S-1 1 d181009ds1.htm FORM S-1 Form S-1
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As filed with the Securities and Exchange Commission October 18, 2021

Registration No. 333-            

 

 

 

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

 

 

FORM S-1

REGISTRATION STATEMENT

UNDER

THE SECURITIES ACT OF 1933

 

 

BrightSpring Health Services, Inc.

(Exact name of registrant as specified in its charter)

 

 

 

Delaware   8082   82-2956404
(State or other jurisdiction of
incorporation or organization)
  (Primary Standard Industrial
Classification Code Number)
 

(I.R.S. Employer

Identification No.)

 

 

805 N. Whittington Parkway

Louisville, Kentucky 40222

(502) 394-2100

(Address, including zip code, and telephone number, including area code, of registrant’s principal executive offices)

 

 

Steven S. Reed, Esq.

Chief Legal Officer

805 N. Whittington Parkway

Louisville, Kentucky 40222

(502) 630-7438

(Name, address, including zip code, and telephone number, including area code, of registrant’s agent for service)

 

 

With copies to:

 

Joseph H. Kaufman, Esq.

Sunny Cheong, Esq.

Simpson Thacher & Bartlett LLP

425 Lexington Avenue

New York, New York 10017

(212) 455-2000

 

Marc D. Jaffe, Esq.

Ian D. Schuman, Esq.

Latham & Watkins LLP

1271 Avenue of the Americas

New York, New York 10020

(212) 906-1200

 

 

Approximate date of commencement of proposed sale to the public: As soon as practicable after this Registration Statement is declared effective.

If any of the securities being registered on this Form are to be offered on a delayed or continuous basis pursuant to Rule 415 under the Securities Act of 1933, check the following box:  ☐

If this Form is filed to register additional securities for an offering pursuant to Rule 462(b) under the Securities Act, please check the following box and list the Securities Act registration statement number of the earlier effective registration statement for the same offering.  ☐

If this Form is a post-effective amendment filed pursuant to Rule 462(c) under the Securities Act, check the following box and list the Securities Act registration statement number of the earlier effective registration statement for the same offering.  ☐

If this Form is a post-effective amendment filed pursuant to Rule 462(d) under the Securities Act, check the following box and list the Securities Act registration statement number of the earlier effective registration statement for the same offering.  ☐

Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, a smaller reporting company or an emerging growth company. See the definitions of “large accelerated filer,” “accelerated filer” “smaller reporting company” and “emerging growth company” in Rule 12b-2 of the Exchange Act:

 

Large accelerated filer      Accelerated filer  
Non-accelerated filer      Smaller reporting company  
     Emerging growth company  

If an emerging growth company, indicate by check mark if the registrant has elected not to use the extended transition period for complying with any new or revised financial accounting standards provided pursuant to Section 7(a)(2)(B) of the Securities Act.  ☐

 

 

CALCULATION OF REGISTRATION FEE

 

 

Title of Each Class of
Securities to be Registered
 

Proposed

Maximum
Aggregate

Offering Price(1)

  Amount of
Registration Fee

Common Stock, $0.01 par value per share(2)

  $100,000,000   $9,270

            % Tangible Equity Units(3)

  $100,000,000   $9,270

Stock Purchase Contracts

       

Amortizing Notes

       

Total

  $200,000,000   $18,540

 

 

(1)

Estimated solely for the purpose of calculating the registration fee in accordance with Rule 457(o) promulgated under the Securities Act of 1933, as amended.

(2)

Includes shares of common stock that the underwriters have the option to purchase. See “Underwriting (Conflicts of Interest).”

(3)

Includes                Tangible Equity Units that are subject to the underwriters’ option to purchase additional Tangible Equity Units. Each Tangible Equity Unit is comprised of a stock purchase contract and an amortizing note. This registration statement also registers an estimated                shares of the Registrant’s common stock that are issuable upon settlement of the purchase contracts that are a component of the Tangible Equity Units registered hereby, at the initial rate of                shares of common stock per purchase contract, based on the assumed initial public offering price of $        per share, which is the midpoint of the estimated price range set forth on the cover page of the common stock prospectus which forms a part of this registration statement and assuming the maximum number of shares issuable upon automatic settlement of such purchase contracts. Under Rule 457(i), there is no additional filing fee payable with respect to the shares of common stock issuable upon settlement of the purchase contracts because no additional consideration will be received in connection with the settlement. The number of shares of the Registrant’s common stock issuable upon such settlement will vary based on the public offering price of the common stock registered hereby. The number of the Registrant’s shares issuable upon settlement of the purchase contracts is subject to anti-dilution adjustments upon the occurrence of certain events described herein. Pursuant to Rule 416 under the Securities Act, the number of the Registrant’s shares to be registered includes an indeterminable number of shares that may become issuable upon settlement of the purchase contracts as a result of such anti-dilution adjustment, solely to the extent permitted by Rule 416.

 

 

The Registrant hereby amends this Registration Statement on such date or dates as may be necessary to delay its effective date until the Registrant shall file a further amendment which specifically states that this Registration Statement shall thereafter become effective in accordance with Section 8(a) of the Securities Act of 1933, as amended, or until this Registration Statement shall become effective on such date as the Securities and Exchange Commission, acting pursuant to said Section 8(a), may determine.

 

 

 


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EXPLANATORY NOTE

This Registration Statement contains a prospectus relating to an offering of shares of BrightSpring Health Services, Inc.’s common stock, or for purposes of this Explanatory Note, the Common Stock Prospectus, together with separate prospectus pages relating to an offering of BrightSpring Health Services, Inc.’s Tangible Equity Units, or for purposes of this Explanatory Note, the Tangible Equity Units Prospectus. The complete Common Stock Prospectus follows immediately. Following the Common Stock Prospectus are the following alternative and additional pages for the Tangible Equity Units Prospectus:

 

   

front and back cover pages, which will replace the front and back cover pages of the Common Stock Prospectus;

 

   

pages for the “Summary—The Offering” section, which will replace the “Summary—The Offering” section of the Common Stock Prospectus;

 

   

pages for the “Risk Factors—Risks Related to the Units, the Separate Purchase Contracts, the Separate Amortizing Notes and Our Common Stock” section, which will be added to the “Risk Factors” section of the Tangible Equity Units Prospectus;

 

   

pages for the “Description of the Units,” “Description of the Purchase Contracts” and “Description of the Amortizing Notes” sections, which will replace the “Tangible Equity Units Offering” section of the Common Stock Prospectus;

 

   

pages for the “Certain United States Federal Income Tax Consequences” section, which will replace the “Certain U.S. Federal Income Tax Consequences to Non-U.S. Holders” section of the Common Stock Prospectus;

 

   

pages for the “Certain ERISA Considerations” and “Book-Entry Procedures and Settlement” sections, which will be added to the Tangible Equity Units Prospectus; and

 

   

pages for the “Underwriting (Conflicts of Interest)” section, which will replace the “Underwriting (Conflicts of Interest)” section of the Common Stock Prospectus.

The following disclosures and references contained within the Common Stock Prospectus will be replaced or removed in the Tangible Equity Units Prospectus:

 

   

references to “shares of our common stock” contained in the first three paragraphs under “Table of Contents” and the first paragraph under “Risk Factors” will be replaced with references to “the Units” in the Tangible Equity Units Prospectus;

 

   

references to “our common stock” contained in the first paragraph under “Summary,” the first paragraph of “Summary—Summary of Risk Factors” and the first paragraph under “Risk Factors” will be replaced with references to “the Units” in the Tangible Equity Units Prospectus;

 

   

the disclosure under “Summary—Concurrent Offering” will be replaced in its entirety with “Concurrently with this offering, we are offering, by means of a separate prospectus,             shares of our common stock (or up to             shares of our common stock if the underwriters in the Concurrent Offering exercise in full their option to purchase additional shares of our common stock). We estimate that the net proceeds to us from the sale of shares of our common stock in the Concurrent Offering will be approximately $            million (or approximately $            million if the underwriters exercise in full their option to purchase additional shares of our common stock), assuming an initial public offering price of $            per share (which is the midpoint of the price range set forth on the cover page of the prospectus relating to the Concurrent Offering), in each case after deducting estimated underwriting discounts and commissions and estimated offering expenses payable by us. The closing of this offering is conditioned upon the closing of the Concurrent Offering, but the closing of the Concurrent Offering is not conditioned upon the closing of this offering, and there can be no assurance that the Concurrent Offering will be completed on the terms described in the prospectus relating to the Concurrent Offering or at all.” in the Tangible Equity Units Prospectus;


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references to “this offering” contained in “Summary Historical Consolidated Financial and Other Data,” “Risk Factors,” “Use of Proceeds,” “Capitalization,” “Dilution,” “Management’s Discussion and Analysis of Financial Condition and Results of Operations,” “Management,” “Executive Compensation,” “Certain Relationships and Related Party Transactions,” “Principal Stockholders,” “Description of Capital Stock,” “Description of Certain Indebtedness,” “Shares Eligible for Future Sale” and “Where You Can Find More Information” will be replaced with references to “the Concurrent Offering” in the Tangible Equity Units Prospectus;

 

   

references to “the concurrent offering of the Units” contained in “Risk Factors,” “Use of Proceeds,” “Capitalization” and “Shares Eligible for Future Sale” will be replaced with references to “this offering” in the Tangible Equity Units Prospectus;

 

   

“Risk Factors—General Risk Factors—There has been no prior public market for our common stock and there may not develop or continue an active, liquid trading market for shares of our common stock, which may cause shares of our common stock to trade at a discount from the initial offering price and make it difficult to sell the shares of common stock you purchase.,” “Risk Factors—General Risk Factors—Our stock price may change significantly following this offering, and you may not be able to resell shares of our common stock at or above the price you paid or at all, and you could lose all or part of your investment as a result.,” and “Risk Factors—General Risk Factors—Investors in this offering will suffer immediate and substantial dilution.” will be removed in the Tangible Equity Units Prospectus;

 

   

the second paragraph under “Risk Factors—General Risk Factors—You may be diluted by the future issuance of additional common stock in connection with our incentive plans, acquisitions or otherwise.” will be removed in the Tangible Equity Units Prospectus;

 

   

the first sentence of the first paragraph under “Dilution” will be replaced in its entirety with “Investors in shares of our common stock in the Concurrent Offering will experience immediate dilution in their investment to the extent of the difference between the initial public offering price per share of our common stock in the Concurrent Offering and the as adjusted net tangible book value per share of our common stock after giving effect to the Concurrent Offering.” in the Tangible Units Prospectus;

 

   

references to the “concurrent issuance of the Units” will be replaced with references to “issuance of Units in this offering” in the Tangible Equity Units Prospectus;

 

   

references to “midpoint of the price range set forth on the cover page of this prospectus” will be replaced with “midpoint of the price range set forth on the cover page of the prospectus relating to the Concurrent Offering” in the Tangible Equity Units Prospectus;

 

   

references to “assuming the number of shares of common stock offered by us, as set forth on the cover page of this prospectus, remains the same” will be replaced with “assuming the number of shares of common stock offered by us in the Concurrent Offering, and as shown on the cover page of the prospectus relating to the Concurrent Offering, remains the same” in the Tangible Equity Units Prospectus;

 

   

the second paragraph under “Use of Proceeds” will be moved as the first paragraph under the section in the Tangible Equity Units Prospectus;

 

   

the references to “, if completed,” will be removed from the second paragraph under the “Use of Proceeds” section in the Tangible Equity Units Prospectus;

 

   

the last sentence of the second paragraph under the “Capitalization” section will be removed in the Tangible Equity Units Prospectus;

 

   

the references to “, as described in “Tangible Equity Units Offering” in footnotes (3) and (4) under the “Capitalization” section will be removed in the Tangible Equity Units Prospectus;

 

   

references to “this prospectus” contained in “Shares Eligible for Future Sale—Lock-Up Agreements” will be replaced with references to “the prospectus relating to the Concurrent Offering” in the Tangible Equity Units Prospectus;


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the reference to “shares of common stock” in “Legal Matters” will be replaced with references to “the tangible equity units, stock purchase contracts and amortizing notes” in the Tangible Equity Units Prospectus; and

 

   

the references to “common stock” and “our common stock” in “Where You Can Find More Information” will be replaced with references to “the tangible equity units, stock purchase contracts and amortizing notes” in the Tangible Equity Units Prospectus.

All words and phrases similar to those specified above that appear throughout the Common Stock Prospectus will be revised accordingly to make appropriate references in the Tangible Equity Units Prospectus.

Each of the complete Common Stock Prospectus and Tangible Equity Units Prospectus will be filed with the Securities and Exchange Commission in accordance with Rule 424 under the Securities Act of 1933, as amended. The closing of the offering of common stock is not conditioned upon the closing of the offering of Tangible Equity Units, but the closing of the offering of Tangible Equity Units is conditioned upon the closing of the offering of common stock.


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The information in this preliminary prospectus is not complete and may be changed. These securities may not be sold until the registration statement filed with the Securities and Exchange Commission is effective. This preliminary prospectus is not an offer to sell these securities nor a solicitation of an offer to buy these securities in any jurisdiction where the offer and sale is not permitted.

 

Subject to completion, dated October 18, 2021

Preliminary Prospectus

                 Shares

 

LOGO

BrightSpring Health Services, Inc.

Common Stock

 

 

This is the initial public offering of common stock of BrightSpring Health Services, Inc. We are offering                  shares of our common stock.

Prior to this offering, there has been no public market for our common stock. We expect that the initial public offering price of our common stock will be between $         and $         per share. We intend to apply to list our common stock on the Nasdaq Global Select Market, or Nasdaq, under the symbol “                .”

Concurrently with this offering, we are also making a public offering of                % tangible equity units, or the Tangible Equity Units or the Units, which is being made by means of a separate prospectus and not by means of this prospectus. In that offering, we have granted the underwriters of that offering an option to purchase, within 13 days beginning on, and including, the date of the initial issuance of the Units, up to an additional                Units. We cannot assure you that the offering of Units will be completed or, if completed, on what terms it will be completed. The closing of this offering is not conditioned upon the closing of the offering of Units, but the closing of the offering of Units is conditioned upon the closing of this offering.

After the completion of this offering, KKR Phoenix Aggregator L.P., an investment entity owned by investment funds and other entities affiliated with Kohlberg Kravis Roberts & Co. L.P., and Walgreen Co., an affiliate of Walgreens Boots Alliance, Inc., will collectively beneficially own approximately                 % of the voting power of our common stock. As a result, we will be a “controlled company” within the meaning of the corporate governance standards of Nasdaq. See “Management—Controlled Company Exemption” and “Principal Stockholders.”

 

 

Investing in our common stock involves risks. See “Risk Factors“ beginning on page 34 to read about factors you should consider before buying shares of our common stock.

Neither the Securities and Exchange Commission, or the SEC, nor any state securities commission has approved or disapproved of these securities or passed upon the adequacy or accuracy of this prospectus. Any representation to the contrary is a criminal offense.

 

     Per
Share
     Total  

Initial public offering price

   $                    $                

Underwriting discounts and commissions(1)

   $        $    

Proceeds, before expenses, to us

   $        $    

 

(1)

See “Underwriting (Conflicts of Interest)” for additional information regarding underwriting compensation.

We have granted the underwriters a 30-day option from the date of this prospectus to purchase up to                  additional shares of our common stock at the initial public offering price, less underwriting discounts and commissions, to cover over-allotments, if any.

The underwriters expect to deliver the shares on or about                 , 2021.

 

 

 

Goldman Sachs & Co. LLC   Jefferies   KKR   Credit Suisse   Guggenheim Securities   SVB Leerink

 

BofA Securities  

BMO Capital Markets

  Deutsche Bank Securities   HSBC
Mizuho Securities  

Morgan Stanley

  Wells Fargo Securities   William Blair

The date of this prospectus is                 , 2021.


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LOGO


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TABLE OF CONTENTS

 

     Page  

Industry and Market Data

     ii  

Trademarks, Tradenames, Service Marks and Copyrights

     ii  

Basis of Presentation

     ii  

Non-GAAP Financial Measures

     iv  

Summary

     1  

Risk Factors

     34  

Forward-Looking Statements

     79  

Use of Proceeds

     82  

Dividend Policy

     83  

Capitalization

     84  

Dilution

     86  

Management’s Discussion and Analysis of Financial Condition and Results of Operations

     88  

Business

     127  

Management

     166  

Executive Compensation

     173  

Certain Relationships and Related Party Transactions

     198  

Principal Stockholders

     201  

Tangible Equity Units Offering

     203  

Description of Capital Stock

     205  

Description of Certain Indebtedness

     213  

Shares Eligible for Future Sale

     217  

Certain U.S. Federal Income Tax Consequences to Non-U.S. Holders

     219  

Underwriting (Conflicts of Interest)

     222  

Legal Matters

     228  

Experts

     228  

Where You Can Find More Information

     228  

Index to Financial Statements

     F-1  

 

 

Through and including the 25th day after the date of this prospectus, all dealers that effect transactions in these shares of our common stock, whether or not participating in this offering, may be required to deliver a prospectus. This is in addition to the dealers’ obligations to deliver a prospectus when acting as underwriters and with respect to their unsold allotments or subscriptions.

