEY INDUSTRY TAKEAWAYS

Capstone Partners’ Healthcare Group is pleased to share its Healthcare Staffing report. The resurgence ofCOVD-19 and Delta variant cases have stressed healthcare systems, creating substantial demand foroutsourced staffing providers. Merger and acquisition (M&A) activity has proliferated as strategic playersconsolidate to bolster service offerings and private equity continues to build and enhance sector portfolios.Several key takeaways are outlined below, followed by analysis on industry trends, drivers of M&A activity, andtransaction valuations.

1. The Travel Nursing segment continues to attract heightened demand through year-to-date (YTD) withindustry participants recording significant revenue growth.

2. Top public companies have achieved strong operating performance through Q2, capitalizing onelevated demand for workforce solutions.

3. M&A volume has increased drastically as potential tax increases and the current favorable transactionenvironment has motivated sellers to pursue a liquidity event.

4. Strategic buyers have led M&A activity while private equity (PE) has also continued to demonstrate astrong appetite for healthcare staffing providers.

Capstone Partners has developed a full suite of corporate finance solutions, including M&A advisory, debtadvisory, financial advisory, and equity capital financing to help privately owned businesses and private equityfirms through each stage of the company’s lifecycle, ranging from growth to an ultimate exit transaction.

To learn more about Capstone’s wide range of advisory services and Healthcare Staffing industry expertise,please contact Capstone Managing Director Eric Williams.

Healthcare Staffing IndustryM&A Surges Amid Substantial Labor Shortage

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https://www.capstonepartners.com/advisors/eric-williams/

TRAVEL NURSING AND ALLIED HEALTH SEE STRONG GROWTH

Clinician burnout coupled with the resurgence ofCOVID-19 and Delta variant cases in the summerstressed the capacity of many healthcareproviders, with those located in high infectionregions experiencing the most significant strain onoperations. Workforce management has proven tobe a key focus for providers to effectively deliverquality care, with staffing firms playing a criticalrole in providing labor flexibility. Notably, nationalhealth system Providence reported a 20% year-over-year (YOY) increase in agency contract laborcosts to address mounting labor shortages,according to its Q2 financial statement.1

While COVID-19 infections represented an acutechallenge for healthcare providers in the first halfof 2021, healthcare providers are now managingclinical staff burnout coupled with an uptick innon-COVID-19 patient volumes. Notably, clinicianfatigue, increasing patient visits, and operatingroom backlog have contributed to drastic laborsupply constraints, noted AMN Healthcare(NYSE:AMN) in its Q2 earnings call.2 Pandemicdisruptions have exacerbated existing laborchallenges as the aging U.S. population andclinician workforce have already created asignificant shortage of healthcare professionals.This has contributed to forecasts for a $21.3 billionHealthcare Staffing industry by year end,according to Cross Country Healthcare’s(Nasdaq:CCRN) investor presentation.3

The Travel Nursing segment continues toexperience robust demand through the first half of2021, with the median revenue growth increasing95% YOY in June, according to Staffing IndustryAnalysts.4 While bill rates have compressed sincethe peak of the pandemic, high volumes havefueled the segment’s healthy performance amid apersistently tight clinical labor market. Notably,leading healthcare staffing provider Cross CountryHealthcare recorded a 50% increase in travelnurse orders in Q2 from the start of the quarter,according to its earnings call.5 In addition, AMNHealthcare

Healthcare Staffing | November 2021

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Aging Population and Workforce Shortages Drive Growth in Healthcare Staffing Market

$15.2 $16.3 $17.1 $18.4$19.9

$21.3

$0

$5

$10

$15

$20

$25

$30

2016 2017 2018 2019 2020 2021

U.S

. Dol

lars

in B

illio

nsHealthcare experienced a 37% YOY increase intravel nurse staffing revenue in Q2. The AlliedStaffing segment of the industry has alsodemonstrated solid growth through the first half of2021, supported by the rebound of therapy orderswhich experienced depressed demand for muchof 2020. Notably, AMN has recorded consistentgrowth in its Allied division over the last threequarters with revenue rising 44% YOY in Q2,according to its earnings report.6

Clinician retention and recruiting challengescontinue to manifest in greater use of outsourcedproviders. As uncertainty relating to the COVID-19and Delta variant cases persist, hospital systemsand healthcare providers are likely to requireefficient flexing of workforces to meet demandsurges. Staffing providers are expected to placeincreased focus on digital tools and recruitmentand onboarding productivity technology tooptimize labor management for their clients.Consolidation activity is expected to play a keyrole in the expansion of staffing services asindustry players seek accretive acquisitions tobolster capacity.

