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Health Tech Update: Buying and Selling Companies in Healthcare

Episode 348

Recommended Books:

Roosevelt Trilogy Bundle

The Last Lion

Guns, Germs and Steel

Best Way to Contact Brett

Email: bmankey@thebraffgroup.com

Linkedin

Health Tech Update: Buying and Selling Companies in Healthcare with Brett Mankey, Managing Director, Head of Digital Health Investment Banking | Convert audio-to-text with the best AI technology by Sonix.ai

Saul Marquez:
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Saul Marquez:
Welcome back to the podcast today I have the privilege of hosting Brett Mankey. He’s a Managing Director, Head of Digital Health Investment Banking at The Braff Group and he is also head of the healthcare technology and software investment banking their healthcare M&A Advisory Boutique consistently ranked as one of the top five healthcare investment banking firms in the United States by Thomson Reuters. Braff has closed more than three hundred twenty five healthcare transactions for clients with over three point eight billion in aggregate annual revenue in the last 20 years. Over a hundred and twenty five of those transactions had PE fund acquirers as buyers including Blackstone, JH Whitney, HIG Capital and Audax among others. Brett is primarily focused on sell-side advisory engagements. Although he has been working a little bit on the buy side as well we’ll dive into that during the interview today. In the U.S. and Europe with a targeted transaction range of 20 million to 200 million in value. Brett has extensive background in mergers and acquisitions, business development, and strategy. In his career, he has been an international transactional lawyer and CEO and board member of several investor backed technology companies. Most recently he was a partner at Leech Tishman in their New York and Pittsburgh offices where he focused on the international corporate M&A transactions ranging in size from twenty five to 200 million. Additionally he served four years as Vice President of Business and Strategic Development for our 950 million annual revenue Nasdaq listed company in Northern Virginia. I’d privilege of meeting and connecting with Brett at the TED MED event last year and I said Wow I gotta get this guy and you all have to hear his perspective because it is definitely about where the puck is going. So without further ado I want to welcome you to the podcast. Brett thanks for joining me.

Brett Mankey:
Thanks for having me Saul. I certainly enjoyed meeting you at TED MED and hanging out at night and I am happy to get on the podcast and talk with you about my experience so where I think the market is headed for digital health and healthcare technology more broadly.

Saul Marquez:
It’ll be very interesting. And so what is it that got you into this space to begin with, Brett?

Brett Mankey:
So in my career over the last 20 years I’ve I have spent almost the entirety of it in the technology space. A lot of it in software some on the device side but I’ve always been in tech and I’ve touched over the years healthcare technology, healthcare software companies and things as an advisor. I never ran a company in this space but I certainly have been in and around it quite a bit over the years and when I was approached by The Braff Group about taking this role, I started digging into the market and I could see that we’re at the front end of a massive consolidation wave that needs to take place and will take place. There’s just been so many companies funded I think according to Rock Health, there have been over twelve hundred companies that have received more than two million dollars of institutional investment in the digital health space in the United States alone. When you think about that you think about all the different categories, there are many people trying to do the same thing in each of these subsectors and not all of them are going to make it right. So some of them will just go out of business but many of them will get acquired some by strategic some by other startups as there will be a couple of ways of consolidation where there’s going to be a lot more successful startups eyeing the less successful startups than private equity funds, buying, potentially buying the more successful startups and strategic then flipping them and selling them to strategic. There aren’t a lot of IPO transactions in this space. I think there have only been a couple in the last four or five years and almost everything ends with an acquisition or a merger at this point.

Saul Marquez:
That’s a really interesting call out Brett because when you take a look at the pure tax base not in healthcare, yeah you do see more IPO compared to healthcare. Why do you think that is?