You should rely only on the information contained in this prospectus or in any free writing prospectus we may authorize to be delivered or made available to you. Neither we nor the underwriters have authorized anyone to provide you with different information. The information in this prospectus is accurate only as of the date of this prospectus, regardless of the time of delivery of this prospectus, or any free writing prospectus, as the case may be, or any sale of shares of our common stock.

For investors outside the United States: we are offering to sell, and seeking offers to buy, shares of our common stock only in jurisdictions where offers and sales are permitted. Neither we nor the underwriters have done anything that would permit this offering or possession or distribution of this prospectus in any jurisdiction where action for that purpose is required, other than in the United States. Persons outside the United States who come into possession of this prospectus must inform themselves about, and observe any restrictions relating to, the offering of the shares of common stock and the distribution of this prospectus outside the United States.

 

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INDUSTRY AND MARKET DATA

Within this prospectus, we reference information and statistics regarding the industries in which we compete. We have obtained this information and statistics from various independent third-party sources, including independent trade associations, industry publications, government publications, reports by market research firms and other independent sources. Some data and other information contained in this prospectus are also based on management’s estimates and calculations, which are derived from our review and interpretation of internal company research, surveys, information from our customers and suppliers, trade and business organizations and other contacts in the markets in which we operate and independent sources. Statements regarding our competitive position, such as our statements that we are the largest independent provider of community-based health services in the United States and that we are one of the largest independent hospice pharmacies in the United States, are based on market share as calculated by revenue. Data regarding the industries in which we compete and our market position and market share within the industries are inherently imprecise and are subject to significant business, economic and competitive uncertainties beyond our control, but we believe they generally indicate size, position and market share within the industries. While we believe such information is reliable, we have not independently verified any third-party information. While we believe our internal company research, surveys and estimates are reliable, such research, surveys and estimates have not been verified by any independent source. In addition, assumptions and estimates of our and our industries’ future performance are necessarily subject to a high degree of uncertainty and risk due to a variety of factors, including those described in “Risk Factors.” These and other factors could cause our future performance to differ materially from our assumptions and estimates. See “Forward-Looking Statements.”

TRADEMARKS, TRADENAMES, SERVICE MARKS AND COPYRIGHTS

We own or have rights to use various trademarks, tradenames, service marks and copyrights, which are protected under applicable intellectual property laws, including, for example: BrightSpring, PharMerica, ResCare, All Ways Caring, Amerita, Onco360, Chem Rx, Equus and Rehab Without Walls. This prospectus also contains trademarks, tradenames, service marks and copyrights of other companies, which are, to our knowledge, the property of their respective owners. Solely for convenience, certain trademarks, tradenames, service marks and copyrights referred to in this prospectus may appear without the ©, ® and symbols, but such references are not intended to indicate, in any way, that we will not assert, to the fullest extent under applicable law, our rights or the rights of the applicable licensors to these trademarks, tradenames, service marks and copyrights. We do not intend our use or display of other parties’ trademarks, tradenames, service marks or copyrights to imply, and such use or display should not be construed to imply, a relationship with, or endorsement or sponsorship of us by, these other parties.

BASIS OF PRESENTATION

Certain Definitions

The following terms are used in this prospectus unless otherwise noted or indicated by the context:

 

   

“ABA” means applied behavioral analysis, a type of therapy that focuses on improving specific behaviors;

 

   

“ABI/TBI” means acquired/traumatic brain injury;

 

   

“Abode” means Abode Healthcare, which we acquired in April 2021;

 

   

“Behavioral” patients and populations mean individuals with intellectual and developmental disabilities including mental illness;

 

   

“BrightSpring,” “BrightSpring Health Services,” “Company,” “we,” “us” and “our” refer to BrightSpring Health Services, Inc. and its consolidated subsidiaries;

 

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“de novo” means new branch, agency, facility, clinic and pharmacy locations;

 

   

“First Lien Facilities” mean, collectively, the First Lien Term Loan Facility, the Revolving Credit Facility and the LC Facility;

 

   

“First Lien Term Loan Facility” means, collectively, the Initial Term Loans, the Tranche B-2 Term Loans and the Tranche B-3 Term Loans, each as described under “Management’s Discussion and Analysis of Financial Condition and Results of Operations — Liquidity and Capital Resources — Debt;”

 

   

“I/DD” means an intellectual/developmental or cognitive disability;

 

   

“KKR Stockholder” means KKR Phoenix Aggregator L.P., an investment entity owned by investment funds and other entities affiliated with Kohlberg Kravis Roberts & Co. L.P.;

 

   

“LC Facility” means our letter of credit facility, as described under “Management’s Discussion and Analysis of Financial Condition and Results of Operations — Liquidity and Capital Resources — Debt;”

 

   

“Neuro” patients and populations mean individuals who have acquired a traumatic brain injury, spinal cord injury, pediatric autism, or other neurological condition;

 

   

“OPPC” means OnePoint Patient Care, which we acquired in September 2020;

 

   

“Revolving Credit Facility” means our senior secured revolving credit facility, as described under “Management’s Discussion and Analysis of Financial Condition and Results of Operations — Liquidity and Capital Resources — Debt;”

 

   

“Second Lien Facility” means our senior secured second lien term loan facility, as described under “Management’s Discussion and Analysis of Financial Condition and Results of Operations — Liquidity and Capital Resources — Debt;”

 

   

“Senior” patients and populations mean individuals who are aged 65 and older;

 

   

“Specialty” patients and populations mean individuals who have unique, specialized and most often chronic/life-long health conditions and needs; and

 

   

“Walgreen Stockholder” means Walgreen Co., an affiliate of Walgreens Boots Alliance, Inc.

Presentation of Financial and Other Information

BrightSpring Health Services, Inc. conducts its operations through its subsidiaries, including its indirect subsidiaries, BrightSpring Health Holdings Corp. and its wholly-owned subsidiary, ResCare, Inc., and PharMerica Corporation, or PharMerica.

Our fiscal year ends December 31 of each year. References to any “year,” “quarter,” “half” or “month” mean “fiscal year,” “fiscal quarter,” “fiscal half year” and “fiscal month,” respectively, unless the context requires otherwise. References to “2018,” “2019” and “2020” relate to our fiscal years ended December 31, 2018, December 31, 2019 and December 31, 2020, unless the context otherwise requires.

In this prospectus, where we discuss the number of de novos opened since 2018, such number includes de novos opened by each business we acquired prior to our acquisition of such business if opened since 2018.

Numerical figures included in this prospectus have been subject to rounding adjustments. Accordingly, numerical figures shown as totals in various tables may not be arithmetic aggregations of the figures that precede them.

 

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NON-GAAP FINANCIAL MEASURES

This prospectus contains “non-GAAP financial measures,” which are financial measures that either exclude or include amounts that are not excluded or included in the most directly comparable measures calculated and presented in accordance with accounting principles generally accepted in the United States, or GAAP. Specifically, we make use of the non-GAAP financial measures “EBITDA” and “Adjusted EBITDA.”

EBITDA and Adjusted EBITDA have been presented in this prospectus as supplemental measures of financial performance that are not required by, or presented in accordance with, GAAP, because we believe they assist investors and analysts in comparing our operating performance across reporting periods on a consistent basis by excluding items that we do not believe are indicative of our core operating performance. Management also believes that these measures are useful to investors in highlighting trends in our operating performance, while other measures can differ significantly depending on long-term strategic decisions regarding capital structure, the tax jurisdictions in which we operate and capital investments. Management uses EBITDA and Adjusted EBITDA to supplement GAAP measures of performance in the evaluation of the effectiveness of our business strategies, to make budgeting decisions, to establish and award discretionary annual incentive compensation, and to compare our performance against that of other peer companies using similar measures.

Management supplements GAAP results with non-GAAP financial measures to provide a more complete understanding of the factors and trends affecting the business than GAAP results alone. EBITDA and Adjusted EBITDA are not GAAP measures of our financial performance and should not be considered as an alternative to net income (loss) as a measure of financial performance or any other performance measures derived in accordance with GAAP. Additionally, these measures are not intended to be a measure of free cash flow available for management’s discretionary use as they do not consider certain cash requirements such as tax payments, debt service requirements, total capital expenditures and certain other cash costs that may recur in the future. The presentations of these measures have limitations as analytical tools and should not be considered in isolation, or as a substitute for analysis of, our results as reported under GAAP. Because not all companies use identical calculations, the presentations of these measures may not be comparable to other similarly titled measures of other companies and can differ significantly from company to company. For a discussion of the use of these measures and a reconciliation of the most directly comparable GAAP measures, see “Summary —Summary Historical Consolidated Financial and Other Data.”

 

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SUMMARY

This summary highlights selected information contained elsewhere in this prospectus. This summary does not contain all of the information that you should consider before deciding to invest in our common stock. You should read the entire prospectus carefully, including “Risk Factors,” “Management’s Discussion and Analysis of Financial Condition and Results of Operations,” and our consolidated financial statements and related notes included elsewhere in this prospectus, before making an investment decision. This summary contains forward-looking statements that involve risks and uncertainties.

Summary Highlights of Our Business

 

   

A leading, diversified, independent provider of home and community-based healthcare services in the United States

 

   

Focus on clinical and operational excellence and coordinated front-line healthcare services to deliver optimal patient outcomes in lower-cost settings and help people live their best lives

 

   

Compelling and proven value proposition for all constituents, including our clients, patients and respective families, customers, partners, payors, employees, and investors

 

   

Purpose-built suite of complementary provider and pharmacy services that more completely address the needs of complex Senior and Specialty patients

 

   

Scaled national platform with a presence in all 50 states, a quality and compliance focus, longer-term customer relationships, a successful M&A track record, and an experienced management team

 

   

Over $1.5 trillion combined market opportunity across our business lines with numerous positive industry trends and drivers

 

   

Growth opportunities through organic expansion in core provider and pharmacy businesses, our ability to leverage complementary services for referral synergies, penetration of adjacent markets, and innovation in value-based care payment models, as well as through strategic M&A

 

   

In 2020, grew revenue by $1.1 billion, or 23.3%, to $5.6 billion with numerous businesses growing organically into the double-digits and growth bolstered by strategic and accretive acquisitions

 

   

In 2020, increased net income by $92.2 million, or 129.8%, to $21.2 million and increased Adjusted EBITDA by $79.5 million, or 23.9%, to $412.0 million

 

   

In 2020, delivered $222.6 million in cash flow from operations

Who We Are

We are a leading home and community-based healthcare services platform, focused on delivering complementary provider and pharmacy services to complex patients. We have a differentiated approach to care delivery, with a purpose-built and scaled model that addresses the three critical services that the highest-need and highest-cost patients require. With a focus on Senior and Specialty patients, which includes Behavioral populations, our platform provides clinical services, supportive care and pharmacy solutions in lower-cost home and community settings to Medicare, Medicaid and commercially-insured populations. We are an essential part of our nation’s health delivery network as a front-line provider of high-quality and cost-effective care to a large and growing number of people, who increasingly require a combination of specialized solutions to enable holistic health care management. Our presence spans all 50 states, we serve over 330,000 patients daily through our approximately 10,000 clinical providers and pharmacists, and our services make a profound impact in the lives and communities of the people we serve.

Our model focuses on delivering high-touch and coordinated services to medically-complex clients and patients, which is a large, growing and underserved population in the U.S. healthcare system. These high-need


 

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and high-cost Senior and Specialty patients comprise a market of over $1.5 trillion across our business lines. The chronic conditions and long-term health needs of these patients not only represent an outsized share of health care spend today, but also are expected to drive a disproportionate share of future expenditures. Americans with five or more chronic conditions make up 12% of the population and account for 41% of total health care spending, on average spending 14 times more on health services than those without chronic conditions. These patients require clinical services, supportive care and pharmacy solutions to achieve quality outcomes, but must often navigate disjointed and separately-administered health services. This can result in uncoordinated care delivery with adverse medical consequences, as compared to receiving timely, proximal and complete care support in the home and community that improves health and reduces cost.

We have built a significant presence and expertise in delivering complementary and high-touch daily healthcare services and programs to complex patients in their homes and in communities in order to address their multiple health needs and requirements more completely. Our provider health services consist of both clinical and supportive care that are customized to individual patient needs. Clinical services consist of Home Health and Hospice to Seniors, as well as Home-Based Primary Care, Rehab Therapy and nursing to Senior and Specialty populations, including Neuro and Behavioral patients. Supportive care consists of services that address activities of daily living and social determinants of health for both Senior and Specialty populations as well. Often in tandem with our provider services, we provide alternative site daily pharmacy solutions across many home and community settings, including Senior Living communities, Hospice sites of care, homes of Seniors who are on a significant number of medications, Neuro and Behavioral clients’ and patients’ homes, Home Infusion, and Specialty Pharmacy (primarily oncology), as well as providing pharmacy solutions to skilled nursing and rehabilitation facilities and hospitals. By providing a complementary and purpose-built suite of services, our care model is designed to address more patient needs and better integrate health services delivery to improve outcomes and patient experiences, while reducing overall costs.

We believe that our care model is well-positioned for the long-term, as it is underpinned by several characteristics and capabilities that suggest continued differentiation and growth:

 

   

Purpose-built suite of complementary services that address whole person health – We purposely built a healthcare platform that brings together provider and pharmacy care to address the full spectrum of interrelated and chronic needs of Senior and Specialty patients. Through our comprehensive care capabilities and unique programs, we are able to develop a multi-year whole-person view of our patients, which enables us to provide skilled clinical services, more closely manage daily medication requirements and adherence, and address social determinants of health and daily care needs. Moreover, we believe that this “whole person” model and capability set will increasingly be the most effective approach for providing high-need and high-cost Senior and Specialty populations the care services and pharmacy solutions they require.

 

   

Serving complex patients in the home and community setting – With over 40 years of experience caring for “must-serve” client and patient populations, we deliver longitudinal care in preferred and lower-cost settings with strong quality results. Our services reduce cost by providing care for many of these individuals in non-institutional home and community settings and reducing hospitalizations. For example, in our Provider Services business, our complex Behavioral clients, often with three or more comorbidities and requiring eight or more medications, spend 360 days a year at home on average. 73% of our Home Health patients are discharged in their communities staying in their homes. We achieve an 85% overall rating of care in Hospice, a patient satisfaction level of 99% in Rehab, and our long-term care pharmacies achieve 99.99% order accuracy, 99.77% order completeness and 98.59% on-time delivery, with “excellent” and “world class” Net Promoter Scores, or NPS, across several businesses. We believe that we are positioned to more effectively deliver care, identify potential medical problems that often go undetected and avoid adverse events due to our presence in the home and community and highly proximate position to patients.


 

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Market-leading scale with a focus on operational excellence and coordinated front-line care – We manage one of the nation’s largest independent platforms of both provider and pharmacy services offered on a daily basis in home and community settings – to address the multiple needs of medically complex Senior and Specialty patients. Our leading scale across all 50 states has important benefits. Our scale provides exposure and access to a broader set of market growth opportunities, while also providing diversification and risk mitigation in payor sources, geographies and end markets. Further, we leverage economies of scale and best practices across the company, including in purchasing, quality, technology, human resources, and advocacy and payor relations. Our scale and services allow us to effectively deliver and coordinate a portfolio of integrated solutions to and across care settings, which we believe will be important in the ongoing development of value-based care solutions. Ultimately, our track record of building market density, expanding into complementary service lines, and replicating this model across new geographies underpins both our historical results as well as our growth strategies.

We are the largest independent provider of community-based health services in the United States, offering skilled, impactful and complementary health and related care solutions. Almost all of the clients and patients that we serve have chronic conditions and the vast majority of them receive their services on a recurring basis over long periods of time, with our Provider Services patient base having an average of six chronic conditions per patient. Our leading clinical and supportive care services delivered over 16 million hours of quality and compassionate care in 2020 to Home Health, Hospice and Senior home care patients, with a current census of over 30,000, and delivered approximately four million hours of clinical care and an additional one-and-a-half million hours of therapy in 2020 to Rehab and Behavioral patients in our Long-Term Specialty Care business, with a current census over 18,000. With an average of nine prescriptions per patient, our daily pharmacy solutions are delivered from 178 pharmacy centers, specialty infusion centers and specialty oncology locations that we operate across all 50 states, with a fast, local, “white-glove” delivery model. In 2020, we provided over 30 million prescriptions across many different patient types and patient settings from our pharmacies and supporting clinical teams. Combined, our daily provider services and pharmacy solutions serve from and to approximately 7,000 office, clinic and customer locations across the country, with over 330,000 patients serviced at any one time, including over 125,000 patients served in their homes at any one time. These provider services and pharmacy solutions are delivered by our approximately 37,000 dedicated full-time equivalent employees across the country, who are focused on improving outcomes in the most efficient way.