Source: Cross Country Healthcare

M&A VOLUME CONTINUES AT RAMPANT PACE

M&A volume in the Healthcare Staffing industryhas surged YTD with 30 transactions announced orcompleted, already outpacing full year 2020 levels.Target companies in the Nursing & Travel Nursingsegment have comprised the largest percentageof transactions (37%) as industry participants lookto capitalize on the sector’s rapid growth. Whilepotential tax increases continue to motivatesellers to transact, fervent buyer appetite androbust valuations have also fueled a historic M&Amarket for healthcare staffing providers. Privatestrategic buyers have dominated M&A activity,comprising nearly 70% of YTD transactions.

Aya Healthcare has established itself as a leadingconsolidator in the sector, continuing toaggressively pursue temporary staffing andworkforce solutions providers, often acquiringtarges

Healthcare Staffing M&A Transaction Volume

Num

ber o

f Tra

nsac

tions

6

Valuation Method Average Revenue Multiple Average EBITDA Multiple

Historic M&A Transactions (2016-YTD)

Public Company Trading Multiples (LTM)

Valuation Insight

M&A transaction EBITDA multiples have averaged 9.3x, with larger companies or companies with a presencein high growth subsectors often commanding the higher multiple ranges. Notably, the median M&Atransaction enterprise value has amounted to approximately $41 million from 2016 to YTD. Comparatively, theenterprise value of publicly traded Cross Country Healthcare and AMN Healthcare stands at $880 million and$5.9 billion, respectively; which currently trade at average of 13.5x EBITDA.

Healthcare Staffing Valuation Analysis

2731

45

1913

30

0

10

20

30

40

50

60

2017 2018 2019 2020 YTD2020

YTD2021

Source: Capital IQ, FactSet, PitchBook, and Capstone Research

targets through its subsidiary, Qualivis. In addition, dealmakers are fielding elevated inquiries from privateequity firms seeking to establish or enhance sector portfolios. Sponsors have benefited from historically lowinterest rates and vast levels of deployable capital creating a favorable backdrop for elevated deal activity. Inaddition, with 2020 representing a lost year for many PE firms, pressure has increased on investors andsponsors to deliver returns under a shorter time frame. Notably, Periscope Equity recently announced itsinvestment in MAS Medical Staffing, a leading per diem and travel nurse provider (more details on thefollowing page).

Capstone expects deal activity to continue at a healthy pace through year end and into 2022 as privateequity continues to target the sector and strategics leverage improved balance sheets to reengage in growthinitiatives. Valuations are expected to favor staffing providers with strong margin growth, large scale, andexpansive client relationships.

Year-to-date (YTD) ended August 23Source: Capital IQ, FactSet, PitchBook, and Capstone Research

13.5x

9.3x

1.4x

1.2x


REPEAT BUYERS FUEL M&A, SPONSORS BUILD SECTOR PORTFOLIOS

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Transaction OverviewAya Healthcare has announced a definitive agreement to acquire Vizient’s ContractLabor Management Business for an undisclosed sum (August). Aya plans to integratethe acquired business into its new subsidiary Vaya Workforce Solutions. "As thedemand for healthcare staffing services evolves, we're thrilled to join forces with Ayato expand our members' unmatched access to exceptional, cost-effectivetemporary staffing services through Vaya Workforce Solutions,” commented BharatSundaram, President and Chief Operating Officer at Vizient, in a press release.7

M&A and Industry TakeawaysThe acquisition of Vizient’s Contract Labor Business extends Aya’s active M&Arecord over the past 12 months. In May, Aya acquired workforce solutions providerDawson Healthcare for an undisclosed sum. In addition, Aya’s subsidiary Qualivis hascompleted two acquisitions since the start of the year, purchasing ChesapeakeRegistry Program of Maryland Hospital Association (February, undisclosed) and thetemporary staffing division of New Mexico Hospital Association (May, undisclosed).

