Tenet Healthcare Corp to Spin Off Conifer Business
On July 24, 2019, before the market open, Tenet Healthcare Corp. (NYSE: THC) announced that the company has completed its strategic reviews process of its Conifer business, which was announced in December 2017, and has decided to pursue a tax-free spin-off of the business. Following the distribution of Conifer shares to THC shareholders, Conifer will be an independent publicly traded company. The transaction is expected to be completed by the end of 2Q 2021, and is subject to customary closing measures including assurance on the tax-free nature of the transaction to THC shareholders, enacting a services agreement between THC and Conifer, the effectiveness of filings with the SEC, and final THC Board approval, among others.
Tenet Healthcare Corp. is the owner and operator of general hospitals and related facilities in about 10 states within the US. As of March 31, 2019, the company operated 65 hospitals, 23 surgical hospitals, and approximately 470 outpatient centers throughout the United States. Additionally, the company operates a subsidiary, Conifer Health Solutions, which provides “healthcare business process services in the areas of hospital and physician revenue cycle management and value-based care solutions”– essentially debt collection services via software that registers patients, authorizes insurance, and billing patients and payers for care.
THC currently operates under three reportable segments: Hospital Operations and Other generated $15.3 billion in revenue and $1.4 billion in adjusted EBITDA in 2018 (representing 80.9% and 55.1%, respectively, of consolidated revenue and EBITDA), Ambulatory Care generated, $2.1 billion in revenue and $792 million in adjusted EBITDA (11.0% and 30.9% of consolidated, respectively), and Conifer, which contributed $1.5 billion in revenue and $357 million in adjusted EBITDA in 2018 (8.1% and 13.9% of consolidated, respectively). It should be noted that Catholic Health Initiatives currently owns 23.8% of Conifer.
The previously announced strategic review and subsequent spin-off announcement are part of THC’s larger restructuring plan. Announced in December 2017, the plan initially outlined cost-savings from $150 million to $250 million, which were to be realized by the end of 2018. At the time of the announcement, and throughout 2018, it was suggested that THC was close to selling the Conifer business, as it was posited that hospitals that currently outsource the revenue cycle management process would look to improve the process by bringing inhouse a software solution. However the revenue growth at Conifer has been fairly stagnant, 1.7% growth in 2017 and a decline of 4.0% in 2018, which likely resulted in lower than anticipated bids for the business. Management states that three companies ultimately did bid but the terms of the offers included equity considerations versus an all cash bid, that was not what the company was expecting.
In late 2018 THC management commented that the sale process was being complicated by the relationship between Conifer and THC, as Conifer serves Tenet’s hospital system. Media reports throughout 2018 suggested that interested suitors for Conifer included UnitedHealth Group Inc. (NYSE: UNH), and the business could be valued at around $2 billion, according to the Wall Street Journal.
PRELIMINARY VALUATION
In approaching valuation, we begin with 2018 revenue for the three segments, and recent growth and margin trends. Conifer revenue declined 4% in 2018, and through 1Q 2019 the segment’s revenue declined 13.6%. Despite revenue declines, segment EBITDA margins increased 560 basis points in 2018 to 23.3% (margins were 24.3% and 23.6% in 1Q 2018 and 1Q 2019). Assuming a 10% decline in revenue in 2019, and a further decline of 5% in 2020, as a standalone company Conifer would generate $1.3 billion in revenue. Assuming margin improvements, which should arise from further cost cutting, primarily offshoring some of the business, are offset by increased corporate costs for being a standalone company, it appears reasonable to assume 2002 EBITDA margins of 21%, resulting in EBITDA of $275 million. Given Conifer’s IT focus, peers to the company would include companies that provide systems such as clinical infrastructure and workforce automation solutions such as Covetrus Inc. (NASDAQ: CVET), Allscripts Healthcare Solutions Inc. (NASDAQ: MDRX), Inovalon Holdings Inc. (NASDAQ: INOV), NextGen Healthcare Inc. (NASDAQ: NXGN), and Omnicell Inc. (NASDAQ: OMCL), which currently trade on average at ~12.0x the consensus 2020 EBITDA estimate. Applying the peer average multiple, Conifer as a standalone entity would have an enterprise value of $3.3 billion.
Following the separation of Conifer, THC would have generated $17.4 billion in revenue and EBITDA of $2.2 billion. Assuming current revenue trend from 1Q 2019 persist through the full year, before improving to flat year-over-year in 2020, the post-spin company would generate $16.9 billion in sales in 2020. Assuming margins of 13%, consisting of 10% for General Hospital and 38% for Ambulatory Care, THC would earn $2.3 billion in EBITDA in 2020. Shares of THC currently trade at 7.2x the consensus EBITDA estimate while competitors such as HCA Healthcare Inc. (NYSE: HCA), Universal Health Services Inc. (NYSE: UHS), Quorum Health Corp. (NYSE: QHC), and Community Health Systems (NYSE: CYH) trade on average at 8.3x (with a range of 7.5x – 8.9x). Assuming shares of post-spin THC trade at the low end of the peer group average at 7.5x, post-spin Tenet would have an enterprise value of $17.1 billion.
Based on the above preliminary valuation exercises, on a sum-of-the-parts basis, shares of THC can be fairly valued at $27 per share when incorporating current net debt of $17.3 billion and 103.1 million shares outstanding. Shares of THC closed last night at $17.57, and are currently trading at $18.04, suggesting that the separation could unlock significant shareholder value.