 

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LOGO

We believe our historical results and success are due to both our scale and diversified yet complementary businesses and service models, which enable us to grow and pursue opportunities in attractive, preferred and targeted markets that are principally based in home and community delivery settings. We target markets and services that can leverage a mix of offerings and provide multiple required services to patients to improve quality, increase revenue per patient, reduce healthcare system costs, and provide a greater opportunity set of strategic and accretive acquisitions. Our 2020 Home and Community Health Provider Services segment revenue was $1,683.8 million, accounting for 30.2% of total revenue, and our 2020 Home and Community Health Provider Services Segment EBITDA was $229.6 million, accounting for 43.6% of total Segment EBITDA. Our 2020 Pharmacy Solutions segment revenue was $3,635.9 million, accounting for 65.2% of total revenue, and our 2020 Pharmacy Solutions Segment EBITDA was $275.5 million, accounting for 52.3% of total Segment EBITDA. Across all of our lines of business, we believe that aggregate market growth combined with our scale, operating capabilities, integrated platform of provider and pharmacy services and acquisition opportunity set have allowed us to grow and increase market share.

From 2018 to 2020, we have grown revenue from $2,536.1 million to $5,580.4 million, largely due to acquisitions, with the BHS Acquisition contributing $1,915.1 million and other acquisitions collectively contributing $386.4 million to our total revenue. We incurred $1,800.0 million of the first lien term loans and $450.0 million of second lien term loans in 2019 and an additional $550.0 million first lien term loans in 2020 to primarily fund our acquisitions, including to refinance the existing debt incurred to fund prior acquisitions, with the remainder being used for general corporate purposes. From 2018 to 2020, we have grown net income (loss) from $(7.6) million to $21.2 million and Adjusted EBITDA from $163.8 million to $412.0 million. For the six months ended June 30, 2021, our total revenue was $3,160.4 million, representing a 17.1% increase from $2,698.1 million in the six months ended June 30, 2020. For the six months ended June 30, 2021 and 2020, our net income was $18.5 million and $6.9 million, respectively. We recorded Adjusted EBITDA of $238.3 million in the six months ended June 30, 2021, representing a 24.5% increase from $191.4 million in the six months ended June 30, 2020. We


 

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incurred an additional $675.0 million of first lien term loans in the six months ended June 30, 2021 primarily to fund our acquisition of Abode. See “—Summary Historical Consolidated Financial and Other Data” for a definition of Adjusted EBITDA and reconciliations of Adjusted EBITDA to net income (loss).

Our Value Proposition

We believe that our care model offers a compelling value proposition for numerous constituents, including our clients, patients, customers, strategic partners, referral sources (including physicians, hospital systems and states), payors, policymakers, federal, state and municipal legislators, clients’ and patients’ families, employees, other healthcare industry stakeholders, and future investors.

We bring value to high-need, medically complex patients: We have purposely built our platform with an intention to provide optimal care for the highest-need, highest-cost and most complex Senior and Specialty patients in the homes and communities in which they live. Our mission is to make a difference in people’s lives and communities, in helping them live more independently and achieve patient-specific health goals and outcomes.

Our consistent quality performance in providing services for patients with challenging conditions is evidenced over time by strong and leading metrics. Our Home Health Star Ratings average greater than 4 (out of 5) and exceed the national average, with a 73% discharge rate of patients in the community, which is higher than the national average of 60%, and an 89% composite score on Home Health Consumer Assessment of Healthcare Providers and Systems, or CAHPS, which is higher than the national average score of 85%. Our 99% Hospice Information Set, or HIS, score (an index comprising seven key quality measures) is seven percent above the national average. 88% of our Rehab patients do not require rehospitalization after therapy. Our long-term care pharmacy patients receive their medications accurately, completely and on-time, at industry leading rates of 99.99%, 99.77% and 98.59%, respectively, which we believe contributes to our “excellent” and “world class” NPS ratings of 51 in long-term care pharmacy and 90 in Specialty pharmacy, respectively.

We bring value to payors and are well positioned for potential shifts towards value-based care arrangements: We believe that proximal, attentive and quality home and community-based services combined with our whole-person approach to care reduces costs in the healthcare system for medically complex populations, while also delivering improved member outcomes. We provide home-based primary care, which is associated with a 50% reduction in readmission and a 20% reduction in emergency room visits. We estimate that the average cost per day of home care is 80% less than hospital care, and the use of personal care is key to delaying or preventing unnecessary facility placement, as well as reducing costs by roughly half relative to the per day cost of institutional long-term care. We reduce the cost of long-term care for Behavioral patients by $115,000 - $165,000 per person per year. Furthermore, our value is uniquely and significantly enhanced by our ability to provide complementary pharmacy solutions. Our daily pharmacy solutions allow our customers and patients to benefit from our proprietary programs to optimally manage medication regimens and drug utilization and minimize adverse medical effects, which result in average savings of approximately $600 per patient, with the potential for $2,400 savings from increased medication adherence.

We bring value to families and communities that care about our clients and patients: By being able to offer multiple, complementary services across various modes of care, and by providing services in the home as well as community clinic settings, we significantly reduce the caregiving burden on clients’ and patients’ family members. Our broad set of services are available in care settings where our patients live, and these services are intimately connected to the quality of life of a patient and their family in the broader community. As a result, and for example, our patient and family satisfaction scores are 99% in our Rehab services, 95% in pharmacy home infusion, 89% for Home Health CAHPS, which is higher than the national average of 85%, and 85% for Hospice CAHPS, and Seniors and Behavioral supportive care recipients and families (and guardians) report an average satisfaction score of well over 4 (out of 5).


 

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We bring value to employees who serve our medically complex patient population: Our national scale and comprehensive range of healthcare solutions creates flexibility of care provision and breadth and depth of services for our providers. For our approximately 37,000 full-time equivalent clinicians, caregivers and support employees, we offer a compelling mission and opportunity to serve complex client and patient populations, forming meaningful relationships and encouraging clients and patients to live their best possible lives. Across all business and service segments, our infrastructure, technology, training and operational processes provide support, flexibility in work schedules and reduce administrative burdens for our teammates to help them concentrate on providing quality care for patients.

We bring value to many healthcare partners, including physicians, health systems, customers, and drug manufacturers by driving shared success: We have a strong and well-established base of care delivery physician and health system referral sources and partners that has been built on years of customer service and quality results. Our company has 425 formal strategic partnerships and contracts with health systems, including approximately 20 home health partnerships and contracts with leading hospital systems and accountable care organizations, or ACOs, across multiple states related to high performance networks, care transitions, indigent patient management, high-risk patient programs, and therapy and heart failure bundles. In addition to health systems and ACOs, we have a unique mobile integrated healthcare program in hospice in partnership and coordination with emergency medical services and fire departments to triage episodes in the home and reduce hospitalizations.

We have preferred or exclusive relationships with pharmaceutical manufacturers in specialty oncology drugs, as manufacturers select and prefer to work with our pharmacy due to leading patient service, reimbursement navigation, nursing support, speed of drug delivery, IT and data solutions, and other proprietary value-add services. At present we have 93 limited distribution oncology drugs, with another nine in the pipeline still to launch, including six exclusive and 43 ultra-narrow and high-control drugs with limited pharmacy access.

We bring value to investors through our purpose-built, broad and diversified platform of services: We offer investors a purpose-built platform of leading scale that combines broad geographic, end market and reimbursement diversification among related and complementary business and service lines with unique levers to drive organic and inorganic growth.

Our platform delivers services primarily in home and community settings, which benefit from industry trends and tailwinds, given patient preference, high-quality and lower cost of services. Approximately 18,000 of our patients receive multiple services from us in their homes today, and we believe that there are over 550,000 additional opportunities to deliver our services to our current census of patients across settings.

The “care relationship” with our patients has historically been multiyear, leading to strong revenue visibility and operational stability. As a result, we have six-month line of sight on approximately 80% of our service volume and 75% line of sight on our service volume over a year.

Our revenue mix is diversified by payor source and program, including, as of December 31, 2020, 43% Medicare (34% Medicare Part D), 27% Medicaid (of which this percentage is further distributed at the state level), 18% Commercial, 5% government programs, and 7% private/other. As reimbursement models continue to evolve, our complementary, value-add services and diversified payor mix enables us to potentially enter into quality and value-based contracts that would allow us to realize greater incentives and savings than today and take risk.

Our platform and financial profile also benefits from an extensive M&A track record and proven ability to source, execute and integrate strategic and accretive acquisitions across multiple fragmented industries. Since 2018, we have completed 42 acquisitions across multiple business lines, including strategic and tuck-in


 

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acquisitions. Our pace of acquisitions has been consistent, with 12 deals completed each year in 2018, 2019 (excluding the BHS Acquisition), and 2020, and six deals completed in the six months ended June 30, 2021. Our combined aggregate purchase consideration has totaled $1.6 billion since 2018, including over $850 million in the six months ended June 30, 2021 due to our acquisition of Abode (and several other transactions). With access to more acquisition opportunities across our broad and large markets comparatively, and through our ability to leverage scale related synergies, we are able to selectively target attractive and value-enhancing acquisitions that we expect to continue to contribute meaningfully to the long-term success of the Company.

Industry Overview and Market Opportunity

Healthcare expenditures in the United States totaled $3.8 trillion in 2019 and are expected to reach $4.2 trillion in 2021. Through our platform we provide a comprehensive set of health services capabilities to high- need, high-cost, medically complex patients that address multiple patient needs. We provide these critical services across Medicare, Medicaid, and commercial plans, which we believe creates over $1.5 trillion of opportunity for our specific and relevant services among the main healthcare funding sources and other pharmacy services payors in the United States.

 

LOGO

Within our over $1.5 trillion market opportunity, our platform is able to benefit from a broad and comprehensive set of capabilities that address a number of favorable underlying markets and trends. For example, as the baby boomer population ages and life expectancy increases, Seniors, who comprise a large portion of our patients, will represent a higher percentage of the overall population. The Office of the Actuary of the Centers for Medicare & Medicaid Services, or CMS, projects that the U.S. population aged 65 and older will grow, on average, by 3% annually over the next five years. Specialty populations, who have unique, specialized and most often chronic/life-long health conditions and needs, are expected to increase by a compound annual growth rate of approximately 5% over the same period. Within our Provider businesses, Home Health expenditures are expected to increase by approximately 5% - 7% over the next five years, with Hospice expenditures expected to increase by 6% - 8% over the same period. Additionally, Personal Care spending is expected to grow by 7% - 9%. In our Pharmacy Solutions segment, our Home and Community-Based Pharmacy markets are expected to grow at a weighted average growth rate of approximately 9% over the next five years.

We believe these trends will continue to drive sustainable growth in our markets and greater utilization of our services in the future, creating opportunities for scaled providers to continue to gain share through our focus on medically-complex Senior and Specialty patient populations with intensive healthcare needs.

We have also managed our business in light of certain challenges in our markets. The U.S. federal and state governments continue to enact and seriously consider many broad-based legislative and regulatory proposals that


 

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have had a material impact on, or could materially impact, various aspects of the healthcare system, the markets we participate in and our business. In particular, as federal healthcare expenditures continue to increase and state governments must balance budgets, including through the COVID-19 pandemic, federal and state governments have made, and may continue to make, significant changes to the Medicare and Medicaid programs. Changes in government healthcare programs may reduce payments we receive or access to, or utilization of, our services, and may require us to modify our internal processes and procedures. Additionally, regulators have increased scrutiny of claims for our services. During the past several years, third-party healthcare payors, such as federal and state governments and insurance companies, have undertaken cost containment initiatives. We expect efforts to impose greater discounts and more stringent cost controls by such payors to continue, potentially reducing the payments we receive for our services. Government and commercial payors may also present us with alternative payment models.

We operate in a highly competitive industry as well. Within our markets, we compete with a broad and diverse set of businesses spanning both provider and pharmacy services. In our Home and Community Health Provider Services segment, we compete with local, regional and national providers of clinical services and supportive care. Within clinical services, our principal competitors are comprised of other home and community health providers, including Amedisys, Inc., Encompass Health Corporation and LHC Group, Inc. Generally, competition in our Personal Care service line comes from local and regional providers, as well as other national providers including Addus HomeCare Corporation. In our Home and Community Health Provider Services segment, we also compete for, among other things, physicians, nurse practitioners, physician assistants and other medical and non-medical personnel.

In our Pharmacy Solutions segment, we compete with local, regional and national pharmacies. While no other company competes with us singularly across all of our pharmacy service lines, on a nationwide basis we compete with several national companies depending on service line. In our Home & Community-Based Pharmacy business, we compete in the large and fragmented home infusion and specialty pharmacy markets for contracts with managed care organizations and other third-party payors. Competitors within the home infusion and specialty pharmacy markets include Coram CVS/specialty infusion services (a division of CVS Health), Accredo Health Group, Inc. (a unit of Cigna), Optum Specialty Pharmacy (a subsidiary of OptumRx, which is a unit of the UnitedHealth Group), Option Care Health, Inc. and various regional and local providers. In our Facility-Based Pharmacy business, owners of skilled nursing and rehabilitation facilities may also provide pharmacy (and provider) services, and on a nationwide basis we compete with Omnicare, Inc., a division of CVS Health, and several others.


 

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Our Platform

We believe our high-quality and complementary health services offerings address significant and important patient and stakeholder needs. Our service model represents a unique and holistic care delivery capability that minimizes the potential disruption associated with procuring multiple services from multiple providers and improves quality of care and patient outcomes through enhanced coordination of provider and pharmacy services. These outcomes are achieved across our Senior patients and Specialty patients, which include our Behavioral, Neuro and Specialty Pharmacy populations, with our services principally delivered in patient-preferred and lower-cost settings. We believe our service capabilities and outcomes position us as a provider of choice for clients, patients, families, referral sources, and payors. Our service capabilities extend across all 50 states in the United States, with co-location of our provider and pharmacy services in approximately 75% of our states. We deliver a higher proportion of services in select regions with favorable demographics and regulatory environments, with approximately 57% of our revenue concentrated in 10 states: New York, Texas, California, Washington, North Carolina, Indiana, Florida, Pennsylvania, Ohio and Massachusetts. We deliver services through two reportable segments: Home and Community Health Provider Services and Pharmacy Solutions.

 

LOGO   LOGO

Home and Community Health Provider Services

In our Home and Community Health Provider Services segment, we provide a variety of impactful and valuable services to address chronic and complex patient conditions and help manage the whole-person health of our client and patients in their homes and communities. These services consist of both clinical and supportive care to over 30,000 Senior and Specialty populations today, with census for home health and hospice services having grown approximately 81.6% over the past year, and include the following:

Home Health Care

Our Home Health services provide patient-centric, highly skilled and compassionate clinical care primarily to Senior patients recovering from surgery or illness or living with chronic diseases. These services help patients avoid unnecessary hospitalizations, speed up recovery time, and allow people to stay in their own homes where they can feel safe and secure. Over $40 billion in annual U.S. health care spending is attributed to hospital readmissions. In particular, the transition from the hospital to the home introduces significant risk for preventable adverse outcomes, with nearly 25% of readmissions considered preventable, and closer follow-up reduces complications and readmissions. Home health care can reduce 365-day post-discharge costs by more than $6,000 per patient.

Our Hospice services provide physical, emotional and spiritual comfort and support primarily for Senior patients with terminal illnesses and their families. Our interdisciplinary hospice teams tailor unique and individualized plans for patients and their families based on a comprehensive understanding of their needs. Generally, patients receiving hospice services have a life expectancy of six months or less. Our Hospice patients all require daily pharmacy support, which we deliver and are fully rolling out internally through our Hospice Pharmacy business. Our HIS composite score of 99% is seven percent above the national average, and we have a score of 85% for Hospice CAHPS as we strive to provide this valuable service in a high-quality way.


 

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Our Personal Care services include supportive care and activities of daily living support that address social determinants of health, including dietary and nutrition management, fall risk management, transportation, cognitive and social engagement, skills building, companionship, and bathing and grooming, as well as professional nursing, medication support, Alzheimer’s/dementia care and other specialized chronic patient condition programs, respite care, other in-home programs, and geriatric care management. Medicare spends an average of three times more on older adults with functional limitations, and we believe supportive care services will continue to become a focus for payors due to the growing importance of managing the social determinants of healthcare to improve outcomes and delay or prevent unnecessary facility placement.

Our patients often receive multiple Home Health Care services from the Company, including Home Health-to-Hospice transitions, Home Health and Personal Care, and Hospice and Personal Care, to improve patient outcomes. In 2021 we launched our Continue Care program, which is a longitudinal medication therapy and risk management program for our Home Health patients, which includes in-home patient assessments, medication reconciliations and medication synchronization with subsequent multi-dose medication delivery on 30 day cycles, all supported by nurse and consultant pharmacist check-ins and interventions. Studies have shown that all-cause hospitalizations are higher in patients with poor medication adherence. We see significant potential for continued and future referral opportunities to our provider segment from patients being served by our pharmacy services in skilled nursing and rehabilitation facilities who discharge approximately 400,000 patients a year. We offer a Discharge Rx program to our skilled nursing customers today to help with the consistency and accuracy of medications for patients post-discharge and to help skilled nursing and rehabilitation facilities manage 30-day hospital readmission post-discharge, and these referral channels enable us to provide continuity of care following a discharge from skilled nursing into our Home Health, Personal Care and Hospice in the future. Our assisted living and home infusion pharmacy customers and patients also provide us with relationships to increasingly introduce Home Health, Personal Care and Hospice in the future. As many patients continue to express a preference to stay at home as long as possible over the life of their care needs, our integrated provider and pharmacy offerings make this option more and more practical for patients and care professionals.