Transaction OverviewLower middle market private equity firm Periscope Equity has announced itsaddition of MAS Medical Staffing to its portfolio through a recapitalization inpartnership with management (June, undisclosed). MAS Medical Staffing is a leadingtech-enabled staffing provider with a community of over 3,400 per diem and travelnurses serving long-term care, acute, and home-based care settings. Its proprietaryMAESTRA platform efficiently connects healthcare facilities with per diem nursesand streamlines credentialing, communication, and payroll.

M&A and Industry TakeawaysThe acquisition marks the first platform investment from the Periscope Equity II fund,with the add-on acquisition criteria for MAS including long-term care medicalstaffing agencies with a regional focus. Periscope typically targets companies withrevenue of $10 million to $50 million, and EBITDA ranging between $2 million and $8million, according to its website.8

Transaction OverviewCross Country Healthcare has completed the asset acquisition of WorkforceSolutions group for an enterprise value of $45 million (June). Workforce Solutionsprovides coordination of in-home care services for local and national healthcareplans and managed care providers. It also offers home care staffing, recruitmentprocess outsourcing, contingent workforce evaluation, and talent acquisition.

M&A and Industry TakeawaysThe acquisition expands Cross Country’s presence in the Home Care sector andcomplements its existing managed service program (MSP) services. In addition, theenterprise value is inclusive of a $15 million earnout based on Workforce Solution’sperformance from 2021 through 2023. With COVID-19 disruptions and supply chainuncertainties remaining in the market, dealmakers are seeing more structureinvolved in M&A sale processes, often to normalize pandemic-affected earnings.

Contract Labor Management Business of


HISTORIC M&A TRENDS AND PUBLIC COMPANY VALUATIONS

M&A Transaction Volume and Value

Recover From 2020

The prospect of tax increases, strong

valuations, and healthy buyer appetite has fueled a historic Healthcare Staffing

M&A market through the first eight months of 2021. Deal activity is forecasted

to continue at elevated levels through year end.

Private Strategic Buyers Comprise Majority of Transaction Activity

Private strategics have remained active acquirers

through year-to-date 2021 while private equity has

continued to demonstrate strong interest in the

sector, although add-on acquisitions have fallen

compared to historic composition levels.

EV/E

BITD

A

Public Healthcare Staffing Trading Multiples Slightly

Trail S&P 500

AMN Healthcare and Cross Country Healthcare have

traded at elevated multiples compared to the

prior year, with an LTM average of 14.5x and 12.5x, respectively. However, the

S&P 500 has modestly outperformed both public

staffing providers.

Perc

ent

of T

rans

actio

nsTr

ansa

ctio

ns


8

U.S

. Dol

lars

in M

illio

ns


Source: Capital IQ and Capstone Research

2731

45

1913

30

$0

$100

$200

$300

$400

0

10

20

30

40

50

60

2017 2018 2019 2020 YTD 2020 YTD 2021

Transactions Average Value

44.4%61.3% 62.2% 57.9%

70.0%

11.1%

6.5% 6.7% 10.5%10.0%

11.1%

12.9% 4.4% 5.3%

10.0%33.3%19.4% 26.7% 26.3%

10.0%

0%

20%

40%

60%

80%

100%

2017 2018 2019 2020 YTD 2021

Private Public PE Platform PE Add-On

0x

5x

10x

15x

20x

25x

Aug-20 Oct-20 Dec-20 Feb-21 Apr-21 Jun-21 Aug-21

S&P 500 AMN Healthcare Cross Country Healthcare


SELECT TRANSACTIONS

Date Target Acquirer Target Business Description Buyer Type

08/30/21 Medical Solutions

Centerbridge Partners, CDPQ

Offers staffing services including travel nurse and travel allied health professionals. Platform Investment

