NEW YORK UNIVERSITYROBERT F. WAGNER GRADUATE SCHOOL OF PUBLIC SERVICE

THE BUSINESS OF HEALTHCARE – HPAM-GP 2848-001

COURSE SYLLABUS – FALL 2017As of September 29, 2017

Subject to Change

Faculty: James S. Vaughanjv59@nyu.eduCell # 646-285-2386

Office hours: Please feel free to email me at any time, and we will set up a mutually convenient time and place to meet or talk on the phone.

Meeting Days/Times: Tuesdays4:55 – 6:35 PMClasses commence Tuesday September 5, 2017

Class Location: Meyer 261

Pre-requisites: Financial Management CORE-GP 1021Intro to Health Policy and Management HPAM-GP 1830Health Care Management I HPAM-GP 4833Understand financial statement analysisUnderstand time value of money and discounted cash flow

Course Title: The Business of Healthcare

Course Description

Summary Course Description

The overall goal of this course is to develop students’ skills in the financial analysis of key strategies for today’s health care organizations. To achieve this goal, we will (1) explore the drivers of value creation, valuation approaches, and differences in capital structures between not-for-profit and for-profit healthcare providers; (2) examine horizontal consolidation among not-for-profit and for-profit providers (mergers and acquisitions, joint ventures, and the like), and vertical consolidation between providers and payers; and (3) consider sources of financing, including

1

private and public equity markets, taxable and tax-exempt financing sources, and the important roles played by real estate investment trusts and entities like the Federal Housing Agency. We will focus on a range of healthcare services, including acute care, post-acute care and senior health and housing, ambulatory surgery centers, behavioral health, and medical insurance companies.

Students participating in the course should have a basic understanding of nonprofit and for-profit financial statement analysis and an understanding of the time value of money and discounted cash flow analysis.

Course Description

Wagner students know well that the U.S. healthcare industry is huge and extremely complex, with national health expenditures of about $3 trillion per year, which approximates 18% of GDP and is growing, despite the still-controversial 2010 Patient Protection and Affordable Care Act (often called “ACA” or “Obamacare”) and the recently failed efforts by the Republican-controlled Congress.

While the goals of the ACA and the healthcare industry are to improve the health of populations, enhance the experiences and outcomes of patients, and lower per capita costs, the actual business of healthcare is generating positive cash flow. Paraphrasing what a leader of The Daughters of Charity once amusingly (but seriously) said, “There can be no mission without a positive financial margin.”

From the perspective of virtually any provider of healthcare services (and any business for that matter), cash is required to build and equip facilities, pay staff and operating expenses, service debt, successfully maintain and modify existing services, and grow and market new services as the medical services industry continues to evolve.

Health insurance companies (payers) require cash to enroll members and pay for contracted medical costs and other provided services, staffs, debt service, and other operational expenses.

For not-for-profit organizations, cash and capital generation most typically depends on positive operating earnings, tax-exempt and taxable borrowings, and charitable contributions. Not-for-profit organizations can also generate cash through the “monetization” or sale of existing assets that other businesses with greater economies of scale can operate more efficiently.

For-profit organizations most typically generate cash and capital from positive operating earnings, taxable borrowings, and the sale of equity ownership, the latter of which may produce more flexibility for for-profit managers than is available to their not-for-profit counterparts. Asset monetization is also available to for-profit organizations.

A Nashville, Tennessee (Nashville is ground zero for for-profit healthcare services companies) CEO of several successful health care services companies once said, again

2

paraphrasing, “Healthcare providers are a bunch of bucket movers. They move their buckets under the payers’ [Medicare, Medicaid, and commercial insurance] spigots to capture the gush of money flowing out.”

This point of view underscores the incredible importance and influence that our public, tax-supported Medicare and Medicaid payers have on the healthcare industry. For example, Medicare, Medicaid and other public payers, like Veterans Affairs, together account for about 40% of total national healthcare expenditures. Medicaid and commercial payer reimbursement (payments) and out-of-pocket consumer payments to providers of all stripes, including physicians, are predominantly keyed off Medicare rates.

The course is emphatically not a lecture course. With heavy student class participation, it will explore various healthcare services subsectors, such as acute care, post-acute care and senior health and housing, ambulatory surgery centers, behavioral health, and medical insurance companies. Within the subsectors discussed, we will explore the drivers of value creation, valuation approaches, differences in capital structures between not-for-profit and for-profit healthcare providers, consolidation among and between not-for-profit and for-profit providers (mergers and acquisitions, joint venture partnering, and the like), and convergence between providers and payers. The course will also consider sources of financing, including the private and public equity markets, taxable and tax-exempt financing sources, and, time permitting, the important roles played by real estate investment trusts and entities like the Federal Housing Agency.

Time permitting, at the end of each session, we will open the floor for discussion of current noteworthy healthcare related transactions and events, articles, or studies that have been written about or discussed in the media during the previous week or so. Students will be expected to come prepared to discuss a relevant topic of their choosing each week, although it is likely that only a few students in a given class session will be called upon to initiate a discussion.

Newsletters that you might want to access and have pushed to your email inboxes are suggested below in the READINGS section.

Upon completion of the course, students will have acquired practical C-suite-related and governance knowledge and gain an appreciation for the many drivers of value and valuation among healthcare services companies.

READINGS

Students are expected to be prepared for class discussions and participate fully. This is not a lecture course. Students will be encouraged to share their own experiences relevant to the topics covered in the class sessions.

Readings associated with a given class session will be listed under the respective sessions. (See below.) A discussion guide will be distributed several days before each

3

class session. The discussion guides will highlight the class objectives and specific portions of the readings to pay attention to.

There will not be a textbook. We will rely on industry, Wall Street, and government publications; periodicals; peer reviewed articles; and articles written by practitioners and consulting and research firms. PDFs of most of the articles relating to a specific Class Week will be available and parked in the respective Class Week folders in the NYU Classes section of the NYU website. Otherwise, a URL will be provided, when a PDF is unavailable.

Selected daily and weekly newsletters that students may wish to source and have pushed to their email inboxes include (in no order):

Kaiser Health News – Morning Brief (and other available Kaiser newsletters) see http://kaiserhealthnews.org and click on email signup. This is a very valuable curated newsletter.

Health Affairs Today – subscribe to this daily newsletter about Health Affairs topics, papers, blogs at http://content.healthaffairs.org/site/subscriptions/etoc.xhtml. See what the healthcare wonks are writing and talking about.

Health Leaders Media Daily News (and other available HLM newsletters) see www.healthleadersmedia.com and click on email sign up

Deloitte health and life sciences newsletters see https://subscriptions.deloitte.com/app/index.html#/optin?sub=a0C300000021TZU&aoi=a0930000003EafEAAS%2Ba0930000003EafWAAS%2Ba0930000003EafXAAS%2Ba0930000003EafeAAC&userselect=1

The Commonwealth Fund see www.commonwealthfund.org click on e-Alerts and Newsletter Sign-up

Becker’s Hospital Review (and other Becker’s segment newsletters) see www.beckershospitalreview.com. This is another very valuable curated newsletter.

The Advisory Board Company, Daily Briefing on Twitter, see www.advisory.com and @daily_briefing

The Incidental Economist, follow on Twitter or have emails pushed to you, see http://theincidentaleconomist.com/wordpress/. Their articles and commentary often appear in The New York Times’ Upshot column.

4

Agency for Healthcare Research and Quality, periodic email summaries and links, sign up at https://subscriptions.ahrq.gov/accounts/USAHRQ/subscriber/new

Modern Healthcare newsletters, see http://www.modernhealthcare.com/section/about-us and click on “Modern Healthcare A. M.” to register for a morning newsletter, for example.

Cain Brothers’ Industry Insights, weekly newsletter, interesting especially for first-of-the-month statistical M&A and valuation recaps of for-profit healthcare services companies; register at http://www.cainbrothers.com/research/login.cfm

The Wall Street Journal, New York Times, and Washington Post all have good reporters covering the healthcare industry, and they are well worth reading.

COURSE REQUIREMENTS

Bio: Prior to the first class session please submit a brief bio-sketch that describes your education and work experience background, general interests, and your expectations for this course. One-half page should be sufficient. The bio-sketch is due no later than 5 PM the day before our first class, or Monday September 4, 2017, in an email to me at jv59@nyu.edu. First Class Session is Tuesday September 5.

There are three basic requirements for the course that emphasize writing and speaking skills as well as an understanding of the course content:

Class Participation – 33%:

Your active participation is critical. This is not intended to be a lecture course. Productive discussion depends on students reading the relevant materials before coming to class and preparing discussion topics and questions to be explored.

Note…Starting with Class Session 2 there is a writing assignment for each class relating to that Class Session’s readings (except for Class Session 9, when we will discuss the Ascension-HCA paper and Sessions 12 and 13, when we do the pitch-a-thon). By 5:00 PM on the day before each class, you will be expected to submit a 300-500-word (max, that’s less than one page) summary of one of that class session’s listed readings. It will be your choice of what article to summarize. The objectives of these exercises are to hone writing skills (selective feedback will be given), and to ensure that articles are actually read and robust discussions are held. Submit your summary to me at jv59@nyu.edu no later than 5 PM on the Monday before the respective Class Sessions.

Time permitting, as mentioned above, at the end of each class session we will open the floor for a discussion of noteworthy developments, news articles, and the like that have occurred during the previous week or two. You are expected to come to class with one or two items to be discussed. Expect to be called upon.