Long-Term Specialty Care

Our Long-Term Specialty Care services provide both patient-centric clinical care and supportive care to Seniors, Behavioral, ABA, and NeuroRehab clients and patients living with age-related acute or chronic conditions, living with life-long indications (including I/DD and autism) or recovering from a catastrophic neuro event (ABI/TBI or stroke) requiring intensive therapy, respectively. These services support individuals of all ages who need various forms of expert clinical care and therapy in addition to assistance with daily living due to serious medical issues they may have. The majority of patients in Long-Term Specialty Care receive daily pharmacy support, delivered through our Home and Community-Based Pharmacy business (with a 94% penetration rate), along with ongoing behavioral therapy consults and primary care medical care, which is increasingly being delivered through our Home-Based Primary Care practice.

Within Long-Term Specialty Care, we view our primary care capabilities, which we are continuing to build out, as central to the future of optimizing client and patient management. Our Home-Based Primary Care clinicians see and manage both Seniors and Behavioral (including I/DD) patients in senior living communities, in individual homes and in group homes, as well as in transitional care visits after patients leave hospitals and skilled nursing facilities. We believe the expertise of our Home-Based Primary Care clinicians applied to settings where complex patients reside every day results in more proactive, insightful and patient-centric care that drives superior client and patient experiences, improved outcomes and lower costs. Home-Based Primary Care serves as the care steward of the patient, pulling together previously disparate information and contact points into one place for more coordinated and informed patient care. Our platform currently participates in the CMS Center for Medicare and Medicaid Innovation, or CMMI, innovation program Comprehensive Primary Care Plus and was selected into the next generation CMS model called Primary Care First, which is a five-year model that rewards value and quality through an innovative payment structure.


 

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Our Rehab Therapy services provide specialized, highly-skilled and custom-designed rehabilitation services, including physical, speech and occupational therapy and ABA, for patients of all ages with a range of injuries and conditions, including brain and spinal cord injuries, stroke, pediatric neuro conditions and autism. Our Rehab services make a dramatic impact on the trajectory of a patient’s independence, skills and life and significantly lower longer-term costs. For example, with our brain and spinal cord injury and stroke patients, 50% of the patients no longer require 24/7 supervision after three months of therapy, and the percent of patients who can be left alone for at least eight hours increased from 22% to 74%. Patients see profound improvements, and 99% of patients are either satisfied or very satisfied with our services and 97% would recommend our services.

Our Community Living services offer a variety of programs, including group homes, supported living, behavioral therapy, short-term or medium-term transitional care, family living (host homes), vocational training, and case management. Our programs are principally administered in individuals’ homes, supported by day programs, and predominantly based on individual support and clinical care plans designed to encourage greater independence, develop daily living skills and social determinants of health goals, and manage medical conditions, as the majority of I/DD individuals have multiple chronic conditions and require eight or more medications.

Pharmacy Solutions

We provide pharmacy services across many care settings, often in coordination with our Home and Community Health Provider Services, and filled over 30 million prescriptions in 2020. We operate 178 pharmacies in total across all 50 states, with services to approximately 3,000 locations, more than 25,000 homes, and approximately 275,000 patients through over 5,200 unique payor contracts. Our best-in-class pharmacy support across settings is achieved through medication availability and reliability, cost containment, staff and patient support programs and solutions, regulatory support, and leading customer service. We have a unique opportunity to increasingly provide more pharmacy services in the future to our provider patients and to patients transitioning across settings of care.

Pharmacy services are a universal need and ubiquitous connection point across medically complex populations and the overlapping patient services we provide across settings. Home and Community-Based Pharmacy and Facility-Based Pharmacy services to complex patients are extremely differentiated compared to retail pharmacy, with dramatically different and more challenging user needs and service requirements. High-need Senior and Specialty patients depend on closely managed daily medication regimens. The average Senior fills approximately 46 medication prescriptions per year and the average BrightSpring pharmacy patient is usually prescribed approximately nine medications at a given time, or at least three times more than the average Senior. As a result, medication appropriateness, accuracy and adherence are critical points of emphasis for managing chronic conditions, treating temporary episodes, and promoting the overall long-term health and well-being of patients. Non-adherence causes approximately 40% of chronic disease treatment failures and 125,000 deaths per year in the United States. Furthermore, approximately one in five new prescriptions are never filled, and among those filled, approximately 50% are taken incorrectly. A 2015 study published by the Annals of Pharmacotherapy showed there is over $500 billion of costs from the lack of medication adherence, and the resulting illnesses, hospitalizations and deaths, a figure that represented 16% of U.S. healthcare expenditures. Our integrated Pharmacy Solutions are designed to drive medication adherence, patient outcomes and customer efficiency and compliance in a number of areas. We deliver on these goals with over 99.99% order accuracy, 99.77% order completeness and 98.59% on-time delivery. We promote overall savings to customers and the healthcare system through programs that result in an 87.6% generic dispensing rate.

Home and Community-Based Pharmacy

Our home and community-based pharmacy solutions ensure that medications are accessible in a timely manner for patients living in home and community-based residential settings that include senior living facilities


 

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(assisted living facilities, or ALFs, and independent living facilities, or ILFs), patient homes for in-home pharmacy, mostly patient homes for hospice pharmacy, home infusion and Specialty pharmacy, I/DD group homes, and rehab settings. Our footprint of 178 pharmacies that covers all 50 states is unique, and our “white-glove” and local pharmacy model is differentiating, as it allows for faster response time for delivery (for first-time, recurring and stat orders) and a better customer and patient experience. Depending on the specific location, we service customer and patient locations typically within a radius of approximately 100 miles or less of our pharmacy locations multiple times a day and 24/7 as needed.

Our Senior Living Pharmacy platform is designed to provide a consistent, best in-class experience for multi-state senior living providers accompanied with local concierge support for individual communities and residents in their homes. We do this through centralized intake and order entry that yields a standardized operations model to drive efficiencies and consistency of experience in all markets for the senior living provider. Our pharmacists optimize medication regimens by eliminating unnecessary medications and addressing potential adverse drug reactions that enables residents to age in place. Our local pharmacies focus on critical pharmacy service elements such as accurate and timely dispensing, reliable emergency and after-hours support, and timely electronic medical record, or eMAR, profiling, leading to quality, consistency, and reliability. Additional value-add services and capabilities include a leading OTC program, on-demand, cycle-fill, and anniversary fill dispensing capabilities, and flexible packaging capabilities that include multi-dose pouches or cards.

Our Hospice Pharmacy provides hospice pharmacy and pharmacy benefit management, or PBM, services for people and families primarily in their homes, as well as in some inpatient units and skilled nursing and rehabilitation facilities where hospice patients can also reside. We believe we are one of the largest independent hospice pharmacies in the United States and have a unique local pharmacy model that delivers same-day medications directly to people’s homes from our own controlled pharmacies.

Our In-Home Pharmacy program called Continue Care was built for Home Health and Personal Care patients, for patient discharges to home from skilled nursing and rehabilitation facilities or hospitals, or for partnering with payors with a focus on any high-risk patient (member) who is living in their home with chronic conditions and an intensive polypharmacy medication need and regimen (typically eight – 12 or more medications). Polypharmacy is now widely acknowledged and appreciated as the number one marker for the highest risk patients. We have developed our Continue Care program over the past year to uniquely and effectively serve these patients in their homes through both medication therapy and risk management and ongoing care support.

Our Continue Care program is a care management program that targets one of the biggest challenges and opportunities in healthcare, which is the ongoing management of high-risk, high-cost, complex patients in their homes to reduce adverse health events and hospitalizations. While multimorbidity and polypharmacy are common in the United States, the optimal approach to improving medication management for patients in homes using complex regimens can involve multiple interventions, with highly integrated medication management models associated with improved adherence and decreased costs of approximately $2,400 per member per year.

We believe our Behavioral Pharmacy (including serving I/DD group homes) platform is one of the largest I/DD specialty pharmacy providers in the United States, designed purposefully for behavioral populations and their specific needs. In this business we provide customized medication management to ensure regulatory compliance through specialized packaging, calendar cycle fill aids, customized labelling with bar codes and medication pass times to ensure adherence and the right dose at the right time, integration with 42 electronic medical record/electronic health record, or eMAR/EHR, products to ensure medication administration documentation, and flexible delivery schedules tailored to client and agency schedules and activities.


 

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Our Home Infusion business provides specialty infusion services in the home focused on pharmaceutical therapies that require expert administration, offering high-touch clinical services to patients. Infusion therapy services are a specialty form of pharmaceuticals that involve the intravenous administration of medications that treat a wide range of acute and chronic health conditions – infections, auto-immune illnesses, cancer pain, multiple sclerosis, hemophilia, and nutritional deficiencies. These medications are high-cost and require special handling, comprehensive planning, and extensive patient training that is provided through our registered nursing staff. Our infusion services receive a 95.4% patient satisfaction score, with 99.9% dispensing accuracy, and 95.9% therapy completion.

Our Specialty Pharmacy business provides dispensing of specialty drugs, care management and other related services to patients, oncology practices, and hospitals. As the leading independent specialty oncology pharmacy in the United States, our services encompass clinical coordination and review, nursing support and patient education, compliance with appropriate oncology protocols, patient assistance with insurance access and outside funding, and timely delivery of medication. Our highly trained, certified oncology pharmacists are available 24/7 to provide critical clinical and care management support for patients and caregivers while working in close coordination with their physicians. We coordinate the administration of medications directly to the patient at the appropriate point of treatment and work directly with payors to bill insurance companies for the medication provided, ensuring all prior authorizations and approvals are obtained.

Our Specialty Pharmacy customer service and quality metrics are best-in-class, such as time-to-first-fill (3.6 day average turnaround time), as compared to peers, and we offer value-add services including technology integrations and real-time analytics on key metrics for both suppliers and payors. As a result of our unique capabilities in serving pharmaceutical manufacturers and biotech, we have exclusive or preferred relationships in specialty oncology drugs, as manufacturers select our pharmacy – exclusively or as part of a group of a few other pharmacies – to distribute and support their therapies in the market. We currently have 93 limited distribution oncology drugs in the market, with an additional nine in the pipeline still to launch, including 49 exclusive and ultra-narrow and high-control drugs with limited pharmacy access. These exclusive and limited access drugs awarded to us by manufacturers represent 92% of our Specialty pharmacy revenue. In 2020, and, again, as a testament to our leading quality and service, we achieved a “world-class” NPS score of 90 from the patients of one of our largest contracted PBMs, which, according to the PBM, only 1% of their pharmacies achieve, and which triggered a quality incentive payment in 2021.

Facility-Based Pharmacy

We make sure critical medications and therapies are accessible in a timely and optimized manner for patients through our skilled nursing and rehabilitation facilities and hospitals, in the process providing value well beyond medication delivery through proprietary operational, clinical, cost, regulatory, and educational support programs for our customers. We purchase, repackage, dispense, and deliver prescription and non-prescription pharmaceuticals in accordance with physician orders, typically to customer locations within a radius of 100 miles or less of our pharmacy locations at least once each day. We provide 24-hour, seven-day per week on-call pharmacist services for emergency dispensing and/or consultation with the facility’s staff or the resident’s attending physician.

In addition to our very strong service delivery metrics, we reduce the costs and complexity of drug procurement and support greater efficiency and sustainability for care facilities, with a 99.9% generic efficiency rate (the percent of drugs dispensed as generic, when both brand and generic versions of a drug are available) and saving customers an average of $64 per therapeutic interchange. Our over 100 nurse consultants also underpin improved results for customers through our service, as our pharmacies perform better than the national average, for example, on antipsychotic usage and percent of patients experiencing falls, with our patients consistently outperforming non-patients on CMS quality measures overall. Our nurses also help customers reduce “F-Tags”


 

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(citings for compliance deficiency). As a result, more of our pharmacy customers received incentive payments and at a higher rate under the CMS Skilled Nursing Facility Value-Based Purchasing program than non-customers. Overall, we believe we have certain comparative strengths in this large and fragmented pharmacy market due to our lower drug purchasing costs, broader distribution and breadth of customer support programs.

Our Team and Culture

We believe an engaged and connected team of employees across the Company is an essential component of our platform and growth strategy. Our dedicated clinicians, caregivers, field, corporate and other administrative support employees, managers, and leaders are the critical elements that have enabled us to build an industry leading and differentiated healthcare platform. We have a combination of long-standing employees at all levels who have worked together for years and newer employees that help to contribute best practices and innovation – all bringing a wealth of experience in healthcare.

Our leadership team has driven a clearly defined vision and mission through the organization. It has fostered and developed a focus on quality, operational excellence and growth across our enterprise, underpinned by strong people and efficient processes. The Company has consistently innovated its service models to drive results and augment our positioning as a valuable partner to industry stakeholders. Our culture is at the heart of all we do, enabling execution of our strategies. Our commitment and passion for helping people guides the way our care and services are delivered, one patient at a time.

As a leading mission-driven and quality-focused health services organization, our employees are fundamental to our ability to maximize our impact in serving clients, patients, families, customers, referrals sources and partners, and all healthcare stakeholders. Focusing on the interests and development of our employees is a top priority, and our ability to attract and retain compassionate and skilled caregivers and pharmacy professionals, as well as talented functional and managerial staff, is fundamental to our future.

 

 

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Operational Excellence

Operational excellence is a focus of our Company. It is a key aspect of our performance, and we believe it will be a driver of our continued growth. Our senior leadership’s attention to how we operate and manage both


 

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our businesses and enterprise support functions is reflected in continuous improvement efforts in both volume and cost efficiency related areas for improved results. In field operations, processes and teams are empowered with clear strategies and goals and managed from the local level up through regions, with key enterprise functions such as finance and accounting, revenue cycle, information technology, quality, compliance, human resources, legal, payroll, accounts payable, communications, sales and marketing, and government relations working to support front-line and field employees and managers to be as knowledgeable and impactful as possible. In addition to large finance and human resources organizations, dedicated Project Management Office, or PMO, Integration Management Office, or IMO, and Procurement teams have been in place for the last four years and serve as control functions, as they evaluate opportunities, drive continuous improvement projects and support the execution of critical initiatives across all business and enterprise functions in the Company as we have continued to grow.

Working collaboratively, these teams have a broad mandate and are empowered from the CEO office to support further growth and realize savings through new strategies to drive volume, people and culture enhancements, process improvements and operational efficiencies, synergy capture from acquisitions, and improved purchasing that leverages our scale. In 2020, the implementation of our continuous improvement program over the past four years has resulted in approximately $35 million of savings from improved processes and working smarter, and these efficiencies have been used to reinvest in employees (both existing employees through wages and benefits and new employees to support key strategies, innovation and infrastructure needs to further scale), quality, technology, and growth initiatives.

We have continued to make investments to improve the overall efficiency and workflow of our business and position ourselves for continued future growth. For example, investments in technology and information systems to support our businesses in recent years have included new and improved EMR and ERP systems across businesses for continued usability improvements, enabling mobile and electronic visit verification, implementation of daily pay and other employee support applications, and enhancements to financial, revenue cycle, recruiting and training systems. We have also addressed customer opportunities and integrations and “Connected Home” technologies deployed across group homes to support Rest Assured remote monitoring, EMR and eMAR deployment and connectivity. Our cloud-based data lake (storage) and business intelligence (analytics) capabilities are now a single digital platform and set up to feed real-time quality, operational and financial metrics tracking across the Company.

Quality and compliance are central to our strategies and mission. We have demonstrated leading and excellent service and customer/patient/family satisfaction scores across the organization, as referenced in prior sections of this prospectus. We invest over $200 million a year in people, training, auditing, signature programs, accreditations, advocacy, and technologies to support quality, compliance and safety as part of our “Quality First” framework. We continue to invest in quality and compliance resources with 108 quality team members (excluding the Clinical (Nursing) Hub) and 44 compliance team members conducting over 100 quality audits in the provider business, approximately 190 pharmacy compliance audits of company-wide field operations annually, and monthly record reviews of 10% of patient charts – in all of these audits the quality and compliance teams using more recently created electronic applications to enter and track data. We have over 900 pharmacies, branches/agencies, and service locations accredited by the leading national accreditation bodies, including ACHC, CHAP, Joint Commission, CARF, ACHC, NABP, URAC, and DMEPOS.