08/19/21 The Fortus Group Job.com Provides health staffing and recruiting services. Private Strategic

08/09/21 Contract Labor of Vizient Aya Healthcare Comprises the contract labor management business. Private Strategic

06/11/21 Vital Medical Staffing

Dedicated Nursing Associates Offers per diem nurse staffing. Private Strategic

06/08/21 MAS Medical Staffing Periscope Equity Provides per diem and travel nurse staffing. Platform Investment

06/08/21 Assets of Workforce Solutions

Cross Country (Nasdaq:CCRN)

Comprises the assets of talent management and consulting solutions ($45mm enterprise value). Public Strategic

05/26/21 Temp. Staffing of New Mexico Hospital Qualivis Provides temporary staffing services. Private Strategic

05/21/21 The Planet Group ProPharma Group

Offers professional staffing to industries including Life Sciences and Healthcare. PE Add-on

05/12/21 Independence Medical ICON Medical Network Provides staffing and search services to the Healthcare sector, including anesthesia professionals. Private Strategic

05/11/21 Dawson Healthcare Aya Healthcare Offers healthcare workforce solutions. Private Strategic

05/07/21 Flexibility Chesapeake Medical Staffing

Provides healthcare staffing solutions. Private Strategic

05/06/21 Synzi AMN (NYSE:AMN) Develops a patient program management platform for healthcare organizations ($42.5mm enterprise value). Public Strategic

04/23/21 Therapia Staffing Gifted Nurses Offers recruitment and placement of professionals in the Healthcare industry. Private Strategic

04/19/21 Staff Today Health Advocates Provides clinical and non-clinical supplemental staffing services. Private Strategic

03/19/21 LG Associates Kyyba Offers staffing and consulting services to industries including Healthcare and Pharmaceutical. Private Strategic

03/17/21 Solutions Nursing Premier Health of America (TSXV:PHA)

Provides nurse staff placement services. Public Strategic

03/03/21 Kamana Triage Staffing Offers a platform that connects healthcare providers with traveling nurses. PE Add-on

02/24/21 U.S. Nursing / Fastaff Travel

Trilantic Capital, Cornell Capital

Provides staffing solutions including travel nurse staffing. Platform Investment

02/11/21 Medpath Health Carousel Offers staffing solutions for the Healthcare industry. Private Strategic

01/14/21 Vitruvian Medical Health Carousel Provides locum tenens and permanent search solutions for anesthesiologists. Private Strategic

01/01/21 Action Healthcare Staffing Actriv Healthcare Provides healthcare staffing solutions including nurses and

allied health professionals. Private Strategic

12/07/20 TalentMine Orbis Clinical Offers life science staffing services. Private Strategic

11/06/20 Field Health Premier Healthcare Professionals

Provides recruitment services to hospitals and agencies. Private Strategic

Source: Capital IQ, PitchBook, FactSet, and Capstone Research

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PUBLIC COMPANY DATA

Price % 52 Wk Market Enterprise LTM EV / LTM

Company 08/26/21 High Cap Value Revenue EBITDA Margin Revenue EBITDA

AMN Healthcare Services, Inc. $108.13 97.4% $5,110.5 $5,899.7 $2,926.3 $407.4 13.9% 2.0x 14.5x

Cross Country Healthcare, Inc. $20.17 93.5% $766.5 $883.4 $1,070.6 $70.8 6.6% 0.8x 12.5x

Mean 10.3% 1.4x 13.5x

Median 10.3% 1.4x 13.5x

Harmonic Mean 9.0% 1.2x 13.4x

EV = enterprise value; LTM = last twelve months$ in millions, except per share dataNM = Not Meaningful