Brett Mankey:
I just think because of the sales cycles, the length of the sales cycles you know didn’t I know that in your day job you sell in this space it is the sales cycles and how long it takes to sell to somebody particularly on the provider side much longer. And it’s very difficult for people to gain significant amounts of traction. One of the filters that I use and whether I would be willing to sell somebody is you know they have to have revenues beyond the proof of concept stage which to me is sort of 3 million or 4 million somewhere in that range because if they they don’t have that much revenue on an annual basis and it shows me that they have maybe some pilots that they’ve had in place maybe one or two customers but to be successful you need multiple customers right. And not just pilot deal. The great thing about these businesses is most of them operate on a recurring revenue business model with multi-year contract. When you get someone who’s successful and they’ve been able to get to certain certain scale because of the nature of those contracts you can start to see how the revenue and the cash flows start to stack up fairly quickly when you get into outer years because if you’re signing new contracts all the time with people that are three or four or five years in duration you can project out very easily the cash flows and the profit margins and all these software gross profit margins should be north of 80%.

Saul Marquez:
Right.

Brett Mankey:
That at least gives you an opportunity to have a bit of margins north of 40%. If you’re performing as it scale. So those are very very attractive attributes for buyers. The problem is I don’t know if you know Joffrey Moore at all but crossing the chasm you familiar with that?

Saul Marquez:
Yes.

Brett Mankey:
So the difficulty lies in crossing the chasm. Here is how do I get from a couple of customers to maybe making it to a point where I’ve now sort of got scalability and that scalability I think comes somewhere around the 3 to 4 million in annual revenue recurring revenue range. I also… it’s crazy to me the number of companies that have been backed by large venture funds, Silicon Valley funds even…

Saul Marquez:
Yeah.

Brett Mankey:
That have raised north of 20 million dollars and have less than a million in revenue. What other world is that an acceptable paradigm for software. I mean it doesn’t take that much money to build a software company anymore. When I ran my first software company we had to have data centers. We had to have infrastructure. AWS is taking all of that out of the equation. And on the developer side people now go to India and other places and they you know they hire three or four developers for the price of one in the US. The model and the cost have gone down so much from a dramatic perspective I think. Here’s where I think the issue is all of the guys and I talked to CEO’s constantly of venture funded startups in particular. I think all of these guys want to own the customer so much that they try to scale into this giant salesforce which they can’t compete on that front. They’re never gonna be able to scale with it. You know it’s too much money to build a giant salesforce. You work for a big company with a giant salesforce. How much does it cost just to maintain that salesforce. You see more of these startups would be willing to sign larger OEM type or distribution deals with the larger companies. I think that you will see a faster uptake in terms of scaling.

Saul Marquez:
Yeah now some fascinating insights there and what I love about conversations with you Brett is that you know there’s there’s a lot of things that you don’t think about and you definitely give this space a lot of thought. You’re deep into it. You’re always questioning assumptions and that’s what I really enjoyed about connecting with you live. And now here on the podcast so that listeners could experience some of that cool insight that you always offer. What would you say is some of your insights on the future of healthcare in general as it relates to people buying companies, people selling companies?

Brett Mankey:
So I think some broad macro level trends are going to happen whether people want them to happen or not. I know it’s almost heresy to say this but I think a couple of things are going to happen. The first thing is I think that AI is going to transition from a tool that is used to help diagnosing to actually doing the first line of diagnosis. I think that’s an inevitable trend. Like doctors are going to be trained differently. They’re going to be trained so that they confirm or deny the diagnosis rather than make the diagnosis and then put the care plan in place. That is going to happen in a number of particularly in the Medical Imaging space because the accuracy is just higher. A lot of these companies are able to have 98, 99% accuracy because the the algorithms keep learning and always are learning from all the data that’s input and fed into the system. And even a top notch radiologist is at about 95, 96% accuracy. So when you can cut time out of the equation in terms of making the initial diagnosis it’s going to be there’s a shortage of radiologists anyway. So it’s going to allow the existing radiologists to be able to make decisions at a much more rapid pace. Right. And that’s going to save lives. And anytime you can cut the decision making time to get someone into surgery for a stroke or whatever and I think that that is a very interesting proposition. So that’s the first sort of thing that I look at and I see I think another thing that is a bit heretical is I think that in the United States I am a capitalist. I think I’ve told you that before but I believe…

Saul Marquez:
Yeah.