Competitive Advantages

As compared to other health services providers, our Company has unique size and scale, our complementary services address multiple needs of the highest cost complex patients, our markets are uniquely large in the aggregate with tangible demand drivers, our services are delivered in preferred lower-cost home and community settings aligned to secular trends, our patients require long-term care and support that results in a high recurring


 

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revenue profile, our services produce excellent and proven quality metrics, and our M&A track record and platform is extensive. Moreover, the combination of our services delivered in homes and communities provides for a greater opportunity set of commercial and clinical alternatives to pursue and deepen in, and it produces a unique model for improved patient and cost outcomes for complex patients and the healthcare system. Both of these advantages and capabilities have led to strong historical growth, augmented by significant M&A execution amidst fragmented markets, and underpinned by a capable, seasoned and proven management team.

Scaled National Platform Focused on Complex Patients in Home and Community Settings: Our reach, breadth and scaled national platform of provider and pharmacy services improve the consistency of results and is designed to solve critical pain points for payors in managing overall healthcare costs for their most complex patients. We are able to drive clinical outcomes and lower cost of care due to our presence in the home and community and highly proximate position to the patients we serve. In 2020, we provided approximately 120 million hours of care and delivered over 30 million prescriptions across all 50 states in the process of serving over 330,000 people per day. We estimate our total addressable market opportunity to be over $1.5 trillion, and the complex populations we serve both comprise the majority of this spend and drive the highest growth within healthcare services. As no competitors offer complementary and integrated daily provider and pharmacy services at a similar scale or address a similar overall patient population, we believe this comparatively enhances our growth and new contract opportunities and provides us with significantly greater long-term potential size, supporting the continued growth of our platform and reaching more high-need patients on a recurring basis. We believe our scaled national platform of integrated service offerings establishes our position as a healthcare provider of choice for patients, families, referral sources, customers, and payors across the platform.

Complementary Service Lines That Address Whole Person Health Over Long Periods of Time: We offer complementary provider and pharmacy services and unique, proprietary programs across our platform that high-need, high-cost and complex patients require, and we have significant engagement with our patients in their homes and communities. Each of our provider and pharmacy services offers patients higher quality care and provides greater efficiency and effectiveness when integrated, with a streamlined partner available to payors to deliver improved outcomes and cost savings. The holistic mix of services that we provide at the scale that we provide them creates both stability – through business, end market, geographic, and payor diversification and relevance – and more revenue opportunities in providing multiple services to patients as a “one-stop” provider and in capturing additional services across settings and transitions of care. The steadily increasing density of our network and proximity to patients allows us to increasingly drive referrals and follow patient needs longitudinally and across their individual care continuum. The vast majority of patients we serve not only have multiple service needs, but also have life-long conditions with long-term, chronic care needs, which results in significant revenue visibility – 79% of our patients are on service for at least six months, 75% of our patients are on service for at least 12 months, which provides for a unique level of recurring revenue comparatively.

Excellent Quality and Compliance with a Focus on Care Coordination: We have demonstrated leading quality metrics and cost-effective care across all service lines of the Company, coordinating high-need and complex individuals with caregivers and support services to improve outcomes for clients, patients and families. Our provider care management tools and programs help to keep our patients safe, enhance their independence, improve their outcomes, and lower their health care costs. Our goal is to try to ensure that every individual receives the right care, at the right time, in the safest environment possible. For example, our Home Health agencies received an average of four or more Stars in the 2020 CMS STAR Ratings, and our infusion services received a 95.4% patient satisfaction score.

Our pharmacies address ubiquitous patient medication needs across all settings and our industry-leading solutions ensure accurate and timely access to needed medications, control costs, enhance customer education,


 

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improve patient outcome measures, and support customer compliance with state and federal regulations. We have dedicated a large and growing amount of resources to support quality and compliance throughout the organization, and we continue to invest in efforts to innovate further towards value-based care capabilities. Together, our quality and compliance programs create an outcomes-based environment centered around clients and patients that enables them to live their best life.

Track Record of Strategic and Accretive M&A Across Our Platform with Proven Ability to Execute: We have an established M&A track record and proven capabilities, positioning us to continue to be effective in acquiring businesses across our service lines in fragmented areas of healthcare. We have successfully acquired 42 businesses since 2018 and our scale and breadth of services creates meaningful opportunities to achieve significant revenue and cost synergies with businesses we acquire. Our M&A capabilities have been honed through years of experience, and today we are able to generate significant synergies beginning on the first day post-closing.

We believe we are an attractive partner for many businesses, who need additional infrastructure, referral source expansion, and purchasing and negotiating power to succeed.

Our M&A platform in health services is advantageous for multiple reasons: our scale enables both revenue and cost synergies; our complementary service line mix provides us with a broader and larger opportunity set of acquisition targets; our well-resourced corporate development team’s ability to identify and execute attractive acquisitions; our IMO team that has extensive experience in managing all elements of the acquisition process pre and post-close and helping to ensure the successful integration of both platform and tuck-in acquisitions into our organization; and the comparatively large amount of our cash flow to fund acquisitions. All markets we participate in are still highly fragmented and benefit from scale, which provides for large, continued consolidation opportunities.

We completed and integrated 12 acquisitions in 2020 that leverage our scale, end market presence and organizational capabilities and build upon our track record of successful M&A. Of note, in 2021 and 2020, we completed the acquisitions of Abode (home health and hospice) and OPPC (hospice pharmacy), respectively, which not only highlight the capabilities of our M&A team and process, but also demonstrate the strategic nature of our approach, as both of these acquisitions added scale in target and attractive business areas and benefited from internal revenue synergies across our business lines.

Experienced Management Team with a Successful Track Record of Building Companies: Our management team, led by our President and Chief Executive Officer Jon Rousseau, has an average of 23 years of healthcare experience, with combined backgrounds across different industries and disciplines and with collective experience in building healthcare platforms. Senior management has a track record of successfully building home health and hospice platforms, managing large pharmacy businesses, turning around and improving businesses, driving volume growth, entering adjacent and new markets, integrating acquisitions, completing joint ventures, executing on de novos, improving quality, implementing new systems and continuous improvement programs, generating stable cash flows, and creating organizations with strong cultures and talented people. Our management team is tenured and has driven revenue growth of over three-and-a-half times since 2017, integrating enterprise infrastructure and processes across clinical, supportive care and pharmacy markets.

Our Growth Strategy

Drive Organic Growth in Home and Community Health Provider Services and Pharmacy Solutions: We expect to continue to pursue and capitalize on compelling growth opportunities in our existing core provider and pharmacy businesses through five principal mechanisms.


 

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First, we plan to benefit from market penetration in both our legacy and newer markets. Through our scale, our delivery of multiple needed patient services, and our ability to improve outcomes for patients, we are able to drive increased penetration of these stable, growing and attractive end markets. While we have leading share and scale in a number of our markets that we have served for longer periods of time, our market share in numerous other service lines and markets that we have more recently entered is still emerging with a large opportunity for further growth. Also, despite the large size of our markets, many potential clients and patients unfortunately still go without care services today, either due to waitlists (Medicaid), lack of knowledge of available services, or access/payment barriers. Continued recognition for the clear value of home and community-based services, which has been exacerbated and demonstrated again by COVID-19, and continuing referral source, client/patient and family education will drive further increases in the number of clients and patients on service.

Second, beyond increasing market penetration and increasing access to existing eligible and appropriate clients and patients, our core business is characterized by markets with favorable demographic and social trends that include an aging population, an increasing number of individuals with chronic, life-long medical conditions, an increasing number of individuals with behavioral and mental health indications, and an increasing preference for home and community-based health solutions. In our core provider services such as Home Health Care and Long-Term Specialty Care, as well as our pharmacy solutions in Home and Community-Based Pharmacy and Facility-Based Pharmacy, there remains significant opportunity to benefit from continued growth in our industries and in the number of available patients in need of our services. Seniors over the age of 65 are expected to grow at three percent a year by 2030, and the population size of people over age 85 is expected to double by 2036. There is an estimated six percent growth rate in the number of Seniors needing supportive care services, and 70% of adults over the age of 65 will need assistance at some point. Hospice services and NeuroRehab services are estimated to grow at six percent. In Pharmacy Solutions, the Senior Living market is expected to grow by seven percent, demand for home infusion is expected to grow at nine percent, and specialty drug spend has historically grown at 15%, with oncology being the biggest and highest growth market within the specialty pharmacy industry and having a large number of innovative therapies in the pipeline.

Third, we believe that we have significant opportunity to serve more patients by further building out our network of locations through high return de novo expansions. Again, it is our scale and complementary service line offerings that afford us this comparatively sized de novo opportunity. We continuously focus on identifying areas of need and gaps in coverage that we can fill by opening new locations. Incremental service coverage represents not only standalone growth, but also represents an opportunity to provide additional integrated care and referral revenues across our various business lines. Our successful track record of de novo expansions highlights our execution and that we have been able to achieve with our model and gives us conviction to continue to invest in new locations to drive long term value creation. Our knowledge of markets, competitors, referral sources, customers, people and our payor contacts and contracts from across businesses helps to inform our selection of new markets for a service line. We have expanded to 75 new locations in 31 states since 2018, having opened eight in 2018, 22 in 2019, 30 in 2020, and 15 in the first six months of 2021. We believe we can replicate our historical performance of opening 20 – 30 de novo locations per year. We have historical performance that indicates that our operating model can succeed across different markets, and, given our size, available service lines and opportunity set of new service locations to choose from, we have prioritized service lines and target markets that we believe will be appealing opportunities for strategic development. While de novos typically take three to five years to reach full maturity, our 75 de novo openings since 2018 have reached profitability within five months on average. In the six months ended June 30, 2021, our 75 de novo locations opened since 2018 generated revenue of $49.4 million, representing 260.0% growth compared to the six months ended June 30, 2020. Our de novo revenue growth in the six months ended June 30, 2021 contributed approximately 1.32% to our overall Company revenue growth of 17.1% compared to the six months ended June 30, 2020.


 

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Fourth, there are numerous, attractive adjacent and ancillary market opportunities available for continued expansion and revenue growth to the Company – both adjacent markets that we have recently entered and additional, new adjacent markets. These adjacent markets and/or ancillary services represent opportunities for future growth, as we continue to grow and scale our services in these markets as compared to today’s levels. Leveraging our current service lines and capability set, we have a demonstrated track record of identifying and entering adjacent markets that we believe make sense, both organically and through acquisitions. More recent historical examples of this include home health, hospice, pediatric autism (ABA) therapy, behavioral therapy, outpatient rehab therapy, senior living pharmacy, hospice pharmacy, in-home pharmacy, ambulatory infusion centers, and primary care, after expanding into behavioral pharmacy, home infusion, and specialty pharmacy in earlier years. All of these adjacent markets and/or ancillary services entered into represent opportunities for future growth, as we continue to advance and scale our services in these markets. Additionally, there are several other adjacent markets that we are currently evaluating, including, for example, additional care settings for infusion and specialty drug therapies. While we are focused on further growing in our longer-standing markets, we will continue to focus on dedicating appropriate resources to grow in newer markets with significant potential, and we will continue to be agile and responsive to attractive new segment and channel opportunities in the broader provider and pharmacy industries.

Fifth, underpinning multiple levers to drive continued growth is a stable reimbursement environment across the various services we provide to our high-need patient population. Our services have significant and evident value. They deliver high quality, reduce costs in the healthcare system, and are provided in patient and family-preferred settings. In order to continue to provide care access and funding solutions to an aging U.S. population, which is increasingly defined by chronic and behavioral health conditions, increased funding for home and community-based services like ours is imperative. Historically, our markets have a demonstrated track record of governmental and payor support and reimbursement stability, which we are optimistic will continue into the future. Reimbursement rates for hospice services have increased by 2.0% on average per year since 2014, and home health rates have grown by 0.2% on average over the past three years, with patient driven grouping models, or PDGM, in 2020 impacting rates. We are optimistic that after PDGM the home health industry will receive continued and appropriate annual rate increases, with a 1.7% increase included in the draft 2022 language as of June. Reimbursement rates, largely Medicaid, in personal (supportive) care and behavioral health (including I/ DD) have increased for the past ten years, with a CAGR of 3.3% and 3.7%, respectively, since 2014. In Pharmacy Solutions, our long-term care pharmacy revenue and gross profit per script has increased at 1.7% and 3.1%, respectively, since 2014, and home infusion and specialty gross profit per script has also increased consistently since 2014. Funding for home and community-based services for the highest-need and highest-cost populations will continue to result in better healthcare system outcomes, in terms of patient access, patient and family preference, and overall cost.

Leverage Complementary Services, Market Presence and Care Management Capabilities to Increase Internal Referral Coordination and Exposure to Emerging Value-Based Care Models: As a combined platform, we provide a holistic set of capabilities, which results in internal quality, care coordination, cross-referral and synergy opportunities. In addition to expanding our footprint more deeply within each service line and respective market and more broadly across the United States, we are focused on pursuing a localized, accretive market development strategy by offering a diverse mix of our Home and Community Health Provider Services and Pharmacy Solutions across our medically complex patient populations. Therefore, we expect continued increases in the number of patients that receive multiple, integrated services for improved outcomes and a better and more coordinated patient and family experience. Most all of the complex patients that we serve require clinical services, supportive care and pharmacy solutions. While our Company’s capability to provide multiple required services to Seniors and Specialty populations increases our overall total addressable market size, overall revenue potential, M&A opportunity set, and de novo possibilities, it also enables us to provide higher-quality and more efficient whole-person care with increased service volume and revenue.


 

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Today, we provide multiple clinical/supportive care and pharmacy services to approximately 18,000 patients, and we believe that there are over 550,000 additional opportunities to deliver our services to current patients, which represents a meaningful future opportunity to better coordinate care and improve patient outcomes and experiences. For example, approximately 400,000 of our skilled nursing and rehabilitation facility pharmacy patients are discharged each year from our facility customers, which represents a large care coordination and referral opportunity to our provider services and Continue Care program. As our density of coverage with multiple services in the same geographic market continues to grow, our proximity to patients and the resulting care network should result in further care provision among our patients across multiple service lines. Our Company’s care management model today is predicated on and defined by our (i) Home Based Primary Care, (ii) Clinical (Nursing) Hub (supporting real-time care insights and coordination) and (iii) Continue Care program (addressing risk and optimization of medication regimens for patients in homes), and the ongoing build-out and roll-out of these programs will be fundamental to provide augmented care management capabilities to drive more whole-person care in the future.

We know that home and community-based settings have demonstrated value, as home health, hospice, home-based primacy care, supportive care, and pharmacy are lower cost alternative care settings that achieve high-quality outcomes for complex patients. There are opportunities for government and private/commercial payors to improve outcomes and costs for their members by proactively managing at-risk and highest-risk patients with chronic conditions and/or polypharmacy utilizing high-touch, holistic and coordinated care management solutions. Healthcare spending is highly concentrated, and frail Seniors and dual-eligible individuals with behavioral needs are among the highest spenders. Medicare beneficiaries with four to five chronic conditions have 33% more hospital admissions, 86% more 30-day readmissions, and 500% greater healthcare spending, and beneficiaries with six or more chronic conditions have 186% more hospital admissions, 243% more 30-day readmissions, and 1,500% greater healthcare spending. The top five percent of health spenders account for 50% of the spending and cost approximately $43,000 a year on average, and the top one percent of health spenders account for 23% of healthcare expenditures and cost approximately $98,000 a year.

Individuals within seven to nine, four to six, and one to three months of end of life have an MLR (medical loss ratio) that is 135%, 175%, and 375% higher, respectively, and individuals with polypharmacy (as defined by five or more medications) have a 20% to 30% higher risk of hospitalization and mortality. We believe there is a continuum of options for organizations to increasingly participate in value-based care in mutually beneficial partnerships with payors.

Some of our payors continue to explore and pursue partnerships and pilot programs to achieve cost-savings through value-based care models. As these models continue to emerge, we are well-positioned to grow with this shift due to the fact that (i) our payors recognize our ability to execute on cost-savings initiatives without sacrificing quality of care; (ii) our high quality, cost-effective holistic care and our complementary services sit at the intersection of clinical services, supportive care addressing activities of daily living and social determinants of health, behavioral supports, and pharmacy solutions; and (iii) our national reach and scale that allow us to partner with payors across larger geographies.

Our daily, interactive patient care relationships lend themselves towards measurable success across improved outcomes, which is an important foundation for risk-based contracts. Preferred provider relationships that are based on quality performance and/or care coordination/ management programs, which may have payment incentives for performance thresholds, are the first step in this healthcare system evolution, and we have numerous relationships and contracts in this area today. We believe that these relationships will proliferate among our payor base. For example, in January 2021, CMS announced its intent to expand its Home Health Value-Based Purchasing (HHVBP) Model, with plans to roll out to all 50 states beginning in 2024. To date, the CMS model has resulted in an average 4.6% improvement in home health agencies’ quality scores and generated over $141 million in annual Medicare savings during its pilot phase.