5

You are expected to attend all classes. I forget who said it, but 80% of success is simply showing up, so now is the time to develop good habits. If you are unable to attend a class, I expect you to email me with an explanation prior to missing class.

During class sessions, if you need to consult your devices other than for taking notes, be good at multitasking, because you may be called on.

Written Analysis – 33%:

You will be asked to compare and contrast Ascension, currently the largest not-for-profit acute care provider in the U.S., and HCA, the largest for-profit acute care provider in the U.S., in a written analysis. The Tuesday October 31 Class 9 session will be used to discuss your analyses and conclusions. The written analysis is due on Friday October 27.

Approximately two to three weeks prior to the paper’s due date, you are welcome and encouraged to submit a draft to me. I will take a “no fault, no judgment” look at the draft paper and give you feedback in writing over a cup of coffee and/or in a phone call at a mutually convenient time. My objective in reviewing drafts is to give constructive criticism so that the final papers turned in are as good as possible.

Oral Pitch – 33%:

Students will each choose either a not-for-profit or for-profit health care organization and make an oral presentation (i.e., the “pitch”) to the class focused on why an institutional investor should purchase the tax-exempt debt in the case of the selected not-for-profit organization or purchase equity in the case of the selected for-profit entity. Power Point materials can be used, and the time limit for the oral presentation will be about 15 minutes. Presentation times will need to take into account the number of students in the class. The rationale for having students present an oral pitch is that oral communication and content skills are extremely important in a career. The pitch will afford an opportunity to work on skills in a safe, friendly atmosphere, and students in the class will continue to learn from each other based on the organizations selected for the pitches. (This is not intended to be Wagner School’s Shark Tank, which is aired on ABC, http://abc.go.com/shows/shark-tank.)

NYU/Wagner grading policy: http://wagner.nyu.edu/current/policies/grading.php

NYU/Wagner academic integrity policy: http://wagner.nyu.edu/current /policies/

COURSE SCHEDULE AND ASSIGNMENTS

Class 1 – September 5 Class organization, student introductions, and logistics

6

Overview of healthcare services sector (I will likely serve up some slides during class to set the stage…subsectors and valuations…Healthcare Services 101 information…what’s not-for-profit and what’s for-profit)

Valuation and credit analysis lingo and exercise (time permitting) Current noteworthy health care business topic(s) discussion; topics suggested by

students (time permitting, but be prepared)

Readings

Read B. Ritholtz, “Many metrics can be used to value markets. Which should you trust?,” The Washington Post, 3/7/15. PDF in Weekly Folder. Note “enterprise value” concept. You will fail the course, if you don’t understand EBITDA and enterprise value.

Become familiar with, download, and bring to class o The selected pages from the 5/12/16 NYU Hospitals Center Revenue

Bonds Official Statement. PDF in Weekly Folder.o The Selected pages from Tenet Healthcare Corporation’s Securities and

Exchange Form 10-K. PDF in Weekly Folder.o The selected pages from the 4/25/17 Kaiser Permanente, Taxable Bonds

Prospectus. PDF in Weekly Folder. Review Moody’s Healthcare Ratio Definitions. One-page PDF in Weekly Folder.

Please print this page and bring it to class.o Pay attention to

Cash on Hand (Days) Debt to Capitalization Cash to Debt Operating Cash Flow Margin (%) Operating Margin (%) Total Comprehensive Debt

Note Adjusted Admissions definition, PDF in Weekly Folder.

In case you’re interested (not required):

D. Blumenthal, et al, “Medicare at 50 – Origins and Evolution,” The New England Journal of Medicine, available at http://www.nejm.org/doi/full/10.1056/NEJMhpr1411701

D. Blumenthal, et al, “Medicare at 50 – Moving Forward,” The New England Journal of Medicine, available at http://www.nejm.org/doi/full/10.1056/NEJMhpr1414856

Kaiser Family Foundation, “An Overview of Medicare,” April 2016, available at http://files.kff.org/attachment/issue-brief-an-overview-of-medicare. PDF in Weekly Folder.

Kaiser Family Foundation, “Medicaid Pocket Primer,” 1/3/2017. PDF in Weekly Folder.

A. Frakt, “Hospitals Are Wrong About Shifting Costs to Private Insurers,” The New York Times, 3/23/2015, available at

7

http://www.nytimes.com/2015/03/24/upshot/why-hospitals-are-wrong-about-shifting-costs-to-private-insurers.html?ref=us&abt=0002&abg=1

“New York University, NY- New Issue-Moody’s assigns Aa3 to New York University’s Series 2016A & B, outlook positive,” Moody’s, 5/20/2016. PDF in Weekly Folder.

“NYU Hospitals Center, NY, New Issue: Moody’s Changes Outlook to Positive and Assigns A3 to NYU Hospitals Center’s (NY) Ser. 2016A,” Moody’s 5/2/2016. PDF in Weekly Folder.

Note, if you like, page 20 for organization diagram of NYU Hospitals Center in the 5/12/2016 $157.3 million NYU Hospitals Center official statement (Dormitory Authority…issuer). PDF in Weekly Folder.

CMS Glossary of Terms, Health Care Financing Review, 2007. PDF in Weekly Folder.

Abbreviations. PDF in Weekly Folder. MedPac, “Health Care Spending and the Medicare Program,” June 2017. Tons of

information about the health care service sectors. PDF in Weekly Folder.

Class Objectives: Highlight various healthcare services sectors and appreciate that acute care is

mostly not-for-profit (although, in my opinion not-for-profit acute care providers behave like for-profits) and other health care services sectors have heavy-to-dominant for-profit participation

Refresh understanding of lingo, valuation and credit analysis metrics Emphasize importance of cash flow and EBITDA as an often used common

denominator Understand “enterprise value” concept

Class 2 – September 12 Reprise Class 1 concepts regarding capital structure, EBITDA, valuation, days

cash on hand, etc. General healthcare themes General macro topics relating to costs and “value” Current noteworthy health care business topic(s) discussion; topics suggested by

students

Readings […placeholder..…slides for class…macro information review] D. Michelson, “The #1 thing you need to know from the 2017 JP Morgan

Healthcare Conference: Follow the money,” Becker’s Hospital Review, 1/12/2017. A quick, easy read. PDF in Weekly Folder.

Read U. Reinhardt, “Sense and Nonsense in Defining ‘Value’,” on pages 77-82 in Altarum Institute, Symposium on Sustainable U.S. Health Spending: the Quest for Value, Monograph 2/12/2015 available at http://altarum.org/sites/default/files/uploaded-related-files/SS14_Monograph_021215_0.pdf PDF in Weekly Folder

8

Read S.Zuvekas and J Cohen, “Fee-for-Service, While Much Maligned, Remains The Dominant Payment Method for Physician Visits,” Health Affairs, 35, No.3 (2016). PDF in Weekly Folder.

Skim “Reducing Waste in Health Care,” Health Policy Brief, Health Affairs, 12/13/2012, available at http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82 . PDF in Weekly Folder.

Skim D. Newman, et al, “Prices For Common Medical Services Vary Substantially Among The Commercially Insured,” Health Affairs, 35, No. 5, 2016. PDF in Weekly Folder.

D. Blumenthal, “The Promise and Pitfalls of Bundled Payments,” The Commonwealth Fund, 9/7/2016. PDF in Weekly Folder.

F. de Brantes, “Medicare’s Bundled Payment Programs Suffer From Fatal Flaws, But There Is A Logical Alternative,” Health Affairs Blog, 5/9/2017. PDF in Weekly Folder.

In case you’re interested:

Moody’s, “Cleveland Clinic Health System Obligated Group, OH,” Credit Opinion, 7/26/2017. PDF in Weekly Folder.

Cleveland Clinic, Official Statement/Prospectus, $988 million tax-exempt and taxable bonds. PDF in Weekly Folder.

Executive Summary of D. Farrell et al, “Accounting for the Cost of U.S. Health Care: A New Look at Why Americans Spend More,” McKinsey Global Institute, 12/2008, available at http://www.mckinsey.com/insights/health_systems_and_services/accounting_for_the_cost_of_us_health_care PDF in Weekly Folder.

M. Chernew et al, “Reconciling Prevention and Value In the Health Care System,” Health Affairs Blog, 3/2015 available at http://healthaffairs.org/blog/2015/03/11/reconciling-prevention-and-value-in-the-health-care-system/

M. Allen, “How Many Die From Medical Mistakes in U.S. Hospitals?,” ProPublica, 9/2013, available at http://www.propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals

M. Makary and M. Dankel, “Medical error– the third leading cause of death in the US,” BMJ, 5/3/2016. PDF in Weekly Folder.

Carroll, A., “Death by Medical Error: Adding Context to Scary Headlines,” The Incidental Economist, 8/17/2016. PDF in Weekly Folder.

S. Keehan, et al, “National Health Expenditure Projections, 2016-2025: Price Increases, Aging Push Sector to 20 Percent of Economy,” Health Affairs 36, No.3, 3/2017. PDF in Weekly Folder.

Dean of Wagner School S. Glied, et al, “Where the Mooney Goes: The Evolving Expenses of The US Health Care System,” Health Affairs 35, no.7 (2016):1197-1203. PDF in Weekly Folder.

9

J. Raskin, “Health Care Facilities Weekly Vol. 5, Issue 30,” Barclays, 7/28/2016 for comments on new Cardiac and Hip Episode (bundled) Payment Models, pages 2-6. PDF in Weekly Folder.