Source: Capital IQ as of August 26, 2021

10

32.9%

23.0%

13.9%

6.6%

0%

10%

20%

30%

40%

50%

AMN Healthcare Cross CountryHealthcare

Gross Margin EBITDA Margin

Perc

enta

geEV

/EBI

TDA

LTM Margin Performance

LTM EBITDA Multiple Performance

11.7x

7.6x

14.5x12.5x

0x

5x

10x

15x

20x


LTM 2020 LTM 2021

1.5x

0.4x

2.0x

0.8x

0.0x

0.5x

1.0x

1.5x

2.0x

2.5x

3.0x


LTM 2020 LTM 2021

EV/R

even

ue

LTM Revenue Multiple Performance

-20%

30%

80%

130%

180%

Dec-20 Apr-21 Aug-21

AMN HealthcareCross Country Healthcare

YTD Share Price Performance

Perc

enta

ge G

row

th


BUYER UNIVERSE

Capstone has developed intricate knowledge of the strategic and financial buyer universe through ongoingconversations with industry participants. If you would like to learn more about relevant buyers in your sector,please reach out to Managing Director Eric Williams.

Leading Strategic Buyers

Source: Capstone Research

Leading Financial Buyers

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https://www.capstonepartners.com/advisors/eric-williams/

HEALTHCARE STAFFING REPORT CONTRIBUTORS

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Eric WilliamsManaging Director [email protected] | 215-854-4065

Based out of Philadelphia, Eric serves as a Managing Director at Capstone Partners andleads the Health and Medical practice. Eric has successfully completed more than 100transactions in sectors including contract manufacturing, pharmaceutical outsourcing,medical devices, and life sciences, and health care services. Prior to Capstone, Eric wasresponsible for managing the Eastern region for Morgan Stanley Smith Barney’s CapitalStrategies Group and its predecessor, Citi Capital Strategies. Eric has 20 years ofexperience managing strategic sale assignments and leveraged recapitalizations forowners of privately held companies.

He has also executed complex cross-border transactions with foreign buyers based inLondon, Germany, Sweden and Switzerland and has structured deals with leadingprivate equity groups and strategic corporate buyers. Previously, Eric worked as a seniorexecutive with Newport Securities Corporation. He graduated cum laude from theUniversity of California and is a Series 7 and 63 Registered Securities Representative aswell as a Series 24 Registered Securities Principal.

Connor McLeodResearch [email protected] | 617-619-3319

Connor currently serves as Research Manager at Capstone Partners. Connor providesM&A insights, capital markets analysis, and macroeconomic trends for C-suite middlemarket executives. He specializes in the coverage of the Healthcare and Consumer &Retail industries.

Prior to joining the Research Team at Capstone, Connor was a specialist with theInvestor Services team at BlackRock where he was responsible for assessing fund andaccount performance, communicating relevant market dynamics, and facilitating tradesfor shareholders, financial advisors, and institutional clients.

Mark [email protected]| 215-854-4063

Mark is a Director in the Philadelphia office with over 15 years of experience in mergers &acquisitions, private placements and financial advisory services. While Mark's primaryfocus includes clients in the health and medical industry, his experience spans a broadrange of industries, including government and defense contracting, manufacturing andoutsourced business services sectors. Prior to investment banking, he enjoyed a careerin the social services field.

Previously, Mark served over 10 years as a senior investment banking professional inMorgan Stanley Smith Barney’s Capital Strategies Group. Over his career, Mark hasfocused on developing deep credentials and expertise in the sale and recapitalization ofprivately held businesses.


FIRM TRACK RECORD

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Capstone has successfully advised on a number of transactions related to the sale of healthcarestaffing and talent management firms. Select Capstone Health & Medical transactions are shown below.The firm’s experience in the sector provides significant insight into the valuable attributes and likelyvaluation of target companies, the active buyers, and the nuances of transactions in the space.

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HAS BEEN ACQUIRED BY HAS BEEN ACQUIRED BY

LEADING MUTI-CLINIC PHYSICAL THERAPY

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http://www.google.com/url?sa=i&rct=j&q=tricore+logo&source=images&cd=&cad=rja&docid=5BnJNF0_g6TytM&tbnid=GLUyEYIygFgpzM:&ved=0CAUQjRw&url=http://www.saba.com/community/content-partners/&ei=rEJwUYTCKNOq4AOc3YC4Cg&bvm=bv.45373924,d.dmg&psig=AFQjCNHPN_IqMOgQTGkAzigsyeSX6zQ4RQ&ust=1366397951127279

ENDNOTES

1. Providence St. Joseph Health, “Financial Statements,” https://www.providence.org/about/financial-statements, accessed August 27, 2021.