 

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Data and patient centric partnerships are a second step and deeper form of strategic preferred provider relationships that feature shared patient and service data among providers and payors with a focus on executing to patient-specific goals and care plans. Alternative payor models and full value-based care is a third step, which can feature shared savings and risk sharing models and ultimately lead to full risk payor contracts and/or direct contracting with Medicare and Medicaid. We continue to work through these various opportunities through payor discussions in a thoughtful way, and we believe that value-based payment structures in the future – supported by holistic care (in our care management model) and data-driven models – represent meaningful opportunities over the next decade, as we continue to support and focus on innovation that benefits clients, patients and families, and all stakeholders in healthcare.

Execute Strategic and Accretive M&A Through Add-on and Tuck-in Acquisitions: We believe we can continue to utilize our size, national presence, existing operations in related markets, integrated platform, deal sourcing capabilities, transaction execution skills, and significant cash flow as an experienced strategic consolidator in fragmented markets made up of mostly smaller and mid-sized local and state-based operators. We also believe there is a robust landscape of potential acquisitions across our target markets that can supplement organic growth, and that in continuing to pursue our M&A strategy we will be able to achieve significant census expansion, improve operational efficiencies, and augment delivery of our care. Industry dynamics continue to support and necessitate scale in our markets, due to the importance of volume growth, investing in people, technology systems, and data and analytics, driving quality best practices, leveraging overhead costs, and working productively with payors.

Our access to and presence in more complementary markets compared to other healthcare service providers allows us to benefit from increased deal opportunity flow, and it also allows us access to acquire certain “tuck-in” companies at lower and highly accretive multiples. We will continue to execute upon both strategic, higher-growth and higher-margin acquisitions in highly-valued markets, which continue to enhance care capabilities, with “tuck-in” acquisitions that have significant synergies and help manage to a target blended acquisitions multiple. Our IMO will continue to be a key asset in executing on transactions and ensuring solid integration of acquired operations into our Company, including the attainment of synergies and post-close growth plans. This is evident through the 42 acquisitions we completed since 2018 and our consistent pace of around 12 acquisitions per year. Due to our scale, breadth of offerings, quality reputation, approach to integrating new companies, and management team, we believe we are an acquirer of choice and a natural consolidator.

Recent Developments

Preliminary, Unaudited Estimated Financial and Other Data as of and for the Nine Months Ended September 30, 2021

We have presented below preliminary, unaudited estimated ranges of certain financial and other information as of and for the nine months ended September 30, 2021, as well as the unaudited condensed consolidated financial and other information for the nine months ended September 30, 2020, as we believe they are useful to investors in understanding our recent comparative operating performance.

We have provided ranges, rather than specific amounts, for certain data below, primarily because our financial closing and analysis procedures for the nine months ended September 30, 2021 are not yet completed. The unaudited estimated consolidated financial and other data set forth below are preliminary, based upon our estimates and currently available information and are subject to revision based upon, among other things, our financial closing procedures and the completion of our interim condensed consolidated financial statements and other operational procedures. The preliminary results as of and for the nine months ended September 30, 2021 and the actual results for the nine months ended September 30, 2020 presented below should not be viewed as a substitute for interim consolidated financial statements prepared in accordance with GAAP. Our actual results


 

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may be materially different from our estimates, which should not be regarded as a representation by us, our management or the underwriters as to our actual results as of and for the nine months ended September 30, 2021. You should not place undue reliance on these estimates. See “Forward-Looking Statements” and “Risk Factors.”

All of the data presented below has been prepared by and is the responsibility of management. Our independent registered public accounting firm, KPMG LLP, has not audited, reviewed, compiled or performed any procedures, and does not express an opinion or any other form of assurance with respect to any of such data.

For the nine months ended September 30, 2021, we estimate that our total pharmacy scripts will range from                  to                 , compared to total pharmacy scripts of 22,082,133 for the nine months ended September 30, 2020. For our provider metrics, we estimate ranges for home health care average daily census of                 to                  and long-term specialty care persons served of                  to                  for the nine months ended September 30, 2021, compared to 25,597 and 16,340, respectively, for the nine months ended September 30, 2020.

For the nine months ended September 30, 2021, we estimate that our consolidated net revenue will range from $             million to $             million, compared to consolidated net revenue of $4,110.9 million for the nine months ended September 30, 2020. We estimate that our consolidated net income (loss) will range from $             million to $             million and Adjusted EBITDA will range from $             million to $             million for the nine months ended September 30, 2021, compared to consolidated net income of $21.6 million and Adjusted EBITDA of $301.3 million for the nine months ended September 30, 2020.

The following table provides a reconciliation of net income (loss) to EBITDA and Adjusted EBITDA for the nine months ended September 30, 2021 (at the low end and high end of the estimated net income range set forth above) and the nine months ended September 30, 2020. In addition, please see “—Summary Historical Consolidated Financial and Other Data” for how we define EBITDA and Adjusted EBITDA, the reasons why we include these measures and certain limitations to their use.

 

     Nine Months Ended  
(In thousands)    September 30,
2021
     September 30,
2021
     September 30,
2020
 
     Low      High      Actual  

Net income (loss)

   $                    $                    $                

Income tax expense (benefit)

        

Interest expense

        

Depreciation and amortization

        
  

 

 

    

 

 

    

 

 

 

EBITDA

   $        $        $    

Non-cash share-based compensation

        

Acquisition-related costs (1)

        

Restructuring-related and other costs (2)

        

Startup costs (3)

        

Legal costs and settlements (4)

        

Significant projects (5)

        

Management fee (6)

        

Unreimbursed COVID-19 related costs (7)

        
  

 

 

    

 

 

    

 

 

 

Total Adjustments

   $        $        $    
  

 

 

    

 

 

    

 

 

 

Adjusted EBITDA

   $        $        $    
  

 

 

    

 

 

    

 

 

 

 

(1)

Represents transaction costs incurred in connection with planned, completed, or terminated acquisitions, which include investment banking fees, legal diligence and related documentation costs, finance and



 

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  accounting diligence and documentation, transaction-related payments to Kohlberg Kravis Roberts & Co. L.P. and Walgreens Boots Alliance, Inc, or the Managers, and integration cost incurred including any facility consolidation, integration travel or severance associated with the integration of an acquisition.
(2)

Represents costs associated with restructuring-related activities, including closure and severance expenses associated with certain enterprise-wide or significant business line cost-savings measures.

(3)

Represents costs associated with certain de novo start-ups.

(4)

Represents potential settlement accruals and defense costs associated primarily with certain PharMerica litigation matters associated with three historical cases.

(5)

Represents costs associated with certain transformational projects and primarily include the implementation of, and transition to, new general ledger and business intelligence systems.

(6)

Represents annual management fees payable to the Managers under a monitoring agreement with the Managers, or the Monitoring Agreement. This Monitoring Agreement will be terminated upon completion of an initial public offering, including this offering. See “Certain Relationships and Related Party Transactions — Monitoring Agreement.”

(7)

Represents unreimbursed COVID-19 related costs incurred by the Company such as incremental personal protection equipment, or PPE, in care of our patients as well as certain hazard pay to our caregivers.

As of September 30, 2021, we estimate that we had cash and cash equivalents of approximately $             million and total debt of approximately $             million.

Summary of Risk Factors

Investing in our common stock involves a high degree of risk. You should carefully consider the risks described in “Risk Factors” before making a decision to invest in our common stock. If any of these risks actually occurs, our business, consolidated results of operations and consolidated financial condition, including cash flows, may be materially adversely affected. In such case, the trading price of our common stock may decline and you may lose part or all of your investment. Below is a summary of some of the principal risks we face:

 

   

we operate in a highly competitive industry;

 

   

if we are unable to maintain relationships with existing patient referral sources or establish new referral sources, our business, financial condition and results of operations could be materially adversely affected;

 

   

a pandemic, epidemic or outbreak of an infectious disease, including the ongoing outbreak of COVID-19, could adversely affect our business;

 

   

changes to Medicare and Medicaid rates or methods governing Medicare and Medicaid payments for our services could materially adversely affect our business;

 

   

cost containment initiatives of third-party payors, including post-payment audits, could adversely impact our business, financial condition and results of operations;

 

   

the implementation of alternative payment models and the transition of Medicaid and Medicare beneficiaries to managed care organizations may limit our market share and could adversely affect our revenues;

 

   

changes in the case mix of patients, as well as payor mix and payment methodologies, and decisions and operations of third-party organizations may have a material adverse effect on our business, financial condition and results of operations;

 

   

our business is reliant on federal and state spending, budget decisions and continuous governmental operations which may fluctuate under different political conditions;


 

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changes in drug utilization and/or pricing, PBM contracts and Medicare Part D/Medicaid reimbursement may negatively impact our profitability;

 

   

changes in our relationships with pharmaceutical suppliers, including changes in drug availability or pricing, could adversely affect our business and financial results;

 

   

our business relies on the continual recruitment and retention of nurses, pharmacists, therapists, caregivers, direct support professionals and other qualified personnel, including senior management;

 

   

we are subject to federal, state and local laws and regulations that govern our employment practices, including minimum wage, living wage, and paid time-off requirements; failure to comply with these laws and regulations, or changes to these laws and regulations that increase our employment-related expenses, could adversely impact our operations;

 

   

our results of operations fluctuate on a quarterly basis;

 

   

our business may be harmed by labor relation matters;

 

   

because we are limited in our ability to control reimbursement rates received for our services, our business could be materially adversely affected if we are not able to maintain or reduce our costs to provide such services;

 

   

delays in collection or non-collection of our accounts receivable, particularly during the business integration process, could adversely affect our business, financial condition and results of operations;

 

   

if we fail to manage our growth effectively, we may be unable to execute our business plan, maintain high levels of service and satisfaction or adequately address competitive challenges;

 

   

our growth strategy is partially dependent upon our ability to identify and successfully complete acquisitions, joint ventures and other strategic initiatives; any failure by us to manage or integrate acquisitions, divestitures and other significant transactions successfully may have a material adverse effect on our business, financial condition and results of operations;

 

   

if we are unable to provide consistently high quality of care, our business will be adversely impacted;

 

   

if we are unable to maintain our corporate reputation, or there is adverse publicity, including negative information on social media, or changes in public perception of our services, our business may suffer;

 

   

if our existing customers do not continue with or renew their contracts with us, renew at lower fee levels, decline to purchase additional services from us or reduce the services received from us pursuant to those contracts, it could have a material adverse effect on our business, financial condition and results of operations;

 

   

our business depends on our ability to effectively invest in, implement improvements to and properly maintain the uninterrupted operation and data integrity of our information technology and other business systems;

 

   

security breaches, loss of data and other disruptions could compromise sensitive business or patient information, cause a loss of confidential patient data, employee data, personal information, or prevent access to critical information and expose us to liability, litigation and federal and state governmental inquiries and damage our reputation and brand;

 

   

we are subject to risks related to credit card payments and other payment methods;

 

   

we may be subject to substantial malpractice or other similar claims;

 

   

we are exposed to various risks related to governmental inquiries, regulatory actions and whistleblower lawsuits that could adversely affect our operating results. Our insurance may not cover all claims against us;


 

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our current insurance program may expose us to unexpected costs and negatively affect our business, financial condition and results of operations, particularly if we incur losses not covered by our insurance or if claims or losses differ from our estimates;

 

   

factors outside of our control, including those listed, could require us to record an asset impairment of goodwill;

 

   

inclement weather, natural disasters, acts of terrorism, riots, civil insurrection or social unrest, looting, protests, strikes or street demonstrations may impact our ability to provide services;

 

   

risks relating to our compliance with our regulatory framework;

 

   

KKR Stockholder and Walgreen Stockholder control us and their interests may conflict with yours in the future;

 

   

our substantial indebtedness of approximately $3.4 billion as of June 30, 2021; and

 

   

our being a “controlled company” within the meaning of Nasdaq and, as a result, qualifying for exemptions from certain corporate governance requirements.

KKR

KKR & Co. Inc., which, together with its subsidiaries, we refer to as KKR & Co., is a leading global investment firm that manages multiple alternative asset classes, including private equity, credit and real assets, with strategic partners that manage hedge funds. KKR & Co. aims to generate attractive investment returns for its fund investors by following a patient and disciplined investment approach, employing world-class people, and driving growth and value creation with its portfolio companies. KKR & Co. invests its own capital alongside the capital it manages for fund investors and provides financing solutions and investment opportunities through its capital markets business.

Walgreens

Walgreens Boots Alliance, Inc. is a global leader in retail and wholesale pharmacy, touching millions of lives every day through dispensing and distributing medicines, and through its convenient retail locations, digital platforms and health and beauty products with sales of $139.5 billion in the fiscal year ended August 31, 2020.

Our Corporate Information

Through our predecessors, we commenced operations in 1974 and have grown organically and through acquisitions. We were incorporated in Delaware on July 19, 2017, as Phoenix Parent Holdings Inc., in connection with KKR Stockholder’s and Walgreen Stockholder’s acquisition of PharMerica Corporation, which was completed in December 2017. In March 2019, we acquired BrightSpring Health Holdings Corp. and its subsidiaries. We recently changed our name to BrightSpring Health Services, Inc. Our principal offices are located at 805 N. Whittington Parkway, Louisville, Kentucky 40222. Our telephone number is (502) 394-2100. We maintain a website at www.brightspringhealth.com. The reference to our website is intended to be an inactive textual reference only. The information contained on, or that can be accessed through, our website is not part of this prospectus.

Concurrent Offering

Concurrently with this offering, we are offering, by means of a separate prospectus,         % Tangible Equity Units (and, to the extent that the underwriters sell more than             Units, up to an additional             Units that the underwriters in such concurrent offering have the option to purchase from us at the initial public offering


 

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price thereof less the underwriting discount, exercisable within 13 days beginning on, and including, the date of initial issuance of the Units), each with a stated amount of $50.00, or the Concurrent Offering. We estimate that the net proceeds from the sale of Units in the Concurrent Offering, if completed, will be approximately $            million (or approximately $            million if the underwriters in the Concurrent Offering exercise in full their option to purchase additional Units), in each case after deducting estimated underwriting discounts and commissions and estimated offering expenses payable by us. The closing of this offering is not conditioned upon the closing of the Concurrent Offering, but the closing of the Concurrent Offering is conditioned upon the closing of this offering, and there can be no assurance that the Concurrent Offering will be completed on the terms described herein or at all. For additional information, see “Tangible Equity Units Offering.”


 

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The Offering

 

Common stock offered by us

                 shares.

 

Option to purchase additional shares of common stock

We have granted the underwriters a 30-day option from the date of this prospectus to purchase up to              additional shares of our common stock at the initial public offering price, less underwriting discounts and commissions, to cover over-allotments, if any.

 

Common stock to be outstanding immediately after this offering

                 shares (or                  shares if the underwriters exercise in full their over-allotment option).

 

Use of proceeds

We estimate that the net proceeds to us from this offering will be approximately $             million (or approximately $             million, if the underwriters exercise in full their over-allotment option), assuming an initial public offering price of $             per share, which is the midpoint of the estimated price range set forth on the cover page of this prospectus, and after deducting the underwriting discounts and commissions and estimated offering expenses payable by us.

 

  We estimate that the net proceeds to us from the Concurrent Offering, if completed, after deducting estimated underwriting discounts and commissions and estimated offering expenses payable by us, will be approximately $             million (or $             million if the underwriters in the Concurrent Offering exercise in full their option to purchase additional Units).

We intend to use the net proceeds to us from this offering and the Concurrent Offering, if completed, to repay $             million outstanding aggregate amount under the Second Lien Facility, with any remainder to be used for general corporate purposes. For a sensitivity analysis as to the offering price and other information, see “Use of Proceeds.”

 

Conflicts of interest

Affiliates of KKR & Co. beneficially own in excess of 10% of our issued and outstanding common stock. Because KKR Capital Markets LLC, an affiliate of KKR & Co., is an underwriter in this offering and its affiliates own in excess of 10% of our issued and outstanding common stock, KKR Capital Markets LLC is deemed to have a “conflict of interest” under Rule 5121, or Rule 5121, of the Financial Industry Regulatory Authority, Inc., or FINRA. Accordingly, this offering is being made in compliance with the requirements of Rule 5121, which requires, among other things, that a “qualified independent underwriter” participate in the preparation of, and exercise the usual standards of “due diligence” with respect to, the registration statement and this prospectus.                      has agreed to act as a qualified independent underwriter for this offering and to undertake the legal responsibilities and liabilities of an underwriter


 

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under the Securities Act, specifically including those inherent in Section 11 thereof.                      will not receive any additional fees for serving as a qualified independent underwriter in connection with this offering. We have agreed to indemnify                  against liabilities incurred in connection with acting as a qualified independent underwriter, including liabilities under the Securities Act. See “Underwriting (Conflicts of Interest).”

 

Controlled company

After the completion of this offering, KKR Stockholder and Walgreen Stockholder will collectively beneficially own approximately     % (or approximately     %, if the underwriters exercise in full their over-allotment option) of the voting power of our common stock. We currently intend to avail ourselves of the controlled company exemption under the corporate governance standards of Nasdaq.