J. Raskin, “Is the Migration Toward Value Based Reimbursement Progressing?,” Barclays, 8-8-2016. PDF in Weekly Folder.

J. Creswell, et al, “The Company Behind Many Surprise Emergency Room Bills, The New York Times, 7/24/2017. PDF in Weekly Folder.

Class Objectives:

Review cost and spending trends Concept of “value” (not “enterprise value”) can be elusive Understand there is lots of room to improve healthcare delivery in U.S.

Class 3 – September 19 Not-for-Profit Acute Care Providers Current noteworthy healthcare business topic(s); topics suggested by students

Readings Medicare Payment Advisory Commission (“MedPac”) Report to Congress, March

2017 available at http://www.medpac.gov/docs/default-source/reports/mar17_entirereport224610adfa9c665e80adff00009edf9c.pdf?sfvrsn=0 and PDF in Weekly Folder. MedPac provides a treasure trove of healthcare business data in its various reports to Congress. Simply note the Table of Contents and scope of this report. We will refer to it from time to time, and you should be aware of its contents. Some of the slides this week use tables and figures from Chapter 3, fyi.

“Top 30 Largest Hospital Systems”. List includes largest nonprofits and largest for-profits. PDF in Weekly Folder.

Moody’s “[FY 2016] Medians – Key financial metrics underperform as pressures mount,” 8/21/2017. PDF in Weekly Folder. Note differences in key ratios among the different rating categories.

Skim Moody’s “Preliminary 2016 Medians Skew Lower…” 5/16/17. PDF in Weekly Folder.

Skim Moody’s, “Medians – AMC Universities Maintain Stability Through Strong Brands, Large Size, and Diverse Operations,” 7/25/2016. PDF in Weekly Folder.

Skim Moody’s “[FY 2015] Medians – Children’s Hospitals’ Strong Demand Drives Superior Financial Strength,” 11/21/2016. PDF in Weekly Folder.

G. Melnick, “Health Affairs Study On Hospital Profitability Gives Us Some Important Factors To Watch Going Forward,” Health Affairs Blog, 6/21/16. PDF in Weekly Folder. The author comments further on the Bai article (below in the “in case” readings).

Note for future deliverable: Ascension Prospectus of May 15, 2017, $225 million taxable debt

10

Ascension Official Statements of April 2016:o $700 million taxable debt 4/25/16o $1.18 billion tax-exempt debt 4/27/16o See separate, audited consolidated financial statements FY 6/30/2016 and

related “Management’s Discussion…” document. FY 6/30/17 will be placed in the Weekly Folder when available.

o PDFs in Weekly Folder. Ascension FY 6/30/2017

o MD&Ao Consolidated financial statementso Consolidated statistical information

Take a minute to become familiar with www.emma.msrb.org and https://www.munios.com/, browse/search for Ascension Health and Ascension Health Alliance debt. Ditto, the NYU Hospitals Center OS.

D. Barkholz, “Ascension sells Wisconsin hospital, vows to in-source all lab work,” Modern Healthcare, 1-10-17. PDF in Weekly Folder.

D. Barkholz, “Accretive Health changes performance, then name to R1,” Modern Healthcare, 1/5/17. PDF in Weekly Folder.

Ascension New Associate Orientation, October 2015, slides in Weekly Folder. Note, however, that this document is two years out of date, so you cannot depend upon it for accurate current numbers.

Ascension Article, “How Collaboration Becomes Partnership,” PDF in Weekly Folder.

Browse www.Ascension.org Becker’s, CEO interview, 7-19-17. PDF in Weekly Folder. D. Barkholz, “Ascension to acquire Presence Health,” Modern Healthcare,

8/22/2017. PDF in Weekly Folder.

In case you’re interested: E. Rosenthal, “Those Indecipherable Medical Bills? They’re One Reason Health

Care Costs so Much,” NYTimes, 5/19/17. PDF in Weekly Folder. Moody’s Not-for-profit Rating Methodology, 11/23/15, PDF available in Weekly

Folder. “Inside Rating Committee: Top Six Ratios for Rating Not-for-Profit Hospitals and

Health Systems,” Moody’s, 7/2005. PDF in Weekly Folder. “Not-for-Profit Hospitals: The Importance of Cash,” Moody’s, 3/2006. PDF in

Weekly Folder. “US Academic Medical Centers: Complex, Successful Organizations Driven by

Integrated University-Hospital Strategies,” Moody’s, 11/2012. PDF in Weekly Folder.

Moody’s Academic Medical Center 2014 Medians, “AMC Hospitals Benefit from Operational Stability and Stronger Balance Sheets,” 10/2015. PDF in Weekly Folder.

Moody’s, Mayo Clinic, MN,” Credit Opinion, 8/16/2017. PDF in Weekly Folder.

11

M. Arrick, “Kaiser Foundation Hospitals (Kaiser Permanente) California: System,” (rating analysis) Standard & Poors Global Ratings, 4/10/17. PDF in Weekly Folder.

G. Bai and G. Anderson, “A More Detailed Understanding of Factors Associated With Hospital Profitability,” Health Affairs 35, No. 5 (2016). PDF in Weekly Folder.

“Nonprofit Hospitals’ Community Benefit Requirements. Under the Affordable Care Act, many nonprofit hospitals must meet new requirements to retain their tax-exempt status,” Health Affairs, Health Policy Brief 2/25/2016. PDF in Weekly Folder.

P. Betbeze, “The Academic Medical Center Model Is Broken. Here’s How to Fix it.” Healthleadersmedia.com, 8/10/2017. PDF will be loaded into Weekly Folder prior to class. Discussion of Banner UMC Phoenix.

Class Objectives: Discuss acute care provider taxonomy Identify and become conversant with financial ratios and analysis that point to

strong and weak providers, key role of rating agencies Highlight profitability factors

Class 4 – September 26 For-Profit Acute Care Providers Current noteworthy healthcare business topic(s); topics suggested by students

Readings “Top 30 Largest Hospital Systems”. List includes 20 largest nonprofits and 10

largest for-profits. PDF in Weekly Folder. J. Raskin et al, “US Healthcare Facilities 2017 Outlook: Looking for Stability in

Light of Known Unknowns,” 1/5/2017. Note Figure 1 page 6: EV/EBITDA statistics. Read Executive Summary pages 7-12. Note, if you like, individual company comments. There is lots of good general information about the acute care sector in this document. PDF in Weekly Folder.

See Moody’s ratings of for-profit hospital management companies: “Appendix from Moody’s For-Profit Acute Care Outlook 3-30-2017.” Note the very low-to-junk bond ratings (i.e., non-investment grade) for the very successful for-profit acute care hospital operators. PDF in Weekly Folder.

J. Raskin, “1Q17 Review: Competition in Outpatient Services,” Barclays, 5/19/2017. PDF in Weekly Folder. See Figure 44 on page 28 for for-profit company debt levels.

Read the conclusion G. Bai and G. Anderson, “Extreme Markup: The Fifty US Hospitals With The Highest Charge-To-Cost Ratios,” Health Affairs, 2015. PDF in Weekly Folder.

Read the conclusion J. Rau, “Doctor-Owned Hospitals Are Not Cherry-Picking Patients, Study Finds,” Kaiser Health News, 9/3/15 available at http://khn.org/news/doctor-owned-hospitals-are-not-cherry-picking-patients-study-finds/ PDF in Weekly Folder.

12

Read the conclusion K. Joynt, et al, “Association Between Hospital Conversions to For-Profit Status and Clinical and Economic Outcomes,” JAMA, 10/22-29/2014. PDF in Weekly Folder.

Read C. Cheney, “Is the distinction beginning to blur between for-profit and nonprofit healthcare organizations?,” HealthLeaders Magazine, 3/2016 available at http://www.healthleadersmagazine-digital.com/healthleadersmagazine/march_2016?pg=12#pg12 This is quick, light reading. Good food for thought. PDF in Weekly Folder.

J. Bartlett, “Steward Health Care announces national plan, $1.25 billion investment,” Boston Business Journal, 9/26/16. Note private equity owner Cerberus Capital Management. PDF in Weekly Folder.

“Steward Health Care and IASIS Healthcare Announce Definitive Agreement to Merge; Steward to Become Largest Privately-Owned For-Profit Hospital Operator in the U.S.,” Steward press release, 5/19/17. Note Medical Properties Trust involvement. PDF in Weekly Folder.

In case you’re interested: M. Evans, “Community Health Systems Retrenches,” The Wall Street Journal,

10/10/16. PDF in Weekly Folder. “Ventas Issues Secured Debt Financing Commitment for Ardent Health Services

to Merge with LHP Hospital Group, Inc,” Ventas press release, 10/6/16. PDF in Weekly Folder.

“Ardent Health Services completes acquisition of LHP Hospital Group,” Ardent press release, 3/13/17. PDF in Weekly Folder.

C. Rigg, “Tenet: Thoughts on Strategic Alternatives,” Deutsche Bank, 9/15/17. PDF in Weekly File.

J. Raskin, “You’re Raskin For It! – Vol. 6, Issue 27” Barclays, 7-6-2-17. First half for-profit healthcare facilities recap. It’s short.

J. Raskin, “Medical Properties Trust Inc. – Further Shift to US Acute Care Attractive w/ Solid Assets from Iasis,” Barclays, 5/22/2017. PDF in Weekly Folder.

D. Englander, “Medical Properties Trust Gets a Good Diagnosis,” Barron’s, 3/11/2017. PDF in Weekly Folder. Article contains comments on Adeptus Health’s financial difficulties (& later bankruptcy). Adeptus operates free-standing ERs.

