The Evolving Landscape of Physician Practice Acquisitions with Holly Buckley of McGuireWoods LLP 6-25-26

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Speaker A: This is Scott Becker with a special combined episode of the Becker's Healthcare Podcast and the Becker Business and Private Equity Podcast. I'm thrilled today to feature Holly Buckley. How he's the chair of the McGuire Woods Healthcare Department and has spent a ton of time over the last decade at the intersection of healthcare systems, working with healthcare systems and also working with physician practice transactions and with private equity funds and invest in healthcare. A fascinating world. We're going to talk today about the state, sort of physician practice acquisitions and more. Holly, uh, let me tee us up by asking you, what's the current state of healthcare private equity funds investing in physician practice management companies? What are you seeing out there?

Speaker B: Yeah, so I would say the market is relatively busy. I wouldn't say it's back to where it was in kind of the 20, 20, 2021 kind of peak. Um, but it's really recalibrated and we're seeing good transaction volume for kind of good quality platforms. But we're also seeing kind of platforms that have really not done so well now trying to deal with, uh, kind of what to do with those assets and how to kind of move forward. Um, so it's really a mixed bag, but certainly seeing some good high quality deals in certain specialties. Um, I think investors are being a lot more selective in terms of what they're buying and I think there's big valuation disparity in terms of high quality versus less high quality assets.

Speaker A: And are there specialties that private equity funds remain excited about? And on the flip side, specialties that private equity funds and investors are less

Speaker B: excited about, I think for sure. I think that in terms of specialties that, uh, investors are interested in, it's got to be kind of a core thesis in terms of why. And some of those why's are around things like ancillary revenue, potential pair mix, uh, potential for alignment. It's not just about having a fragmented segment that could be consolidated. It really has to kind of have more of a why to it than that. And some of the specialties that fall into those categories are women's health, urology, MSK and orthopedics, cardiology, GI and even dental, which is kind of the, the original uh, PPM that just keeps on tracking. And I think uh, one other area I think that kind of creates attractiveness is the whole site of service, uh, differential. So where we can see um, uh, services moving from higher cost venues such as hospitals to outpatient or hospitals or outpatient even to patients home. That's another big driver of interest I think in terms of sectors that haven't been doing as well. Some of those could include primary care without a value based infrastructure or over consolidated platforms. We're not seeing as much activity for example in dermatology and then also uh, platforms where there's high Medicaid exposure, um, but not necessarily uh, super subspecialty specific.

Speaker A: Thank you very very much. What about interest rates, reimbursement rates? One big beautiful bill. How are these impacting people's thoughts on practice management acquisitions or not having a big impact?

Speaker B: I think certainly has an impact. I mean I think we're seeing a fair amount of reimbursement pressure. Ah, the fee schedule compression is accelerating. Um, and so I think that. And then similarly with interest rates, I mean higher cost of capital is making it so just straight up acquisition strategies or platforms built on just an aggressive acquisition strategy just don't work as well as they used to when capital was much cheaper. I think now there's much more focus on what can we do organically, um, and how can we really improve the platform through robust operations rather than just kind of how can we add as much to it as possible. So I think it, those, those factors have definitely fed into the trend of investors needing to be more selective and really focus on doing things very well as opposed to just let's buy something and add a lot more to it and make something much bigger and have that pan out.

Speaker A: Thank you. And where do you see like if you went back 30 years ago, the physician practice management business all but blew up. Now it seems like there's more sustainability at least in specialties where there's ancillary is good reimbursement. They're not overleveraging them. Any thoughts on what you see sort of looking ahead for physician practice acquisitions? Will it blow up, blow up? Or are you more bullish or cautious on health care private equity investing in physician practices going into 2027 and going forward?

Speaker B: I mean I don't think they can blow up and kind of dissipate in the same way as I understand they did 30 years ago when I was not practicing law. But um, I think that the reality is it's much too expensive to operate a high quality medical business today than it it was even adjusting for inflation. There's just so many more capital costs, A.I. costs. Um, and so I think the model of having well capitalized medical businesses is just, is critically important such that private equity investment in PPM can't just go away. I think it's more a matter of with increasing regulatory headwinds, the businesses just need to be done well and done in a careful and prudent way. But I think, you know, I think of Oregon as kind of an experiment where Oregon has really now said we really don't want private. They haven't said directly but through the legislative environment they've kind of uh, more or less made it very difficult for uh, private equity backed PMs to really grow in the state at this point. And I think what that's going to do is really uh, make it impactful from an access perspective for patients. And so I think if you take away PE backed PPM businesses, you know, on a, on a broader basis it's going to have a very negative impact on patients ability to receive high quality care. Ah, especially in, in geographies that are maybe more rural, the distance to hospitals and health systems and other providers is much greater. And so I think uh, I don't expect the model to blow up, I expect the model to prevail. But I think that there's going to be continued pressure on how these businesses are operated and the guardrails they need to have in place to ensure that clinicians are really driving the clinical operations of the business and the incentives are appropriate, aligned to kind of ensure that care is high quality and uh, and so forth. So yeah, I don't foresee a blow up, I just foresee continued scrutiny and the need for businesses to be operated carefully and prudently.

Speaker A: And when you talk to practices over the years the firm has done a ton of work both helping private equity sponsored platforms and private equity funds buy big practices and midsize practices. And then we've also worked a lot with large and small practices and medium size selling into platforms and private equity funds. Is there interest currently from practices and where do you see that and any advice for practices that are considering this type of effort?

Speaker B: I mean we definitely still see that. And I think my advice is always talk to the other physicians who have already joined the practice and not just the ones who the platform is giving you like Kind of seek out the, the practices that have already gone down this pathway and see what they wish they knew before they entered into the transaction and see if it's going to be a good cultural fit. Because I do think that in general there's going to be a big change. You're taking uh, an upfront payment to become part of something much greater, uh, from a size perspective and an operational perspective. And it needs to be the right thing for you. And if, if independence and autonomy and control are really the most important things to you, you may not get all that when you join a private equity backed platform, but there are a number of other things that you will likely get and those are kind of access to resources and potentially uh, a broader network of clinicians to work with to deliver care for your patients and um, a lot of administrative support and so forth. And so I think it's just really important to do your diligence ideally before you get to the letter of int stage to make sure that this is actually going to work for you and, and fit with your, your life goals and the goals of others within your practice, especially kind of the next generation that you've been building in and mentoring and make sure that they have a pathway to if uh, that's important to you. So really just kind of doing your diligence. And as with all things, there are multiple different flavors and uh, you want to make sure you pick the right one.

Speaker A: Thank you. And I couldn't agree with that more, but about there being multiple different flavors and really doing your care and diligence up front because this isn't something you really want. What are really your goals, your practice? Do you really want to partner with these people? Do you not want to partner at all? And so forth and so on. And what are you trying to get out of it? Is it just money to exit? Is it resources to get better? Is it something else that you're trying to do or you put yourself in a spot where you have to do a transaction? Uh, but what are you really trying to do in alignment internally in the practice is so important as well. Again, Holly Buckley is with us today, one of the most brilliant leaders I've had a chance to work with in my career. The leader of the McGuire Woods Healthcare uh, practice, uh, works a ton with large hospitals and health systems as well as uh, investors in healthcare. Holly, thank you so much for taking the time with us today. Thank you so much.

Speaker B: Thank you so much Scott. Really appreciate it.