 

Dividend policy

We have no current plans to pay dividends on our common stock. Any decision to declare and pay dividends in the future will be made at the sole discretion of our board of directors and will depend on, among other things, our results of operations, cash requirements, financial condition, legal, tax, regulatory and contractual restrictions, including restrictions in the agreements governing our indebtedness, and other factors that our board of directors may deem relevant. See “Dividend Policy.”

 

Risk factors

Investing in shares of our common stock involves a high degree of risk. See “Risk Factors” for a discussion of factors you should carefully consider before investing in shares of our common stock.

 

Certain U.S. federal income tax consequences to non-U.S. holders

For a discussion of certain U.S. federal income tax consequences that may be relevant to non-U.S. stockholders, see “Certain U.S. Federal Income Tax Consequences to Non-U.S. Holders.”

 

Nasdaq trading symbol

“                    .”

 

Concurrent Tangible Equity Units Offering

Concurrently with this offering of common stock, we are making a public offering, by means of a separate prospectus, of                  Units, and we have granted the underwriters of that offering a 13-day option to purchase up to an additional                  Units.

 

  We cannot assure you that the offering of Units will be completed or, if completed, on what terms it will be completed. The closing of this offering is not conditioned upon the closing of the Concurrent Offering, but the closing of the Concurrent Offering is conditioned upon the closing of this offering. See the section of this prospectus entitled “Tangible Equity Units Offering” for a summary of the terms of the Units and a further description of the Concurrent Offering.

Unless we indicate otherwise or the context otherwise requires, this prospectus reflects and assumes:

 

   

no exercise of the underwriters’ option to purchase additional shares of our common stock;


 

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an initial public offering price of $             per share of common stock, which is the midpoint of the estimated price range set forth on the cover page of this prospectus;

 

   

the              -for-one stock split of our common stock, which will occur prior to the consummation of this offering;

 

   

the filing and effectiveness of our second amended and restated certificate of incorporation and the adoption of our amended and restated bylaws immediately prior to the consummation of this offering; and

 

   

the completion of the concurrent offering of                  Units, with no exercise by the underwriters of the Concurrent Offering of their option to purchase additional Units.

Unless we indicate otherwise or the context otherwise requires, the number of shares of common stock to be outstanding after this offering excludes:

 

   

                 shares of common stock issuable upon exercise of outstanding options as of June 30, 2021, (i)                      of which are vested, with a weighted-average exercise price of $             per share, and (ii) (A)                      of which are time-based options that are not vested, with a weighted-average exercise price of $             per share, and (B)                      of which are performance-based options that are not vested, with a weighted-average exercise price of $             per share, in each case, issued under the Amended and Restated Phoenix Parent Holdings Inc. 2017 Stock Incentive Plan, or the 2017 Stock Plan. See “Executive Compensation—Equity Incentive Plans—2017 Stock Incentive Plan”;

 

   

                 shares of common stock reserved for future issuance under our new 2021 Incentive Plan, or the 2021 Incentive Plan, which we intend to adopt in connection with this offering. See “Executive Compensation—Equity Incentive Plans—2021 Incentive Plan”; and

 

   

up to                  shares of common stock (or up to                  shares if the underwriters in the Concurrent Offering exercise in full their option to purchase additional Units) issuable upon settlement of the purchase contracts that are a component of the Units being offered in the Concurrent Offering, in each case, at the rate of                  shares of common stock per purchase contract, based on the assumed initial public offering price of $                 per share, which is the midpoint of the estimated price range set forth on the cover page of this prospectus, and assuming the maximum number of shares issuable upon automatic settlement of such purchase contracts, subject to certain anti-dilution adjustments.


 

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SUMMARY HISTORICAL CONSOLIDATED FINANCIAL AND OTHER DATA

Set forth below are our summary historical consolidated financial and other data as of the dates and for the periods indicated. The summary historical financial data as of December 31, 2020 and 2019 and for 2020, 2019 and 2018 have been derived from our audited consolidated financial statements included elsewhere in this prospectus. The summary historical financial data as of June 30, 2021 and for the six months ended June 30, 2021 and 2020 have been derived from our unaudited condensed consolidated financial statements included elsewhere in this prospectus. The summary historical financial data as of June 30, 2020 has been derived from our unaudited condensed consolidated financial statements not included in this prospectus. The results of operations for any period are not necessarily indicative of our future financial condition or results of operations. Share and per share data in the table below have been retroactively adjusted to give effect to the              -for-one stock split, which will occur prior to the consummation of this offering.

You should read the following summary financial and other data below together with the information under “Capitalization” and “Management’s Discussion and Analysis of Financial Condition and Results of Operations” and our audited consolidated financial statements and related notes and our unaudited condensed consolidated financial statements and related notes, each included elsewhere in this prospectus.

 

     Year Ended     Six Months Ended  
(In thousands, except per share data)    December 31,
2020
     December 31,
2019
    December 31,
2018
    June 30,
2021
     June 30,
2020
 

Statement of Income (Loss) Data:

            

Revenues:

            

Products

   $ 3,635,898      $ 3,022,334     $ 2,536,053     $ 2,082,765      $ 1,748,491  

Services

     1,944,474        1,502,875       —         1,077,662        949,643  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

Total revenues

     5,580,372        4,525,209       2,536,053       3,160,427        2,698,134  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

Cost of goods

     3,099,365        2,564,669       2,160,144       1,778,590        1,485,814  

Cost of services

     1,432,269        1,126,634       —         790,893        700,875  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 
Gross profit      1,048,738        833,906       375,909       590,944        511,445  

Selling, general and administrative expenses

     883,547        770,592       312,128       487,681        435,548  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 
Operating income      165,191        63,314       63,781       103,263        75,897  

Interest expense, net

     138,953        166,893       74,613       78,656        72,359  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

Income (loss) before income taxes

     26,238        (103,579     (10,832     24,607        3,538  

Income tax expense (benefit)

     5,087        (32,491     (3,211     6,114        (3,331
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

Net income (loss)

   $ 21,151      $ (71,088   $ (7,621   $ 18,493      $ 6,869  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

Net income attributable to redeemable noncontrolling interests

     341        1,293       —         463        123  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

Net income (loss) attributable to BrightSpring Health Services, Inc. and subsidiaries

   $ 20,810      $ (72,381   $ (7,621   $ 18,030      $ 6,746  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

Per Share Information:

            

Weighted average shares used in computing income (loss) per share

            

Basic

     7,452        7,055       4,847       7,473        7,452  

Diluted

     7,492        7,055       4,847       7,639        7,456  

Net income (loss) per share

            

Earnings (loss) per common share, basic

   $ 2.79      $ (10.26   $ (1.57   $ 2.41      $ 0.91  

Earnings (loss) per common share, diluted

   $ 2.78      $ (10.26   $ (1.57   $ 2.36      $ 0.90  

 

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     Year Ended     Six Months Ended  
(In thousands, except per share data)    December 31,
2020
    December 31,
2019
    December 31,
2018
    June 30,
2021
    June 30,
2020
 

Balance Sheet Data (end of period):

          

Cash and cash equivalents

   $ 262,005     $ 18,295       $ 240,617     $ 20,275  

Working capital(1)

     547,591       248,713         466,721       249,626  

Total assets

     4,541,073       3,817,337         5,370,573       3,843,758  

Total debt, net of unamortized debt issuance costs

     2,693,840       2,182,331         3,347,756       2,181,602  

Total shareholders’ equity

     704,984       656,873         734,786       665,756  

Cash Flow Data:

          

Net cash provided by operating activities

   $ 222,641     $ 110,912     $ 76,454     $ 202,382     $ 112,288  

Net cash used in investing activities

     (452,867     (1,532,218     (37,336     (860,120     (95,752

Net cash provided by (used in) financing activities

     473,936       1,409,077       (32,208     636,350       (14,486

Capital expenditures

     (51,908     (51,221     (33,201     (28,961     (26,748

Other Financial Data (unaudited):

          

EBITDA(2)

   $ 346,693     $ 218,182     $ 144,950     $ 201,056     $ 163,667  

Adjusted EBITDA(2)

     412,028       332,573       163,819       238,258       191,403  

 

(1)

We define working capital as current assets less current liabilities.

 

(2)

We define EBITDA as net income (loss) before income tax expense (benefit), interest expense and depreciation and amortization. We defined Adjusted EBITDA as EBITDA, further adjusted to exclude non-cash share-based compensation, acquisition-related costs, restructuring-related and other costs, certain startup costs, legal costs and settlements associated with certain historical matters for PharMerica, significant projects, management fee and unreimbursed COVID-19 related costs. We describe these adjustments reconciling net income (loss) to EBITDA and Adjusted EBITDA in the table below.

EBITDA and Adjusted EBITDA have been presented in this prospectus as supplemental measures of financial performance that are not required by, or presented in accordance with, GAAP. We believe EBITDA and Adjusted EBITDA assist investors and analysts in comparing our operating performance across reporting periods on a consistent basis by excluding items that we do not believe are indicative of our core operating performance. Management believes these measures are useful to investors in highlighting trends in our operating performance, while other measures can differ significantly depending on long-term strategic decisions regarding capital structure, the tax jurisdictions in which we operate and capital investments. Management uses EBITDA and Adjusted EBITDA to supplement GAAP measures of performance in the evaluation of the effectiveness of our business strategies, to make budgeting decisions, to establish and award discretionary annual incentive compensation, and to compare our performance against that of other peer companies using similar measures.

Management supplements GAAP results with non-GAAP financial measures to provide a more complete understanding of the factors and trends affecting the business than GAAP results alone. EBITDA and Adjusted EBITDA are not recognized terms under GAAP and should not be considered as an alternative to net income (loss) as a measure of financial performance or any other performance measures derived in accordance with GAAP. Additionally, these measures are not intended to be a measure of free cash flow available for management’s discretionary use as they do not consider certain cash requirements such as tax payments and debt service requirements, total capital expenditures and certain other cash costs that may recur in the future. In evaluating Adjusted EBITDA, you should be aware that in the future we may incur expenses that are the same as or similar to some of the adjustments in this presentation. Our presentation of Adjusted EBITDA should not be construed to imply that our future results will be unaffected by any such adjustments. Management relies on our GAAP results in addition to using EBITDA and Adjusted EBITDA in a supplemental manner.


 

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Our EBITDA and Adjusted EBITDA measures have limitations as analytical tools, and you should not consider them in isolation, or as a substitute for analysis of our results as reported under GAAP. Some of these limitations are:

 

   

they do not reflect costs or cash outlays for capital expenditures or contractual commitments;

 

   

they do not reflect changes in, or cash requirements for, our working capital needs;

 

   

they do not reflect the interest expense, or the cash requirements necessary to service interest or principal payments, on our debt;

 

   

they do not reflect period to period changes in taxes, income tax expense or the cash necessary to pay income taxes;

 

   

they do not reflect the impact of earnings or charges resulting from matters we consider not to be indicative of our ongoing operations;

 

   

although depreciation and amortization are non-cash charges, the assets being depreciated and amortized will often have to be replaced in the future, and these measures do not reflect cash requirements for such replacements; and

 

   

other companies in our industries may calculate these measures differently than we do, limiting their usefulness as comparative measures.

Because of these limitations, EBITDA and Adjusted EBITDA should not be considered as measures of discretionary cash available to invest in business growth or to reduce indebtedness.

The following table provides a reconciliation of net income (loss) to EBITDA and Adjusted EBITDA for the periods presented:

 

     Year Ended     Six Months Ended  
(In thousands)    December 31,
2020
     December 31,
2019
    December 31,
2018
    June 30,
2021
     June 30,
2020
 

Net income (loss)

   $ 21,151      $ (71,088   $ (7,621   $ 18,493      $ 6,869  

Income tax expense (benefit)

     5,087        (32,491     (3,211     6,114        (3,331

Interest expense

     138,953        166,893       74,613       78,656        72,359  

Depreciation and amortization

     181,502        154,868       81,169       97,793        87,770  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

EBITDA

   $ 346,693      $ 218,182     $ 144,950     $ 201,056      $ 163,667  

Non-cash share-based compensation

     6,268        3,709       3,106       2,000        3,033  

Acquisition-related costs (a)

     12,100        76,756       8,085       12,537        3,941  

Restructuring-related and other costs (b)

     16,631        17,832       1,483       9,138        8,229  

Startup costs (c)

     4,269        5,460       —         1,952        1,947  

Legal costs and settlements (d)

     12,278        7,013       4,695       5,958        4,181  

Significant projects (e)

     3,480        861       —         2,532        1,500  

Management fee (f)

     4,220        2,760       1,500       2,059        2,053  

Unreimbursed COVID-19 related costs (g)

     6,089        —         —         1,026        2,852  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

Total Adjustments

   $ 65,335      $ 114,391     $ 18,869     $ 37,202      $ 27,736  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

Adjusted EBITDA

   $ 412,028      $ 332,573     $ 163,819     $ 238,258      $ 191,403  
  

 

 

    

 

 

   

 

 

   

 

 

    

 

 

 

 

(a)

Represents (i) transaction costs incurred in connection with planned, completed, or terminated acquisitions, which include investment banking fees, legal diligence and related documentation costs, finance and accounting diligence and documentation, transaction-related payments to the Managers and integration cost incurred including any facility consolidation, integration travel or severance associated with the integration


 

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  of an acquisition. These costs were $12.1 million for the year ended December 31, 2020, $45.1 million for the year ended December 31, 2019 and $8.1 million for the year ended December 31, 2018. These costs were $12.5 million and $3.9 million for the six months ended June 30, 2021 and 2020, respectively. The year ended December 31, 2019 included significant transaction-related and integration costs associated with the BHS Acquisition; and (ii) the debt extinguishment costs incurred in connection with the BHS Acquisition of $31.7 million in 2019.
(b)

Represents costs associated with restructuring-related activities, including closure and severance expenses associated with certain enterprise-wide or significant business line cost-savings measures.

(c)

Represents costs associated with certain de novo start-ups.

(d)

Represents potential settlement accruals and defense costs associated primarily with certain PharMerica litigation matters associated with three historical cases.

(e)

Represents costs associated with certain transformational projects and primarily include the implementation of, and transition to, new general ledger and business intelligence systems.

(f)

Represents annual management fees payable to the Managers under the Monitoring Agreement. This Monitoring Agreement will be terminated upon completion of an initial public offering, including this offering. See “Certain Relationships and Related Party Transactions — Monitoring Agreement.”

(g)

Represents unreimbursed COVID-19 related costs incurred by the Company such as incremental PPE in care of our patients as well as certain hazard pay to our caregivers.


 

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RISK FACTORS

Investing in our common stock involves a high degree of risk. You should carefully consider the risks and uncertainties described below and the other information set forth in this prospectus before deciding to invest in our common stock. If any of the following risks actually occurs, our business, results of operations and financial condition may be materially adversely affected. In such case, the trading price of our common stock could decline and you may lose all or part of your investment.

Risks Related to Our Business

We operate in a highly competitive industry.

The U.S. healthcare industry in which we operate is highly competitive. We compete with a broad and diverse set of businesses spanning both provider and pharmacy services. In our Home and Community Health Provider Services segment, we compete with local, regional and national providers of home health, hospice, rehab therapy, personal and behavioral health services in each of the geographical areas in which we operate. In our Pharmacy Solutions segment, the competition for the distribution of pharmaceuticals to patients and also to healthcare facilities is intense. In each geographic market, there are national, regional and local facility-based pharmacies that provide services comparable to those offered by our pharmacies. In addition, owners of skilled nursing facilities are also entering the facility-based pharmacy market, particularly in areas of their geographic concentration. We also compete in the large and highly fragmented hospice, infusion and specialty pharmacy markets. Failure to compete effectively could have a material adverse effect on our market share, business, financial condition and results of operations.

We compete based on the availability of personnel, the quality of services, expertise of clinicians, caregivers, pharmacists and pharmacy professionals, and in certain instances, on the price of our services. Some of our competitors may have greater financial, technical and marketing resources, name recognition or a larger number of patients and payors than we do. Often our contracts with payors are not exclusive, and local competitors may develop strategic relationships with referral sources and payors, limiting our ability to retain referrals and payors in local markets. Some of our competitors may negotiate exclusivity provisions with managed care plans or otherwise interfere with the ability of managed care companies to contract with us. We may experience increased competition for managed care contracts due to state regulation and limitations. These competitive advantages could result in pricing pressures, loss of or failure to gain market share or loss of patients or payors, any of which could harm our business. In addition, our competitors may offer more services than we do in the markets in which we operate, introduce new or enhanced services that we do not provide, or be viewed by consumers as a more desirable local alternative. This, in combination with industry consolidation and the development of strategic relationships by our competitors (including mergers of competitors with each other and with insurers), could cause a decline in revenue, loss of market acceptance of our services or a negative impact on our results of operations. In addition, some of our competitors have vertically integrated business models with commercial payors, or are under common control with, or owned by, pharmaceutical wholesalers and distributors, Managed Care Organizations, or MCOs, pharmacy benefit managers, or PBMs, or retail pharmacy chains and may be better positioned with respect to the cost-effective distribution of pharmaceuticals. In addition, some of our competitors may have secured long-term supply or distribution arrangements for prescription pharmaceuticals necessary to treat certain chronic disease states on price terms substantially more favorable than the terms currently available to us. Consequently, we may be less price competitive than some of these competitors with respect to certain pharmaceutical products.