Brett Mankey:
That in the longer term the trend is going to be everyone is going to have some form of baseline insurance coverage and…

Saul Marquez:
Single payer?

Brett Mankey:
On top of… well I think it’s going to be some element of single payer and on top of that there’s going to be private insurance for those people that is actually treated as a benefit. I lived and worked in England for almost five years. I had three different jobs there. Every job I had there I had always had NHS access but I always had private insurance paid for by my employer that I got taxed on as a benefit. But I didn’t have to pay any money to it. That was the state of the job market right. So in professional jobs you would still have your private insurance and a single payer system the United States I believe. But the people that don’t have coverage they get cancer won’t have to file for bankruptcy in order to try to stay alive. I think that is something that’s going to happen and it may not happen in the next two or three or four or five years that in the next 10 or 15 years it’s bound to happen because the people that are the millennial generation and younger they think it’s barbaric that we’re the only Western style democracy that doesn’t have that level of baseline coverage.

Saul Marquez:
Right now. And then I’ll say that I definitely believe that 63% of all bankruptcies having to do with healthcare is definitely unacceptable.

Brett Mankey:
I look at that and I just I’m flabbergasted by that number. Right it’s horrible.

Saul Marquez:
You know the crazy thing is that as I found out that out of those 63%, the majority of them had insurance.

Brett Mankey:
Well I can tell you from a personal perspective, my wife was in a car accident once she was pregnant with my youngest daughter.

Saul Marquez:
Oh my gosh.

Brett Mankey:
And my toddler who was like eleven months was in the backseat and a guy ran a red light and hit my wife at a T bone accident. He was going 45 miles an hour and a Dodge Durango while she was going 25 miles an hour and he hit her dead right on the driver’s side door right.

Saul Marquez:
Wow. Oh my gosh.

Brett Mankey:
And my wife taken to the hospital rushed to the hospital though such a force. She was driven through the intersection. We had a BMW X3. The X3 flipped hit a truck on the other side of the parked on the corner.

Saul Marquez:
Were you there?

Brett Mankey:
I wasn’t there.

Saul Marquez:
Oh wow.

Brett Mankey:
I was sitting at home watching a football game and I got a call from someone who was just at the scene who said hey I know your wife and I was walking down the street and I saw it and put an ambulance with your kids.

Saul Marquez:
Wow. Oh my God.

Brett Mankey:
You probably want to know about it.

Saul Marquez:
Can’t even imagine.

Brett Mankey:
I just sold my second vehicle and this was in Northern Virginia and we lived in Washington D.C. at the time. And so I had to find someone to give me a ride because it was before Uber Lyft.

Saul Marquez:
Yeah.

Brett Mankey:
And it was hard to get a taxi to come to your house in Washington D.C. And so it took me like two hours to get to the emergency room.

Saul Marquez:
Oh men.

Brett Mankey:
So my wife ended up fracturing ribs. Developing placenta previous while she was pregnant. So the baby wasn’t born right away. She was put on bed rest in our house. I got a nanny for my toddler. I was working at Venable at the time and over by the rising center as a lawyer and I made the decision that I had enough money saved up and I really needed to just help get my wife through this pregnancy so I quit my job which I was inclined do anyway. I quit on a Friday.

Saul Marquez:
Wow.

Brett Mankey:
On Sunday my wife had a placental abruption and we woke up in a pool of blood. I called my OBGYN she said, my wife’s OBGYN she said “listen put a towel between your wife’s legs…”

Saul Marquez:
Oh my gosh.

Brett Mankey:
“Put her in the car run every red light. Don’t worry about calling an ambulance, it’s going to take too long. I’ll meet you at the hospital” it’s like six thirty in the morning. She said in the last the last thing she said to me is “Don’t forget your toddler” because I would’ve forgotten.

Saul Marquez:
Oh my gosh. That’s a good point.