H. Meyer, “For-profit hospitals blaze separate path to efficiency, quality,” Modern Healthcare, 5/28/2016. PDF in Weekly Folder.

R. Rittenmeyer, “Tenet Healthcare CEO to Step Down as Activist Flare-Up Continues,” Wall Street Journal, 8/31/2017. PDF in Weekly Folder.

A. Thomson, “KKR Extends Health Flurry with $2.4 Billion Ambulance Deal,” Beckers Hospital Review, 8/8/2017. PDF in Weekly Folder.

Class Objectives: Highlight differences between not-for-profit and for-profit acute care providers,

including operating performance, capital structure, and how cash flow is spent and/or distributed

13

Role of private and public equity markets

Note for Future Reference Regarding HCA (for future writing assignment) An overview of HCA, somewhat dated, but useful, available at

http://marketrealist.com/2014/12/unraveling-history-hca-holdings/ HCA Holdings, Inc. Annual Report and Form 10-K for the period ending

12/31/2016. Note “Business Description” section and financial statements. Income statement and balance sheet on pages F-4 and -5 at the end of the document. PDF in Weekly Folder.

Browse www.hcahealthcare.com HCA prospectus filed 6/12/2017 $1.5 billion 5.50% notes due 2047. PDF in

Weekly Folder. See pages S-10 and -11 for Income Statement Data and EBITDA; Capitalization on page s-25, if you like.

Moody’s “Rates HCA’s secured notes offering Ba1.” PDF in Weekly Folder. J. Raskin, “HCA Holdings Inc. Positioned For the Future of Healthcare,” Barclays

8/17/2016. PDF in Weekly Folder. J. Raskin,” HCA Holdings 1Q17 10-Q Report Review,” 5/19/2017. PDF in

Weekly Folder. “HCA to Purchase Memorial Union MC for $710 million,” Becker’s Hospital

Review, 4/20/17. PDF in Weekly Folder HCA to add 7 hospitals, looks to M&A for more growth,” Becker’s Hospital

Review, 5/2/2017. PDF in Weekly Folder. "HCA acquires second hospital from CHS in 2 weeks,” Becker’s Hospital Review,

7/24/17. PDF in Weekly Folder. A. Ellison, “Tenet sells 3 Texas hospitals to HCA,” Becker’s Hospital Review,

8/1/2017. PDF in Weekly Folder.

Class 5 – October 3 Acute Care Provider Consolidation, including deal structures Governance considerations Antitrust considerations Current noteworthy healthcare business topic(s); topics suggested by students

Readings

Skim, but note Table 10-5, page 307, MedPac , “Chapter 10, Provider Consolidation: The role of Medicare Policy,” Report to Congress June 2017. PDF in Weekly Folder

See Health Care Advisory Board’s “The Field Guide to Hospital Partnership and Affiliation Models.” PDF in Weekly Folder. This is a helpful one-page graphic that will give you a brief overview about various kinds of combinations.

Read/skim parts of Cain Brothers, “What’s the Deal? Focus on Hospital M&A and Thoughts for Not-for-Profit Trustees,” Strategies in Capital Finance, Vol. 67, Fall 2011. Despite its age, this monograph is still very applicable in today’s world. Very distinguished author, too. PDF in the Weekly Folder.

14

-Note Horwitz’s comments at the bottom of page 3 and top of page 4 regarding FP and NFP behavior after a merger, acquisition, or consolidation; what are the apparent differences between FPs, NFPs, and government-owned hospitals?-Have a brief look at Figure 3 on page 4 and think about your own conclusions about the data presented; do you agree that the right partner, whether FP or NFP, can continue missions successfully?-In the “Perspectives” section, note Cutler’s two choices (page 7) for financially challenged providers and his analysis of admissions and profitability in various markets.-Spend a little bit of time on the “Alternative Transactions Structures” section on pages 10-12. We’ll discuss these in class. Our dreaded “enterprise value” reenters the picture, so you should think about what’s going on in the various deal structures described in the monograph.-Understand what community foundations are and how they are formed through the consolidation process, page 13.-Breeze through “Sell-Side” and “Buy-Side comments on pages 14 and 15; wear your CEO and CFO hats, when you consider these brief sections.

Skim “Joined at the Hip: Not-for-Profit Hospitals Pursue Virtual Mergers,” Moody’s, 8/2013. PDF in Weekly Folder. Spend a couple of minutes on Figure 1 on page 4.

Skim “Hospitals Look to Nontraditional Partnerships to Diversify Operations,” Moody’s, 5/16/2016. PDF in Weekly Folder. This is only four pages, an easy read, and Exhibits 1 & 2 are informative.

In case you’re interested: P. Betbeze, “MD Anderson’s Unusual Partnership Could Cut Care Costs,”

HealthLeaders Media, 8/31/17. PDF in Weekly Folder. A. Fowler, et al, “Corporate Investors Increased Common Ownership in Hospitals

and Postacute Care and Hospice Sectors,” Health Affairs, 9/2017. PDF in Weekly Folder.

D. Barkholz, “Dignity and Catholic Health Initiatives are in merger talks,” Modern Healthcare, 10/24/2016. PDF in Weekly Folder.

A. Rege, “Ardent Health Services completes acquisition of LHP Hospital Group, Becker’s, 3/14/2017. PDF in Weekly Folder.

“Steward Health Care announces national plan, $1.25 billion investment,” Boston Business Journal, 9/26/2016. PDF in Weekly Folder.

“Steward Health Care and IASIS Healthcare Announce Definitive Agreement to Merge,” Steward Health Care press release, 5/19/2017. PDF in Weekly Folder.

A. Ellison, “Lahey, Beth Israel and others ink merger agreement to create 13-hospital system,” Becker’s Hospital Review, 7/14/2017. PDF in Weekly Folder.

A. Kacik, “RWJBarnabas Health and Rutgers form partnership,” Modern Healthcare, 7/2017. PDF in Weekly Folder.

A. Alexander, et al, “Carolinas HealthCare System joining with UNC to form hospital giant,” Charlotte Observer, 8/31/2017. PDF in Weekly Folder.

15

S. Livio, “Another merger is creating N.J.’s 4th largest hospital chain,” nj.com, 9/1/2017. PDF in Weekly Folder.

A Frakt, “Accountable Care Organizations: Like H.M.O.s, but Different,” New York Times, 1/19/2015. PDF in Weekly Folder. Another four-page easy-read, which contains some good history and explanations in language we can all understand. ACOs are very much part of the healthcare landscape today.

D. Muhlestein, et al, “Growth of ACOs and Alternative Payment Models in 2017,” Health Affairs Blog, 6/28/2017.

S. Baseman, et, al, “Payment and Delivery System Reform in Medicare: A Primer on Medical Homes, Accountable Care Organizations, and Bundled Payments,” Kaiser Family Foundation, pages 15-22 on ACOs. PDF in Weekly Folder.

“Accountable Care Financial Arrangements: Options and Considerations,” Health Care Transformation Task Force, June 2016. PDF in Weekly Folder. This reading also applies to Week 8 on convergence.

D. Peiris, et all, “ACOs Holding Commercial Contracts Are Larger and More Efficient Than Noncommercial ACOs,” The Commonwealth Fund, October 5, 2016. PDF in Weekly Folder.

R. Abelson, “Cornerstone: The Rise and Fall of a Health Care Experiment,” The New York Times, 12/23/16. Physician group becomes an ACO and later implodes. PDF in Weekly Folder.\

H. Neprash, et al, “Little Evidence Exists To Support The Expectation That Providers Would Consolidate To Enter New Payment Models,” Health Affairs, 36 No 2, February 2017. PDF in Weekly Folder.

C. Terhune, “As Hospital Chains Grow, So Do Their Prices for Care,” Kaiser Health News, June 13, 2016. (Only three-plus pages.) PDF in Weekly Folder. This is another short read. Dominant providers in markets can lift prices. It doesn’t matter whether they are FP or NFP. PDF in Weekly Folder.

“Implications of the Rising Activity and Scope of Federal Antitrust Enforcement Activity Related to Healthcare Entity Integration,” Cain Brothers’ Comments, 8/4/15. PDF in Weekly Folder. This is a short, high-level discussion of what’s going on in the antitrust area. There is lots of tension between the ACA drive toward integration and “value” and what the Department of Justice (DOJ) thinks it should be pursuing and protecting.

“Federal Appeals Court Blocks PA Hospital Merger,” 2 articles, including analysis by law firm McDermott Will & Emery. PDF (of both) in Weekly Folder. This court decision is a perfect illustration of the conflict between ACA’s drive toward integration (and scale to drive down costs) and the DOJ’s antitrust mission.

“Ninth Circuit Affirms Divestiture of Consummated Physician Practice Acquisition,” McDermott Will & Emery, 2/2015, available at http://www.mwe.com/Ninth-Circuit-Affirms-Divestiture-of-Consummated-Physician-Practice-Acquisition-02-27-2015/

M. Gamble, “FTC challenges Sanford Health’s acquisition of North Dakota clinic: 8 things to know,” Becker’s Hospital Review 6/22/2017. PDF in Weekly Folder.

16

B. Fulton, “Health Care Market Concentration Trends in the United States: Evidence and Policy Responses,” Health Affairs, 9/2017. PDF in Weekly Folder.

C. Capps, et al, “Physician Practice Consolidation Driven By Small Acquisitions, So Antitrust Agencies Have Few Tools To Intervene,” Health Affairs, 9/2017. PDF in Weekly Folder.