2. Seeking Alpha, “AMN Healthcare Services, Inc. (AMN) CEO Susan Salka on Q2 2021 Results - Earnings Call Transcript,” https://seekingalpha.com/article/4446852-amn-healthcare-services-inc-amn-ceo-susan-salka-on-q2-2021-results-earnings-call-transcript, accessed August 16, 2021.

3. Cross Country Healthcare, “Investor Relations Q1 2021,” https://ir.crosscountryhealthcare.com/static-files/26ca67ce-0ec9-4ea5-9dd8-884c9dcd9967, accessed August 21, 2021.

4. Staffing Industry Analysts, “HEALTHCARE PULSE: TRAVEL NURSE STAFFING REVENUE ALMOST DOUBLES, COVID VACCINATIONS A CONCERN,” https://www2.staffingindustry.com/Editorial/Healthcare-Staffing-Report/Aug.-12-2021/Healthcare-Pulse-Travel-nurse-staffing-revenue-almost-doubles-Covid-vaccinations-a-concern, accessed August 26, 2021.

5. Seeking Alpha, “Cross Country Healthcare, Inc. (CCRN) CEO Kevin Clark on Q2 2021 Results - Earnings Call Transcript,” https://seekingalpha.com/article/4446682-cross-country-healthcare-inc-ccrn-ceo-kevin-clark-on-q2-2021-results-earnings-call-transcript, accessed August 26, 2021.

6. AMN Healthcare, “AMN Healthcare Announces Second Quarter 2021 Results,” https://ir.amnhealthcare.com/press-releases/press-releases-details/2021/AMN-Healthcare-Announces-Second-Quarter-2021-Results/, accessed August 28, 2021.

7. Cision, “Aya Healthcare announces agreement to acquire Vizient Contract Labor Management; launches Vaya Workforce Solutions,” https://www.prnewswire.com/news-releases/aya-healthcare-announces-agreement-to-acquire-vizient-contract-labor-management-launches-vaya-workforce-solutions-301351256.html, accessed August 26, 2021.

8. Periscope Equity, “Firm Factsheet,” http://periscopeequity.com/wp-content/uploads/2021/08/Periscope-Equity-Profile.pdf, accessed August 26, 2021.

C ommon Goa ls . Uncommon Resul t s .

DisclosureThis report is a periodic compilation of certain economic and corporate information, as well as completed and announced merger andacquisition activity. Information contained in this report should not be construed as a recommendation to sell or buy any security. Anyreference to or omission of any reference to any company in this report should not be construed as a recommendation to buy, sell ortake any other action with respect to any security of any such company. We are not soliciting any action with respect to any securityor company based on this report. The report is published solely for the general information of clients and friends of CapstonePartners. It does not take into account the particular investment objectives, financial situation or needs of individual recipients.Certain transactions, including those involving early-stage companies, give rise to substantial risk and are not suitable for all investors.This report is based upon information that we consider reliable, but we do not represent that it is accurate or complete, and it should notbe relied upon as such. Prediction of future events is inherently subject to both known and unknown risks and other factors that maycause actual results to vary materially. We are under no obligation to update the information contained in this report. Opinionsexpressed are our present opinions only and are subject to change without notice. Additional information is available upon request.The companies mentioned in this report may be clients of Capstone Partners. The decisions to include any company in this report isunrelated in all respects to any service that Capstone Partners may provide to such company. This report may not be copied orreproduced in any form or redistributed without the prior written consent of Capstone Partners. The information contained herein shouldnot be construed as legal advice.

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$65.1Maverage

transaction value

51deals involving foreign

private equity firms

65%completed with a European partner

218M&A transactions

completed in 2020

30%of our deals are cross-

border

$12.5Baggregate

transaction value

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deals under $500m

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