Brett Mankey:
I grabber drive with all the red light she meets me there. She tells me on the way in. I need you to pick your wife or your baby that’s inside her, which was crazy right. That’s an insane thing to tell someone.

Saul Marquez:
That is insane.

Brett Mankey:
I said I’d pick my wife obviously.

Saul Marquez:
Yeah.

Brett Mankey:
So my daughter was born eleven weeks prematurely, spend five weeks in the NICU. My wife lost half the blood in her body. She was in for three weeks almost in the hospital. And when I got all the bills total amount of bills was like four hundred fifty thousand dollars. Normally you would have a cap because of all of the people that were out of network that I didn’t know about even then I end up having to pay almost eighty thousand dollars and I had insurance right.

Saul Marquez:
Yeah. So you…

Brett Mankey:
You know if I didn’t have money saved up then how would I have been able to afford that I would have had to file bankruptcy right.

Saul Marquez:
Yeah yeah.

Brett Mankey:
So what you said doesn’t surprise me at all. You know I have personal evidence of it and if I were in the UK where I been you know this was in 2006 by the time that my daughter was born. But six years earlier I wouldn’t have to worry about anything. It would have just been taken care of. So that’s a big problem and what in all the upper middle class kind of guy. I’m very fortunate in that regard. But I grew up lower middle class. I was come I come from a family of steel workers and coal miners and people like that. Right.

Saul Marquez:
Yeah.

Brett Mankey:
Union members. Now the union that we had good insurance. But you know my mom was a single mom who raised three boys. If something were to happen like that to her we would have had she would’ve had to file bankruptcy.

Saul Marquez:
Yeah.

Brett Mankey:
Right. So I look at the where the world is headed and where it is come from. The current path where we are today is not a sustainable point. It’s going to have to evolve. A lot of that is going to be driven by how do we take cost out of the system and the costs that can be taken out of the system through technology. There are still going to be providers. There are still going to be payers a lot are going to change and who they serve someone. I think the first thing that’s going to happen is Medicare is going to be extended downhill to a younger age. And there’s going to be earlier Medicare Advantage. That’s just sort of a logical place for this to go. That’s an opportunity for the insurers the payers in my view because they’re going to get a period of time that’s going to allow them to transition. There’s going to be a lot of creative destruction about business models. If you’re not willing to be nimble and adapt you’re going to be destroyed.

Saul Marquez:
Brett thanks for sharing that story. Definitely…you lived it and thankfully you were able to absorb it and everybody’s okay. And I know that Brett’s two lovely daughters are still… are doing well and so that you fast forward to today folks if you’re wondering his daughters are doing awesome. So is his wife. So you know there’s a happy ending to his story but unfortunately not for 63% of people filing for bankruptcy. So tell us about a time when maybe you or one of the companies that you work with had a setback. We’d like to learn from setbacks and mistakes here. And what could have been done differently and to be better?

Brett Mankey:
Sure. So I thought about this question when you raised it earlier to me and I think if there’s a lesson that I can impart upon people I would say the following. I became the CEO of a company that was venture funded in London at a very young age I would say in comparison I was 28 years old. The CEO that I replaced and that business was one of the Co-founders. And he stayed in the business with me. That he had at a board level approved me as the CEO. Right. It wasn’t my idea to become the CEO. The board decided that they needed somebody that was different than the guy that was the CEO to be the CEO and we were raising a 25 billion or 25 million dollar round with Deutsche Bank where we’re about to and they knew that he wasn’t comfortable dealing with venture capital funds and investment bankers and the like. And I had spent already a couple of years my career dealing with those sorts of folks at the big law firm for in London called asteroids that had when I was there nine hundred lawyers. So when I got replaced and when I replaced him I probably should have not let him stay in the company. And as the CEO you come in and it’s not your company and you become the CEO not something that is normally would think about it that time but every time at a board level that we took a decision that he wasn’t happy with he would undermine me, to the employees that had worked for him for a period of years before I became the CEO. Right.