NYU Wagner Dean Sherry Glied and Stuart Altman, “Analysis and Commentary: Beyond Antitrust: Health Care And Health Insurance Market Trends And The Future Of Competition,” Health Affairs, 9/2017. PDF in Weekly Folder.

K. Schorsch, “Why the feds block some hospital marriages – and bless others,” Modern Healthcare, 8/2017. PDF in Weekly Folder.

R. Herzlinger et al, “Market-Based Solutions to Antitrust Threats – The Rejection of the Partners Settlement,” The New England Journal of Medicine, 3/2015, available at http://www.nejm.org/doi/full/10.1056/NEJMp1501782 PDF in Weekly Folder.

T. Greaney, “Dubious Health Care Merger Justifications: The Sumo Wrestler And ‘Government Made Me Do It’ Defenses,” Health Affairs Blog, 2/24/2016. PDF in Weekly Folder.

S. Saxena et al, “Succeeding in Hospital & Health Systems M&A: Why So Many Deals Have Failed, and How to Succeed in the Future,” Strategy& (formerly Booz & Co.), 2/2013, available at http://www.strategyand.pwc.com/media/file/Strategyand_Succeeding-in-Hospital-and-Health-Systems-MA.pdf

Deloitte, “The great consolidation: The potential for rapid consolidation of health systems,” 2014. PDF in Weekly Folder.

M. Morris, et al, “Academic Medical Centers: Joining forces with community providers for broad benefits and positive outcomes,” Deloitte Center for Health Solutions, 2015. PDF in Weekly Folder.

D. Muhlestein and N. Smith, “Physician Consolidation: Rapid Movement From Small To Large Group Practices, 2013-2015,” Health Affairs 35, No. 9, 2016. PDF in Weekly Folder.

Read C. Beith and D. Johnson, “Asset-Light and Ready: Physician Groups Embrace Accountable Care,” Cain Brothers’ Comment, 3/31/2016. PDF in Weekly Folder.

N. Tepper, “DuPage Medical Group snags $1.45 billion to expand outside metro Chicago,” Modern Healthcare, 8/16/2017. PDF in Weekly Folder.

B. Sweeney, “Independent and hungry, DuPage Medical Group pushes into Chicago’s northwest suburbs,” Modern Healthcare, 6/21/2017. PDF in Weekly Folder.

Kaiser Health News, “In Appalachia, Two Hospital Giants Seek State-Sanctioned Monopoly,” 7/24/2017. PDF in Weekly Folder.

T. Hussein and M. Collins, “With The ACA Under Fire, Can Health Conversion Foundations Patch the Safety Net for Low-Income Americans?,” Health Affairs Blog, 7/27/2017. PDF in Weekly Folder.

A. Kacik, “RWJBarnabas Health and Rutgers form a partnership,” Modern Healthcare, 7/2017. PDF in Weekly Folder.

17

Note: You are invited to submit your draft Ascension-HCA comparison papers to me any time after October 10. (Actually, anytime is okay. However, the later you submit, the less likely I will have time to give you constructive feedback.) I will give you “no fault, no judgment” comments back at a mutually convenient time. Your paper is due in final form no later than Friday October 27, and we’ll discuss your findings in class on October 31.

Class 6 – October 10 Managed care, payers Current noteworthy healthcare business topic(s); topics suggested by students

Readings […placeholder for Managed Care 101 slides …to come….] J. Raskin, “U.S. Healthcare-Managed Care, 2017 Outlook: Sentiment and

Operations Aligned: Reiterate Positive,” Barclays, 1/5/2017. Note that managed care valuations are tracked using earnings per share (and Raskin now uses “adjusted” EPS) and not Enterprise Value/EBITDA, which is used in the hospital management sector. Note Figure 1 page 6 sector specialties and P/E valuations. Note Summary of Investment Positives and Negatives on pages 14-18. Note expenditures by type of payer Figure 23 page 27. Note also the extensive company consumer capabilities on Figure 72 page 57 held by Aetna, Anthem, Cigna, Humana, and UnitedHealth Group. PDF in Weekly Folder.

See list of “Managed Care M&A 2007-2015” Barclays 1/6/2016. PDF in Weekly Folder. A ton of activity.

C. Housworth, “Health Insurance M&A,” Cain Brothers, 6/12/2017. Great recap of recent events and prospects. Only one page.

B. Southerland, “UnitedHealth Group, Inc.,” Bloomberg, 9/7/2017. PDF in Weekly Folder. Only one page. Discussion about strength of UNH and resulting higher valuation.

Skim pages 43-46, “Singing the ACA Blues: U.S. BCBS Plans Stand Strong in the Post-Reform Insurance World,” Standard & Poor’s Credit Week, Special Report, U.S. Health Care, 1/14/2015. PDF in Weekly Folder. BCBS companies are often the dominant health insurer in state markets.

B. Herman, “How some Blues made the ACA work while others failed,” Modern Healthcare, October 15, 2016. PDF in Weekly Folder. This is an easy read that focuses on the Obamacare individual market “exchanges” and different underwriting strategies pursued by the Blues, some successful and some not successful. The article also points out that the ACA’s individual market reimbursement mechanisms, like risk corridors (profitable plans subsidizing unprofitable plans), have so far proved insufficient, and the U.S. government is being sued by unprofitable plans for compensation.

Deloitte, “Provider-sponsored health plans: Positioned to win the health insurance market shift,” 2016. Have a look at the text box “PSPs versus ACOs on page 3, which highlights important differences between ASOs and PSPs (provider-sponsored plans). Some cynics might say that the health system sponsoring its

18

own health plan can choose to take profits either in the health system or the health plan, because it controls both and, in effect, negotiates with itself. On the other hand, the article points out that PSPs seem to operate with lower levels of risk based capital versus other health plans in their states, because the owner-health system can use provider assets to support, at least in part, required capital to meet and exceed minimum regulatory levels. See Figure 3 on page 3 and the associated discussion. Can PSPs compete with other established health plans in their markets? What are some of the factors influencing profitability? PDF in Weekly Folder.

B. Herman, “Why venture capital firms are pouring money into health insurance,” Modern Healthcare, 3/19/2016. This article contains some familiar private company and unicorn names like Oscar and Zenefits. How are start-ups trying to disrupt traditional health insurance and do you think they will ultimately be successful? PDF in Weekly Folder.

E. Roberts, et al, “Market Share Matters: Evidence of Insurer And Provider Bargaining Over Prices,” Health Affairs 36 No. 1 January 2017. PDF in Weekly Folder.

Watch four-minute video by Kaiser Health News on Pharmacy Benefit Managers at http://players.brightcove.net/1875348214/Sy7mrdF0_default/index.html?videoId=5516377396001&utm_campaign=KFF-2017-The-Latest&utm_source=hs_email&utm_medium=email&utm_content=54896281&_hsenc=p2ANqtz-8WSBzYf8-Bum6GCXcKrfxn8yig12dQPc_ZTKb8QDvhkmQOWvT0XGKNqTg_aFmvPe3cfJRtmgwuPSulpvkSpJrLSf_pmg&_hsmi=54896281

In case you’re interested:

M. Haefner, “3 M&A trends in the payer services market,” Becker’s Hospital Review, 9/8/2017. PDF in Weekly Folder.

M. Haefner, “Economists: 3 takeaways from failed insurer mega-mergers,” Becker’s Hospital Review, 9/18/17. PDF in Weekly Folder.

R. Scheffler and D. Arnold, “Insurer Market Power Lowers Prices in Numerous Concentrated Provider Markets,” Health Affairs, 9/2017. PDF in Weekly Folder.

J. Raskin, “Judge Denies AET/HUM Merger w/ Industry Setback on Market Definition,” Barclays, 2/24/2017. PDF in Weekly Folder.

J. Raskin, “ANTM/CI Judge Blocks Merger; Debate Moves to Break-Up Fee,” Barclays, 2/9/2017. PDF in Weekly Folder.

J. Raskin, “Aetna Inc – Investor Day Review: Did You Know Aetna is a Growth Company?,” Barclays, 5/15/2017. PDF in Weekly Folder.

J. Raskin, “Centene Corp – Invoking a Strategy of Alekhine’s Defense,” Barclays, 6/19/2017. PDF in Weekly Folder.

A. Mathews, “Centene Agrees to Buy Fidelis Care in $3.75 Billion Deal,” The Wall Street Journal, 9/12/2017. PDF in Weekly Folder.

C. Rigg, “Centene: Initial Thoughts on Fidelis Acquisition,” Deutsche Bank, 9/12/2017. PDF in Weekly Folder.

19

J. Raskin, “CIGNA Corp – 2017 Investor Day Review: It’s a Go!,” Barclays, 6/22/2017. PDF in Weekly Folder.

J. Raskin, “You’re Raskin For It! – Vol. 16, Issue 27,” Barclays, 7/6/2017. Comments in first half performance of the publicly traded managed care sector. PDF in Weekly Folder.

J. Raskin, “Magellan Health Inc. – SHW Acquisition Jump Starts MCC Segment Growth,” Barclays, 7/13/2017. PDF in Weekly Folder.

J. Raskin, “UnitedHealth Group – 2QRev.: At Home in the Current Environment, More Deals to Come?,” Barclays, 7/19/2017. PDF in Weekly Folder.

C. Rigg, “UNH to Acquire The Advisory Board’s Healthcare Business,” Deutsche Bank, 8/29/2017. PDF in Weekly Folder.

UnitedHealth Group press release, “Optum and the Advisory Board Company’s Health Care Business to Combine,” 8/29/2017. PDF in Weekly Folder.

C. Rigg, “UnitedHealth Group: On the Road with UnitedHealth,” Deutsche Bank, 9/5/2017. PDF in Weekly Folder.

J. Commins, “Moody’s Backs UnitedHealth’s Advisory Board Acquisition,” HealthLeaders Media, 9/5/2017. PDF in Weekly Folder.

M. Haefner, “Bloomberg: UnitedHealth to acquire Advisory Board’s healthcare arm,” Becker’s Hospital Review, 7/7/2017. PDF in Weekly Folder.

C. Rigg, “UNH in discussion to acquire Chilean MCO,” Deutsche Bank, 9/11/2017. PDF in Weekly Folder.

WSJ, “How the Molina Brothers Got Bounced From the Family Health-Care Firm,” Wall Street Journal, 5/31/2017. PDF in Weekly Folder.

M. de la Merced, “Oscar Health to Join Humana in Small-Business Venture,” The New York Times, 7/12/2017. PDF in Weekly Folder.

C. Rigg, “Humana: Highlights from Management Meetings,” Deutsche Bank, 9/11/2017. PDF in Weekly Folder.

L. Dafny, et al, “Narrow Networks On The Health Insurance Marketplaces: Prevalence, Pricing, And The Cost Of Network Breath,” Health Affairs, 9/2017. PDF in Weekly Folder. Narrow networks have lower prices.

A. Frakt, “Savings? Yes. But Narrow Health Networks Also Show Troubling Signs.,” New York Times, October 17, 2016. PDF in Weekly Folder.

B. Copeland et al, “Escaping Rapunzel’s tower: How single-state health plans can build scale and meet new capability demands,” Deloitte, 2014, available at http://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lshc-report-single-state-bs-health-plans.pdf

“You’re Raskin for it! – Vol 14, Issue 32,” Barclays, 8/13/2015. Starting on page 2, Raskin discusses AHA’s view of large managed care company mergers. Note comments about Herfindahl-Hirschman Index (HHI) on page 2, which relates to antitrust analysis of competition. DOJ also uses HHI analyses to assess competition. PDF in Weekly Folder.

J. Robinson, “The Curious Conversion Of Empire Blue Cross,” Health Affairs, July-August 2003. PDF in Folder. This is a great read. Note what NY State did with the community, or what Robinson calls “social” assets. (Hint: a foundation was not created.)

20

J. Robinson, “For-Profit Non-Conversion And Regulatory Firestorm At CareFirst BlueCross BlueShield,” Health Affairs, July-August 2004. PDF in Weekly Folder. This is a Blue Cross conversion to for-profit that hit a “firestorm” as Robinson says.

J. Robinson, “Association of Reference Pricing for Diagnostic Laboratory Testing With Changes in Patient Choices, Prices and Total Spending for Diagnostic Testing,” JAMA, 7/25/2016. You should be familiar with “reference pricing.” PDF in Weekly Folder.

M. Chernew and A. Schwartz, “Innovations in health insurance design,” Incidental Economist, 2/2015 available at http://theincidentaleconomist.com/wordpress/innovations-in-health-insurance-design/ More on reference pricing.

C. White, “High and Varying Prices for Privately Insured Patients Underscore Hospital Market Power,” Center for Health System Change, Research Brief 27, 9/2013, available at http://www.hschange.org/CONTENT/1375/?words=Hospital%20Market%20Power

J. Robinson, et al, “Whither Health Insurance Exchanges under the Affordable Care Act? Active Purchasing Versus Passive Marketplaces,” Health Affairs Blog, 10/2/15 available at http://healthaffairs.org/blog/2015/10/02/whither-health-insurance-exchanges-under-the-affordable-care-act-active-purchasing-versus-passive-marketplaces/

R. Scheffler and Wagner School’s Dean Sherry Glied, “States Can Contain Health Care Costs. Here’s How,” New York Times, 5/2/2016. I probably should have made this required reading. PDF in Weekly Folder.

Health Policy Brief, “Regulation of Health Plan Provider Networks. Narrow networks have changed considerably under the Affordable Care Act, but the trajectory of regulation remains unclear,” Health Affairs, 7/28/2016. Good definitions of HMO, POS, EPO, PPO, Tiered Networks, and Reference Pricing. PDF in Weekly Folder.

J. Hancock and S Luthra, “Studies: Employer Costs Slow As Consumers Use Less Care, Deductibles Soar,” Kaiser Health News. PDF in Weekly Folder.

“You’re Raskin for it! – Vol. 15, Issue 38,” Barclays, 9/22/2016, Pages 2-8. Summary of Kaiser’s 2016 Employer Health Benefits. This is an easy-to-digest summary of a big topic. Note the costs for single and family coverage on page 2. Note the size of (cash) premium and growth curve of family coverage for small and large firms (200+ employees) in Figure 2, page 3. Figure 3 illustrates that virtually all large employers offer health insurance versus a bit more than half of small firms offering insurance. Figure 5 page 5 illustrates the penetration of High Deductible Health Plans (HDHP). Figure 7 page 6 breaks down various ways employers share costs with workers. PDF in Weekly Folder.

J. Raskin, “Managed Care Weekly, Vol 15, Issue 39,” Barclays, 9/20/2016. Starting on page 2 see “What are recent cost and utilization trends among consumer-driven health plans (CDHPs).” PDF in Weekly Folder.

G. Claxton, et al, “Health Benefits In 2017: Stable Coverage, Workers Faced Considerable Variation in Costs,” Health Affairs, 10/2017. PDF in Weekly Folder.

21

C. Terhune, “Are Blues’ Plans Benefiting Unfairly From Program To Offset Cost of Sicker Patients?, California Healthline, October 18, 2016. PDF in Weekly Folder. Another easy, quick read. This is an interesting slant. Insurance plan competitors in the individual market exchanges claim some of the Blues are bloated, administratively speaking, charging high premiums, and therefore are unfairly benefiting from the ACA’s “three Rs”: risk corridor (and reimbursements flowing from profitable plans to unprofitable plans), reinsurance (payments to plans enrolling higher-cost individuals), risk adjustments (payments to compensate for adverse selection).

Kaiser Family Foundation, “Individual Insurance Market Performance in Early 2017,” Issue Brief, 7/2017. PDF in Weekly Folder.

M Jarzemsky and B. Tweh, “KKR to Buy WebMD in $2.8 Billion Deal,” Wall Street Journal, 7/24/2017. PDF in Weekly Folder.

Class Objectives: Understand current dynamics, including consolidation, and participants in

healthcare insurance

Class 7 – October 17 Fairness opinions Valuation methodologies More on EBITDA Current noteworthy healthcare business topic(s); topics suggested by students

Readings Skim Cain Brothers, “Fairness Opinions: Is the One You Receive Beyond

Dispute?,” Strategies in Capital Finance, Vol.45, 1/2005. PDF in Weekly Folder. Despite the article’s age, it’s still highly relevant.

Read The University of Arizona Fairness Opinion. PDF in Weekly Folder. Pages to focus on will be highlighted in the week’s discussion guide. This is a huge, complicated document; plan to spend time on it; you only need to focus on the acute care valuation sections.

Read (again) B. Ritholtz, “Many metrics can be used to value markets. Which should you trust?,” The Washington Post, 3/7/15. PDF in Weekly Folder.

Skim “Aetna-Humana and Anthem-Cigna Form S-4 Reviews,” Barclays, 8/2015. PDFs in Weekly Folders. Note fairness opinion summaries on both sides of each proposed transaction. These were very high profile fairness opinions. What are the various projection discounted cash flow terminal value assumptions?

Class Objectives: Understand use of enterprise value and the three traditional valuation

methodologies Achieve a high-level understanding the capital asset pricing model (CAPM) and

its role in discounted cash flow analysis (Weighted Average Cost of Capital or WACC)

Understand fairness opinions and rationale

22

Class 8 – October 24

Provider and payer convergence Current noteworthy healthcare business topic(s); topics suggested by students

Readings […Placeholder for slides illustrating convergence transaction M&A…] A. Baumgarten, LLC, “Analysis of Integrated Delivery Systems and New

Provider-Sponsored Health Plans,” Robert Wood Johnson Foundation, June 2017. PDF in Weekly Folder.

K. Wagner, “Blurred Lines: Providers, Health Plans Integrate in Response to Value Based Care,” hfma, 11/17/2016. PDF in Weekly Folder.

A Frakt, “Accountable Care Organizations: Like H.M.O.s, but Different,” New York Times, 1/19/2015. PDF in Weekly Folder. A four-page easy-read, which contains some good history and explanations in language we can all understand. ACOs are very much part of the healthcare landscape today.

You may also want to skim Frakt’s Health Affairs article listed in the “In case you’re interested” section, below.

Moody’s “Hospitals Entering Insurance Business Gamble on Long-Term Payoff,” 9/2015. PDF in Weekly Folder.

J. Raskin, “United Health Group – Significant Savings Potential for 30% of Spend with Leading ASC Platform [Surgical Care Affiliates or SCAI],” Barclays, 1/9/2017. PDF in Weekly Folder.

A. Rege, “[UnitedHealth Group’s] Optum to acquire 230-physician Reliant Medical Group in Massachusetts,” Becker’s Hospital Review, 5/17/2017. PDF in Weekly Folder. (Only a half-page of text.)

Skim J. Goldsmith et al, “Integrated Delivery Networks: In Search of Benefits and Market Effects,” National Academy of Social Insurance, 2/2015. PDF in Weekly Folder. Note that NYU Wagner Dean Sherry Glied is a contributor to this article.