Saul Marquez:
It’s troublesome.

Brett Mankey:
What’s ironic is he was sort of the guy who wanted me to come take the job that I took in the company in the first place and I was friends with him. So I wasn’t expecting it.

Saul Marquez:
Right.

Brett Mankey:
The longer this time progressed, it became more and more of an issue. And at one point in 2000, someone offered us 50 million dollars in cash for a business with 4 million in revenue. And I took it to my board and said let’s sell. And the board said let’s sell. And he and another guy controlled 53% of the shares on a fully diluted basis. And they convinced the other technology guy who’s now on my advisory board ironically and has been a digital help for the last 20 years as the CTO of venture funded digital health companies. He convinced that guy to reject the deal. The Internet bubble popped. I had to do a fire sale of the business. To this day it’s the fastest deal I’ve ever done in my life. From the first time I spoke to somebody closing it was 17 days. I’ve never done a deal that’s out. I had to do it.

Saul Marquez:
Speedy.

Brett Mankey:
I have a choice right. But I guess the lesson I learned is if you become the CEO something and you replace someone who has been in that business for a long period of time, you should take them out of the business. He could have stayed on the board that wouldn’t have been an issue. On a day to day operations of the business, it’s something that he obviously has relationships built. And if he doesn’t agree with the past that the board sets with you as the CEO, he can completely undermine you or she. Right.

Saul Marquez:
Right.

Brett Mankey:
And I would say to you that that is a lesson that in hindsight that I learned from that experience. Now to this day I had a good result with the guy who was my COO who is the younger guy. We tried to buy a company together with private equity fund in London. After that you know 10 years later the guy who was my CTO is the other Co-founder was the technologist who wasn’t the CEO is now on my advisory board for The Braff Group which is really interesting. That was one of the things that attracted me to The Braff Group is other than the number of deals that they’ve closed they were willing to invest in the sector in a way that I thought would make me successful. I have a nine person advisory board that is a paid position where they are a resource for me and it’s people that have been I have two guys that were CTO’s of five or six companies that have been venture funded that have been sold. One in London, one in the US. I have the CMO of Navy Health, I have the CEO of venture fund a company called Stick Care, a woman named Kelsey Mallard. I just added a woman who was named Madel Briggs who was one of the five founding team members of the Martin Luther King Junior hospital in Compton and got voted the most wired Hospital one of most large hospitals in the country. And she was the one who determined all the technology from the ground up as a clinician. So it’s top notch quality people on that board and that was one of the things that sort of drew me to this role. I knew that they were going to invest the right way.

Saul Marquez:
It’s a commitment.

Brett Mankey:
Yeah. It’s a commitment on their part. And there are certain areas that I’m interested in that they’re letting me pursue. I am definitely interested in AI particularly in the medical imaging space. I think that remote patient monitoring and wearables is a thing that’s going to continue to have momentum. I think interoperability anything that solves sort of the deep interoperability issues that a lot of providers have is a very interesting area. Telemedicine the trend is going to have more and more I think tied to remote patient monitoring in many ways. And then I think a lot of the which is tied to A.I. but predictive analytics and things of that nature when coupled with AI are going to lead to a change in how we diagnose diseases. And there’s obviously a lot of other categories but those are some of the ones that really interesting to me. Yeah.

Saul Marquez:
Yeah. Nice. They definitely have a lot of a lot of exciting things going on right now Brett and definitely appreciate your insights there. What book would you recommend to the listeners?

Brett Mankey:
So I thought about this because I read constantly I’m always on airplanes.

Saul Marquez:
You do a lot of audio and you do a lot of you like to read it in your hand or Kindle.

Brett Mankey:
And I need it in my hand saying I can’t do Kindle. I haven’t been able to do it on the trees probably don’t like me for it but I guess part of my old school nature and you know even being a lawyer by training you get used to putting your head in a book right.

Saul Marquez:
Yeah for sure.

Brett Mankey:
So I would say on the fiction side anything by Umberto Eco or Gabrielle Garcia Marquez I like. So if I had to pick to maybe one hundred years of solitude or to calls pendulum and then I read a ton of non-fiction so there’s a three part Roosevelt Teddy Roosevelt biography by Edmund Morris. It’s really good. I… Last Lion by William Manchester which is a Churchill biography I read recently and then I’d say the third category I have that I’ve been reading a lot of lately is things that are multi dimensional in terms of you know a mixture of history and science and all the different things I don’t know if you’ve read anything any of the Ferrari books.

Saul Marquez:
Oh you know what we’ve… I haven’t but he he’s the guy that wrote Sapiens?

Brett Mankey:
Yeah. Now in Homo Deus and…

Saul Marquez:
Homo Deus. Yeah. And those are my…

Brett Mankey:
Those are really good.

Saul Marquez:
But yeah.

Brett Mankey:
And then the other one that’s sort of a precursor to all that stuff. I don’t know if you’ve ever read any. Jared Diamond he wrote Guns Germs and Steel and Collapse but they are really broad take into a number of areas of study that they digest information and presented to you. It’s really fascinating when you can have that broad view and I I would say they’re almost in their own category. Right yeah. Because they’re not history. They’re not just science. They’re not just economics. All of those things are together. And yeah I just think…

Saul Marquez:
It makes one area.

Brett Mankey:
Yeah.

Saul Marquez:
Yeah.

Brett Mankey:
I think that’s right. And I think you know I went to a liberal arts college so I think part of that sort of appeal to me I was actually premed for two years. You just helping in this. Yeah.

Saul Marquez:
Yeah you did tell me that you did tell me that.

Brett Mankey:
Yeah. So it’s sort of coming full circle.

Saul Marquez:
That’s really cool.

Brett Mankey:
For me but I’m enjoying this space immensely. I think it’s very dynamic fast moving other than on the customer side. But there’s a lot of right ways to put these things together and I think that the number of buyers who aren’t obvious who are now buying things and bases you wouldn’t expect is growing rapidly I mean there are payers that are you wouldn’t think would be buyers or buyers there are pharma companies there are device manufacturers. There are obviously there’s all the private equity guys and then you have things like CBS and Aetna and Apple and Amazon and everybody’s attacking this from a different perspective because they all realize this is a market that’s got a lot of change coming. And I would say that you know I’m not only a proponent of Buffett but if you believe some of the things that he believes anytime there’s chaos and there’s blood in the streets there’s opportunity right.

Saul Marquez:
Yup.

Brett Mankey:
So there are going to be people that don’t take advantage of the chaos and are gonna be left behind eventually. So on the larger company side, you’ve got to be willing to destroy your own business. And if you’re not willing to do that or reinvent it someone else is going to do it to you.

Saul Marquez:
Love it man. You definitely left us with a lot to think about. And so Brett I think this is definitely has been an interesting discussion. Folks you know wish we could stay on a little bit longer but we’ve gotten to the end here. Brett is available you could check out a lot of his work and reach out. Brett what would be the best way for them to reach out or follow you?

Brett Mankey:
Yeah. So I’m on Linkedin although I only usually link in with people that I know that was in the first 700000 people in Linkedin and I still only have less than 800 Contacts. I guess I leave my network open so I want to make sure that I know everybody that’s in there. But I think that you know you can reach out to me and my Braff email address which is beingmankey@thebraffgroup.com or you know I’m happy to have anybody there’s a phone number also lists on our website. They can call me if they want to give me a call. I’m happy to speak with them.

Saul Marquez:
Outstanding Brett. Really appreciate the thoughts you shared today and maybe we’ll get you back on here in the next year because it’s always a pleasure to speak to you so appreciate you carving out the time for us.

Brett Mankey:
You’re welcome Saul I enjoyed it as well. Thanks. I look forward to talking again soon.

Thanks for listening to the Outcomes Rocket podcast. Be sure to visit us on the web at www.outcomesrocket.com for the show notes, resources, inspiration, and so much more.

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