J. Goldsmith, "Geisinger’s Transformation: Balancing Growth And Risk,” Health Affairs Blog, 3/8/2017. PDF in Weekly Folder.

M. Dowling, “The issue of ill-conceived regulation and how it led to CareConnect’s demise,” 9/25/17. PDF in Weekly Folder.

In case you’re interested: S. Nir, “New York’s Largest Hospital System Is Closing Its Insurance Business,”

The New York Times, 8/24/2017. PDF in Weekly Folder. Convergence doesn’t always work.

A. Frakt, “The Downside of Merging Doctors and Hospitals,” The New York Times, 6/13/2016. PDF in Weekly Folder.

R. Berenson, “A Physician’s Perspective On Vertical Integration,” Health Affairs, 9/2017. PDF in Weekly Folder.

“Sutter Health and Aetna to Establish New Health Plan in Northern California,” Business Wire, 6/13/2017. PDF in Weekly Folder.

23

C. Johnson, “One of the most prestigious brands in medicine [Cleveland Clinic] is jumping into Obamacare [with Oscar],” Washington Post, 6/15/2017. PDF in Weekly Folder.

A. Frakt and R. Mayes, “Beyond Capitation: How New Payment Experiments Seek To Find the ‘Sweet Spot’ In Amount Of Risk Providers and Payers Bear,” Health Affairs 31, No. 9 (2012). PDF in Weekly Folder.

“Healthcare Industry Convergence Continues: The Beat Goes On,” Cain Brothers’ Comment, 9/10/2015. PDF in Weekly Folder.

B. Kutscher, “Ascension invests in Accretive Health, hands over more business,” Modern Healthcare, 12/8/2015, available at http://www.modernhealthcare.com/article/20151208/NEWS/151209891 (follow up to the above Cain Brothers’ Comment) PDF in Weekly Folder.

A. Frakt, “All the plan-provider vertical integration literature to date,” The Incidental Economist, 6/27/2017. Document in Weekly Folder. This is a survey of the literature concerning IDSs, and it references the Goldsmith (and Glied) document in the Reading section above.

D. Peiris, et al, “ACOs Holding Commercial Contracts Are Larger And More Efficient Than Noncommercial ACOs,” Health Affairs 35:10, October 2016. PDF in Weekly Folder.

C. Colla, et al, “Hospitals Participating In ACOs Tend To Be Large And Urban, Allowing Access to Capital and Data,” Health Affairs 35:3, March 2016. PDF in Weekly Folder.

G. Khanna et al, “Provider-led health plans: The next frontier – or the 1990s all over again?,” McKinsey & Company, 1/2015. PDF in Weekly Folder. Note Exhibits 1 and 5.

Regarding United Health Groupo J. Raskin, “Logical Step in PBM Industry Evolution Put UNH in Big 3,”

Barclays, 3/31/2015. PDF in Weekly Folder.o J. Raskin, “Management Dinner Takeaways [Optum comments],”

Barclays, 3/14/2017. PDF in Weekly Folder.

Class Objectives: Discuss how providing healthcare services and accepting payment risk are

converging; understanding phenomenon of convergence of providers and payers

Class 9 – October 31

Acute Care, NFP/FP company comparison writing assignment discussion, what did you learn? Written assignment due Friday October 27 via email to me at jv59@nyu.edu

o Written assignment class discussiono Through writing and discussing Ascension-HCA paper, understand

similarities and differences between not-for-profit and for-profit acute care providers through focus on income statements and capital structures

Class 10 – November 7

24

Post-acute care, senior health & housing REITs Current noteworthy healthcare business topic(s); topics suggested by students

Readings

C. Carter, et al, “A Unified Medicare Payment System For Post-Acute Care Is Feasible,” Health Affairs Blog, 9/28/2016. Appreciate that there are different payment systems for the various post-acute subsectors. PDF in Weekly Folder.

Skim, note particularly Figures 1 and 12, “Integrating Acute and Post-Acute Care: The Emerging Merging of the Sectors,” Cain Brothers, Strategies in Capital Finance, Vol. 71, summer 2012. PDF in Weekly Folder.

-This monograph should give you a sense of the interrelationships between acute care and PAC services and an appreciation why acute care providers are aligning more closely with PAC providers through ownership, outsourcing, and joint venturing. Be prepared to discuss the underlying dynamics.-Please pay attention to acute care discharge patterns and the PAC ecosystem downstream of acute care providers and upstream readmissions to acute care providers in Figures 1 and 12.-Spend two minutes on Figures 15 and 16 page 12; integration and coordination of care makes dollars and cents sense.

Thumb Chapters 7-12, “Report to the Congress, Medicare Payment Policy,” Medicare Payment Advisory Commission, 3/2017. PDF in Weekly Folder. Good sector snapshots are provided.

Chapter 7: Post-Acute Care: The Congress and CMS must act to implement recommended changes to PAC paymentsChapter 8: Skilled nursing facility servicesChapter 9: Home health servicesChapter 10: Inpatient rehabilitation facility servicesChapter 11: Long-term care hospital servicesChapter 12: Hospice services

PAC is a huge industry! E. Teichert, “Site-neutral pay rule leaves hospital-owned outpatient facilities with

uncertain future,” Modern Healthcare, 11/2/2016. PDF in Weekly Folder. Payment system changes coming.

Skim pages 61-81, J. Raskin, “2016 Outlook: Laboring Through Post-ACA Period,” Barclays, 1/6/2016. PDF in Folder.

-Note Figures 71-73, pages 63-65; comments about custodial and transitional care businesses.-Note comments about RIDEA structure on page 68. -See Figure 90 on page 77 for 25 largest senior housing providers.-See Figure 216 on page 179 for major REITs and portfolio segments

25

Read “2017 Outlook: Nonprofit Continuing Care Retirement Communities,” Fitch Ratings, 12/8/2016. PDF in Weekly Folder.

“Skim Not-for-Profit Continuing Care Retirement Communities Rating Criteria, Fitch Ratings, 7/2014. PDF in Weekly Folder.

Glance at “2015 Median Ratios for Nonprofit Continuing Care Retirement Communities,” Fitch Ratings, 9/16/2015. PDF in Weekly Folder.

G. Sokolow and P. Rizzo, “Sector Briefing: Nonprofit Continuing Care Retirement Communities,” Fitch Ratings, May 2017, slides. PDF in Weekly Folder.

W. Ritchie and D. Johnson, “Skilled Nursing Facilities and REITs: A Symbiotic Relationship Facing Significant Disruption,” Cain Brothers’ Comments, 3/28/17. PDF in Weekly Folder.

Selected pages TBA. J. Raskin, “REITs/Ops 1Q Review: Focus on SNF Rule as Investment Landscape Thaws,” Barclays, 5/19/2017. PDF in Weekly Folder.

M. Margulies, “Realignment and Consolidation in Home Health and Hospice,” Cain Brothers, 0/11/17. PDF in Weekly Folder.

In Case You’re Interested

A. Fowler, et al, “Corporate Investors Increased Common Ownership in Hospitals and The Postacute Care and Hospice Sectors,” Health Affairs, 9/2017. PDF in Weekly Folder.

J. McHugh, et al, “Reducing Hospital Readmissions Through Preferred Networks Of Skilled Nursing Facilities,” Health Affairs, 9/2017. PDF in Weekly Folder.

B. Costa, et al, “Post-Acute Healthcare Shaken by Regulatory Announcements Despite ACA inaction,” Fitch Ratings, 8/30/2017. PDF in Weekly Folder.

D. Barkholz, “Hospitals find national operators for home care JVs [joint ventures],” Modern Healthcare, 6/7/2017. PDF in Weekly Folder.

D. Barkholz, “Christus turns to national operator to run home health business,” Modern Healthcare, 8/2/2017. PDF in Weekly Folder.

D. Barkholz, “Kindred, Genesis partner to create virtual network of post-acute facilities,” Modern Healthcare, 2/4/2017. PDF in Weekly Folder.

Hostetter, M., et al, “Aging Gracefully: The PACE Approach to Caring for Frail Elders in the Community,” The Commonwealth Fund, 8/2016. PDF in Weekly Folder.

R. Blumenthal, “A Healthy Glow Will Return to DaVita’s Shares,” Barron’s, 12/12/2016. PDF in Weekly Folder.

K. Thomas, “Medicare Toughens Standards on Nursing Homes,” The New York Times 2/20/2015 available at http://www.nytimes.com/2015/02/21/business/nursing-home-ratings-fall-as-toug1her-standards-take-effect.html?_r=0

D Stevenson, “Nearly Half of All Medicare Hospice Enrollees Received Care From Agencies Owned by Regional Or National Chains,” Health Affairs 1/2015. PDF in Weekly Folder.

26

E. Cook, et al, “CMS Releases CY 2017 Final Rule Implementing Changes to Outpatient Prospective Payment System,” McDermott Will & Emery, 11/3/2016. PDF in Weekly Folder.

E. Fung, “Health-Care REITs Back Off Nursing,” The Wall Street Journal, 10/11/2016. PDF in Weekly Folder.

C. Weaver et al, “Hospital Discharges Rise at Lucrative Times, Facilities Release Medicare Patients After Rules Trigger Higher Payments,” The Wall Street Journal, 2/17/15. PDF in Weekly Folder.

J. Raskin, “Ventas – 2016 10-K Review,” Barclays, 2/16/2017. PDF in Weekly Folder.

J. Raskin, “Sabra Healthcare REIT – Strong Results, Better Outlook and Accelerated Diversification All Positive,” Barclays, 2/23/2017. PDF in Weekly Folder.

J. Raskin, “Welltower Inc. – Maintaining an Edge in a More Challenging Environment,” Barclays, 2/23/2017. PDF in Weekly Folder.

J. Raskin, “You’re Raskin For It – Vol. 6, Issue 6,” Barclays, 2/9/2017, comments on post-acute spending. PDF in Weekly Folder.

J. Raskin, “REITs/Ops 1Q Review: Focus on SNF Rule as Investment Landscape Thaws,” Barclays, 5/19/2017. PDF in Weekly Folder.

J. Raskin, “Kindred Healthcare – SNF Sale Proceeds Just Above High End of Expectations,” Barclays 7/3/2017. PDF in Weekly Folder.

J. Raskin, “HealthSouth Corp. – Name Change to Encompass Health Has Many Undertones,” Barclays, 7/11/2017. PDF in Weekly Folder.

J. Raskin et al, “US Healthcare Facilities 2017 Outlook: Looking for Stability in Light of Known Unknowns,” 1/5/2017. PDF in Weekly Folder. Figures 101 & 102 page 79, largest AL operators, largest independent living operators. Figure 100 page 78 largest senior housing operators.

Class Objectives: Understand dynamics and trends in post-acute care services

Note: During this class session, we will draw names out of a hat to establish the pitch-a-thon order of appearance.

Class 11 – November 22

Ambulatory Surgery Centers (ASCs) Current noteworthy healthcare business topic(s); topics suggested by students

Readings

Skim Chapter 5, “Ambulatory surgery center services,” MedPac, Report to Congress, March 2017. PDF (entire report) in Weekly Folder.

Skim “You’re Raskin For It! – Vol 4 – Issue 34,” Barclays, 8/27/2015. PDF in Weekly Folder. Helpful discussion of ownership structures.

27

J. Raskin, “Surgery Partners, Inc. – Slower Growth in 2017 Still Well Aabove Facilities Peers,” Barclays, 3-13-2017. PDF in Weekly Folder. Market shares in Figure 2 page 4.

Skim “2017 ASC Valuation Survey,” HealthCare Appraisers. PDF in Weekly Folder.

Read “Tenet, United Surgical Partners International and Welsh Carson to Create the Nation’s Largest Ambulatory Surgery Platform,” Tenet Healthcare press release, 3/23/2015. PDF in Weekly Folder.

Skim slides from “Joint Venture with United Surgical Partners International,” Tenet Healthcare slides, 3/23/2015. PDF in Weekly Folder.

J. Raskin, “Surgery Partners Inc. – NSH Provides Path to Lower Leverage and Higher Value [comments on National Surgery Healthcare acquisition],” Barclays, 5/11/2013. PDF in Weekly Folder.

J. Raskin, “Envision Healthcare Holdings Inc. – 1Q17 Form 10-Q Review,” 5/17/17 (AmSurg and EHH completed merger.) PDF in Weekly Folder.

J. King, “Increasing Strategic and Financial Buyer Focus on Outpatient Surgery,” Cain Brothers, 9/18/17. PDF in Weekly Folder.

In Case You’re Interested: J. Robinson, “Total Expenditures per Patient in Hospital-Owned and Physician-

Owned Physician Organizations in California,” JAMA, 2014;312(16):1663-1669.dol:10.1001/jama.2014.14072. PDF in Weekly Folder.

J. Raskin, “2Q16 Preview: Focus on Outpatient,” Barclays, 7/13/16. PDF in Weekly Folder. Substantial coverage of the sector.

J. Raskin, “1Q17 Review: Competition in Outpatient Services,” Barclays, 5/19/17. PDF in Weekly Folder. Figure 2, page 5.

E. Teichert, “Site-neutral pay rule leaves hospital-owned outpatient facilities with uncertain future,” Modern Healthcare, 11/2/2016. PDF in Weekly Folder.

K. Carey, “Price Increases Were Much Lower In Ambulatory Surgery Centers Than Hospital Outpatient Departments In 2007-2012,” Health Affairs, 10/2015. PDF in Weekly Folder.

Class Objectives: Obtain familiarity with ASC sector and issues

Class 12 – Behavioral Health

Behavioral Health Current noteworthy healthcare business topic(s); topics suggested by students

Readings Kaiser Family Foundation, “Facilitating Access to Mental Health Services: A

Look at Medicaid, Private Insurance, and the Uninsured,” June 2017. PDF in Weekly Folder. Fact Sheet. It’s very short.

28

Skim C. Roehrig, “Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion,” Health Affairs, June 2016. PDF in Weekly Folder.

Skim “Behavioral Health,” Cain Brothers, Strategies for Health Care Leaders, Vol. 74 Winter, 2014. Fantastic background by a great researcher and writer. PDF in Weekly Folder.

Read C. Barry, et al, “Federal Parity In The Evolving Mental Health And Addiction Care Landscape,” Health Affairs 35, No. 6 (2016), available at http://ezproxy.library.nyu.edu:3333/content/35/6/958.full.pdf . PDF in Weekly Folder.

Read H. Huskamp & J Iglehart, “Mental Health and Substance-use Reforms – Milestones, Reached, Challenges Ahead,” The New England Journal of Medicine, 375;7, 8/18/2016. PDF in Weekly Folder.

In Case You’re Interested J. Zhu, et al, “Networks In ACA Marketplaces Are Narrower For Mental Health

Care Than For Primary Care, Health Affairs, 9/2017. PDF in Weekly Folder. Kaiser Family Foundation, “What are the current costs and outcomes related to

mental health and substance abuse disorders,” posted 7/31/17, slide deck. Available at http://www.kff.org/slideshow/what-are-the-current-costs-and-outcomes-related-to-mental-health-and-substance-abuse-disorders/

S. Goodell, et al, “Enforcing Mental Health Parity. Five years after the Mental Health Parity and Addiction Equity Act took effect, access to equal benefits and qualified providers remains elusive for many insured Americans,” Health Affairs Health Policy Brief, 11/9/2015. PDF available in Weekly Folder.

T. Mark, et al, “Insurance Financing Increased for Mental Health Conditions But Not For Substance Use Disorders, 1986-2014,” Health Affairs 35, No.6, (2016), available at http://ezproxy.library.nyu.edu:3333/content/35/6/958.full.pdf. PDF in Weekly Folder.

M. Ollove, “Amid Shortage of Psychiatric Beds, Mentally Ill Face Long Waits for Treatment,” The Pew Charitable Trusts, August 2016. PDF in Weekly Folder. Good, short summary of deinstitutionalization of psychiatric treatment.

Class Objectives Obtain familiarity with behavioral health sector and issues

Class 13 – November 28 First class session pitch-a-thon (format, presentation order details, and logistics to

be announced)

Class 14 – December 5 Pitch-a-thon concludes

December 12 Legislative Day; classes meet according to Monday schedule

29

30

In Case You Are Interested – Topics Not Covered in Class

“Smart” money, private capital, disruptive services and technologies articles:

C. Robbins et al (including yours truly), “Private Equity Investment in Health Care Services,” Health Affairs, 9/2008, available at http://content.healthaffairs.org/content/27/5/1389.full.pdf+html?sid=dical Innovation b61826da-fe12-4f35-a955-f6f78f912fa0 PDF in Folder. Still relevant.

J. Flemming, “The Decline of Venture Capital Investment in Early-Stage Life Sciences Poses a Challenge to Continued Innovation,” Health Affairs, 2/2015, available at http://content.healthaffairs.org/content/34/2/271.full.pdf+html?sid=1d621b31-b3ec-4dc0-a7c8-68be6ae80829

J. Robinson, “Biomedical Innovation In the Era of Health Care Spending Constraints,” Health Affairs, 2/2015 available at http://content.healthaffairs.org/content/34/2/203.full.pdf+html?sid=2a447f6b-1df7-482d-aa21-d89bf1bb76fa

J. Baltzell and J. Robinson, “Medical Technology: What Changing Venture Capital Investments Signal,” Health Affairs Blog, 1/9/2017. PDF in Folder.

D. Misfeldt and J. Robinson, “Orphan Diseases Or Population Health? Policy Choices Drive Venture Capital Investments,” Health Affairs Blog, 7/21/2017. PDF in Folder.

J. Rauch, “Disruptive entrepreneurship is transforming U.S. health care,” Center for Effective Public Management at Brookings, 3/2015, available at http://www.brookings.edu/research/papers/2015/03/17-disruptive-entrepreneurship-health-care-rauch

A. Prathipati et al, “Evolution of healthcare technology,” Duke, Master of Engineering Management, 9/2014, available at http://memp.pratt.duke.edu/sites/memp.pratt.duke.edu/files/Evolution%20of%20Healthcare%20Technology%20Final.pdf

J Anderson, et al, “The Innovative Potential of Venture-Backed Primary Care,” Health Affairs Blog, 5/16/2016, available at http://healthaffairs.org/blog/2016/05/16/the-innovative-potential-of-venture-backed-primary-care/

C. Bischoff, et al, “The next act in healthcare private equity,” McKinsey & Co., December 2016. PDF in Folder.

M. Collier, et al, “Artificial Intelligence: Healthcare’s New Nervous System,” Accenture, 2017. PDF in Folder.

J. Frew, “Unicorns and Perceived Potential,” commentary. Word Document in Folder.

McKinsey & Co., “Valuing high-tech companies,” 2016, PDF in Folder. This methodology relates to Unicorns like Oscar.

31