In our Home and Community Health Provider Services segment, there are few barriers to entry in states that do not require a certificate of need, or CON, or permit of approval, or POA. Although state CON and POA laws may limit the ability of competitors to enter into certain markets, these laws are not uniform throughout the United States and are frequently the subject of efforts to limit or repeal such laws. If states remove existing CON or POA requirements, we could face increased competition in these states. There can be no assurances that other states will not seek to eliminate or limit their existing CON or POA programs, which could lead to increased competition in these states.

 

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In our Pharmacy Solutions segment, we must maintain good working relationships with pharmaceutical manufacturers, wholesalers, and distributors. Any loss of a supplier relationship or other changes to these relationships could have an adverse effect on our business, financial condition and results of operations. Additionally, access to limited distribution pharmaceuticals provides us with significant competitive advantages in developing relationships with payors and healthcare providers, and our failure to continue obtaining access to new limited distribution pharmaceuticals or the loss of our current access could have a material and adverse impact on our business. We also provide a significant amount of services related to patient access to specialty pharmaceuticals, and our failure to provide services at optimal levels could result in losing access to existing and future products. If pharmaceutical manufacturers require significant additional services and products to obtain access to their products without a corresponding increase in service fees, our profitability could be adversely impacted.

If we are unable to maintain relationships with existing patient referral sources or establish new referral sources, our business, financial condition and results of operations could be materially adversely affected.

Our success is heavily dependent on referrals from physicians, hospitals, long-term care facilities, other institutional health care providers and other sources in the communities we serve, such as case managers and placement agencies, and on our ability to maintain good relationships with these referral sources. Our referral sources are not obligated to refer patients to us and may refer their patients to other providers. Our growth and profitability depend, in part, on our ability to establish and maintain close working relationships with these patient referral sources, comply with applicable laws with respect to such relationships, and to increase awareness and acceptance of the benefits of our home and community health provider services and pharmaceutical solutions by our referral sources and their patients. Many of our referral sources are becoming increasingly focused on finding quality services. If we should fail to attain our goals regarding acute care hospitalization readmission rates and other quality metrics, we expect our ability to generate referrals would be adversely impacted. Our ability to attract and retain referral sources could also be adversely affected if we fail to provide or maintain a reputation for providing cost-effective care as compared to other providers in the same geographic area. If we lose, or fail to maintain, existing relationships or fail to develop new referral relationships or if we are perceived by our referral sources for any reason as not providing high quality or cost-effective patient care and solutions, our patient volumes and the quality of our patient mix could suffer, and our revenue and profitability could decline.

A pandemic, epidemic or outbreak of an infectious disease, including the ongoing outbreak of COVID-19, could adversely affect our business.

The actual or perceived effects of a disease outbreak, epidemic, pandemic or similar widespread public health concern, such as the ongoing COVID-19 pandemic, could negatively affect our business, financial condition and results of operations. The COVID-19 pandemic has adversely impacted economic activity and conditions worldwide, including workforces, liquidity, capital markets, consumer behavior, supply chains and macroeconomic conditions. We have faced and may continue to face decreased demand for our services, interruption in the provision of our services, increased costs of services and adverse impact on our liquidity position.

We may be more vulnerable to the effects of a public health emergency than other businesses due to our complex patient populations and the physical proximity required by our operations. The majority of our patients are medically complex individuals, many of whom may be more vulnerable than the general public during a pandemic or in a public health emergency, due to chronic illnesses, disabilities, behavioral health issues or other socioeconomic factors. Demand for home and community health provider services could be significantly diminished due to heightened anxiety among our patients regarding the risk of exposure to COVID-19 as a result of home and community visits, as well as fluctuations in the population of long term facilities that we serve. Local and state governments have in the past and may in the future impose limits on the provision of certain healthcare services and we believe some members of the communities we serve had been avoiding elective healthcare visits and procedures earlier during the COVID-19 outbreak. Although the applicable authorities have

 

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designated our services as “essential,” exempting our services and providers from many of the restrictions put in place for the COVID-19 pandemic, our home and community health services providers have experienced some difficulty at times in accessing facility-based patients because of concerns about the spread of COVID-19, and this difficulty may continue.

Our primary COVID-related impacts have been in prescription drug volume with our skilled nursing and rehabilitation facility customers. During 2020, we experienced a script reduction of approximately 2.7 million scripts when compared with our pre-pandemic levels early in January and February 2020. These script volume impacts were due largely to industry declines in skilled nursing and rehabilitation facility occupancy rates. We believe that these COVID related effects had an impact of approximately $134.3 million reduction in revenue in our Pharmacy Solutions segment, when compared to pre-pandemic levels. During the six months ended June 30, 2021, we continued to experience script reductions when compared to our pre-pandemic levels early in January and February 2020, which equated to approximately 1.9 million scripts, and an estimated impact on revenue of approximately $(94.4) million.

Our clinicians, caregivers and employees are also at greater risk of contracting contagious diseases due to their increased exposure to vulnerable patients and the essential nature of their work. If there is a reduction in our available healthcare providers due to concerns around COVID-19 related risks or if substantial numbers of our healthcare providers were to contract COVID-19 or otherwise be required to quarantine due to exposure to COVID-19, our ability to provide services to our patients may be significantly interrupted or suspended. In addition, in states that have not enacted liability protection laws for providers, we could face litigation if our employees or patients contract COVID-19 while our employees perform their duties. In addition, if our healthcare providers are unable to obtain vaccines in a timely manner or are not willing to receive a COVID-19 vaccine, demand for our services may be reduced if there is a perception that other service providers would offer less risk than our health care providers. If the existing COVID-19 pandemic does not abate or worsens, we could suffer significant losses to our patient population or a reduction in the availability of our employees and, at a high cost, be required to hire replacements for affected workers. The COVID-19 pandemic has led to a constrained supply environment, and staffing, equipment (including PPE for our clinicians, caregivers and employees), pharmaceutical and medical supplies shortages could adversely impact our ability to schedule, treat and care for patients and deliver our pharmaceutical solutions. In addition, a number of our employees are continuing to work from home, and remote working may heighten cybersecurity, information security, and operational risks and affect the productivity of our employees.

In addition to a number of factors that could adversely impact demand for our services and our ability to provide services to our patients, we may experience increased cost of care and reduced reimbursements as a result of COVID-19. We have incurred and expect to continue to incur additional costs related to protecting the health and well-being, and meeting the needs, of our patients, clinicians, caregivers and employees as we implement operational changes in response to the pandemic. In particular, we have already experienced higher costs due to the higher utilization and cost of PPE as well as increased purchasing of other medical supplies, cleaning, and sanitization materials. We have also experienced significant changes in referral patterns and sources due to the pandemic.

The extent of future impact will depend on future developments that are highly uncertain and cannot be accurately predicted at this time, including the severity and transmission rate of COVID-19, new information that may emerge, the extent and effectiveness of containment actions taken, the rollout, availability, and adoption of effective medical treatments and vaccines, and the impact of any viral mutations or variants.

Changes to Medicare and Medicaid rates or methods governing Medicare and Medicaid payments for our services could materially adversely affect our business.

We derive substantial revenue from government healthcare programs, primarily Medicare and Medicaid. Payments received from Medicare are subject to changes made through federal legislation and regulation. Payments received from Medicaid may vary from state to state. These payments are subject to statutory and regulatory changes, administrative rulings, interpretations and determinations concerning patient eligibility requirements, funding levels

 

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and the method of calculating payments or reimbursements. Changes in government healthcare programs may decrease the reimbursement we receive or limit access to, or utilization of, our services, and in turn, could cause our revenues and profitability to decline. When such changes are implemented, we must also modify our internal billing processes and procedures accordingly, which can require significant time and expense. As federal healthcare expenditures continue to increase and state governments may face budgetary shortfalls, including as a result of the COVID-19 pandemic, federal and state governments have made, and may continue to make, significant changes to the Medicare and Medicaid programs and reimbursement received for services rendered to beneficiaries of such programs. Changes that may occur at the federal or state level include:

 

   

administrative or legislative changes to the base rates under the applicable prospective payment systems;

 

   

the reduction or elimination of annual rate increases;

 

   

redefining eligibility or enrollment standards or coverage criteria for government healthcare programs or the receipt of services under those programs or changes in documentation requirements;

 

   

the imposition of prior authorization and concurrent utilization review programs that may further limit the services for which government healthcare programs will pay and shift patients to lower levels of care and reimbursement;

 

   

the imposition or increase of mechanisms shifting more responsibility for a portion of payment to beneficiaries, such as co-payments;

 

   

adjustments to the relative components of the wage index used in determining reimbursement rates;

 

   

decreasing benefits, such as limiting the number of hours of personal care services that will be covered;

 

   

changing reimbursement methodology;

 

   

slowing payments to providers;

 

   

increasing utilization of self-directed care alternatives or “all inclusive” programs;

 

   

changes to cap limits and per diem rates;

 

   

changes to case mix or therapy thresholds;

 

   

the reclassification of home health resource groups; and

 

   

the reclassification of long-term care diagnosis-related groups.

Additionally, regulators are increasing scrutiny of claims, which may require additional resources to respond to audits, and which may cause additional delays or denials in receiving payments. Medicare currently provides for an annual adjustment of the various payment rates based upon the increase or decrease of the medical care expenditure, which may be less than actual inflation. This adjustment could be eliminated or reduced in any given year. Additionally, the Coronavirus Aid, Relief, and Economic Security Act, or CARES Act, and subsequent COVID-19 relief legislation temporarily reversed prior reductions in Medicare reimbursement through the 2% sequestration mandated by earlier legislation through December 31, 2021, and we cannot anticipate if the temporary reversal will be extended beyond that date. Further, Medicare routinely reclassifies home health resource groups and long-term care diagnosis-related groups, and as a result, we could receive lower reimbursement rates depending on the case mix of the patients we service. If our cost of providing services increases by more than the annual Medicare price adjustment, or if these reclassifications result in lower reimbursement rates, our business, financial condition and results of operations could be adversely impacted. Certain of these measures have been implemented by, or are proposed in, states in which we operate.

Additionally, CMS changed the Home Health Prospective Payment System case-mix adjustment methodology through the use of a new Patient-Driven Groupings Model, or PDGM, for home health payments. This change was implemented on January 1, 2020, and also includes a change in the unit of payment from a

 

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60-day payment period to a 30-day payment period and eliminates the use of therapy visits in the determination of payments. While the changes are intended to be implemented in a budget-neutral manner to the industry, the ultimate impact will vary by provider based on factors including patient mix and admission source. Additionally, in arriving at the rate that is budget-neutral, CMS has made assumptions about behavioral changes that resulted in a 4.36% reduction to reimbursement. The Patient Protection and Affordable Care Act and the Health Care Education and Reconciliation Act, or collectively, the ACA, added a new Medicare requirement for face-to-face encounters to support claims for home health services, which continues to be one of the most complex issues and can be the source of claims denials if not fulfilled, and extended the same requirements for face-to-face encounters to the case of physicians making certifications for home health services under Medicaid. Although CMS has issued guidance stating that the face-to-face encounter requirement may be performed via telehealth as a result of CMS’s COVID-19 emergency declaration waiver authority under section 1135 of the Social Security Act, it is unclear whether such encounters will be permissible once the public health emergency ends.

For hospice patients receiving nursing center care under certain state Medicaid programs who elect hospice care under Medicare or Medicaid, the state must pay, in addition to the applicable Medicare or Medicaid hospice per diem rate, an amount equal to at least 95% of the Medicaid per diem nursing center rate for “room and board” furnished to the patient by the nursing center. The reduction or elimination of Medicare payments for hospice patients residing in nursing centers would significantly reduce our home and community health services revenues and profitability. In addition, changes in the way nursing centers are reimbursed for “room and board” services provided to hospice patients residing in nursing centers could adversely affect our ability to obtain referrals from nursing centers.

If changes in Medicare, Medicaid or other state and local programs result in a reduction in available funds for the services we offer, a reduction in the number of beneficiaries eligible for our services or a reduction in the number of hours or amount of services that beneficiaries eligible for our services may receive, then our revenues and profitability could be negatively impacted. We cannot assure you that reimbursement payments under governmental payor programs, including supplemental insurance policies, will remain at levels comparable to present levels or will be sufficient to cover the costs allocable to patients eligible for reimbursement pursuant to these programs. In some cases, commercial insurance companies and other private payors rely on government payment systems to determine payment rates. As a result, changes to government healthcare programs that reduce Medicare, Medicaid or other payments may negatively impact payments from private payors, as well. Any reduction in reimbursements from governmental or private payors, as well as the imposition of co-payments that dissuade the use of our services, could also materially adversely affect our profitability.

Cost containment initiatives of third-party payors, including post-payment audits, could adversely impact our business, financial condition and results of operations.

During the past several years, third-party healthcare payors, such as federal and state governments, insurance companies and employers, have undertaken cost containment initiatives. As part of the efforts, such payors are increasingly demanding discounted fee structures or the assumption by healthcare providers of all or a portion of the financial risk relating to paying for care provided, often in exchange for exclusive or preferred participation in their benefit plans. We expect efforts to impose greater discounts and more stringent cost controls by government and other third-party payors to continue, potentially reducing the payments we receive for our services. For example, the Medicaid Integrity Program is increasing its scrutiny of Medicaid providers and reimbursements received through the program, which could result in recoupments of alleged overpayments. Similarly, private third-party payors also engage in post-payment audits which can result in recoupments. Additionally, private third-party payors may be successful in negotiating reduced reimbursement schedules for our services. Fixed fee schedules, capitation payment arrangements, exclusion from participation in or inability to reach agreements with private insurance organizations or government funded programs, reduction or elimination of payments or an increase in the payments at a rate that is less than the increase in our costs, or other factors affecting payments for healthcare services over which we have no control, could have a material adverse effect on our business, financial condition, results of operations and prospects. Further, we cannot assure you that

 

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our services will be considered cost-effective by third-party payors, that third-party payor reimbursement will continue to be available or that changes to third-party payor reimbursement policies will not have a material adverse effect on our ability to provide our services on a profitable basis, if at all.

In addition, certain third parties, known as conveners, offer patient placement and care transition services to managed care companies, Medicare Advantage plans, bundled payment participants, ACOs and other healthcare providers as part of an effort to manage costs. Given their focus on perceived financial savings, conveners customarily suggest that patients avoid higher cost settings altogether or move as soon as practicable to lower-cost settings. However, conveners are not healthcare providers and may suggest a setting or duration of care that may not be appropriate from a clinical perspective. Efforts by conveners to avoid our care settings or suggest shorter lengths of stay in our care settings could have a material adverse effect on our business, financial condition and results of operations.

The implementation of alternative payment models and the transition of Medicaid and Medicare beneficiaries to managed care organizations may limit our market share and could adversely affect our revenues.

Many government and commercial payors are transitioning providers to alternative payment models that are designed to promote cost-efficiency, quality and coordination of care. For example, ACOs, incentivize hospitals, physician groups, and other providers to organize and coordinate patient care while reducing unnecessary costs. Conceptually, ACOs receive a portion of any savings generated above a certain threshold from care coordination as long as benchmarks for the quality of care are maintained. Providers are then paid based on the overall value and quality (as determined by outcomes) of the services they provide to a patient rather than the number of services they provide. Pursuant to the ACA, CMS has established several separate ACO programs, the largest of which is the Medicare Shared Savings Program, or MSSP, for care provided to Medicare fee-for-service beneficiaries. The ACO rules adopted by CMS are extremely complex and remain subject to further refinement by CMS. Several states have implemented, or plan to implement, accountable care models for their Medicaid populations. Eligible providers, hospitals and suppliers may participate by creating, participating in or contracting with an ACO. If we are not included in these programs, or if ACOs establish programs that overlap with our services, we are at risk for losing market share, including a loss of our current business.

The trend in the healthcare industry toward value-based purchasing of healthcare services is growing among both government and commercial payors. Value-based purchasing programs emphasize quality of outcome and efficiency of care provided, rather than quantity of care provided. For example, Medicare requires home and community health services companies to report certain quality data in order to receive full reimbursement. Failure to report quality data or poor performance may negatively impact the amount of reimbursement received. We may incur additional expenses in an effort to comply with additional and changing quality reporting requirements. CMS currently has a value-based purchasing program affecting home health providers in a number of pilot states, whereby providers receive payment bonuses or penalties based on their achievement of specified performance measures, and intends to expand this program. In the future, CMS may establish new value-based purchasing programs affecting a broader range of providers. Additionally, commercial payors have expressed intent to shift toward value-based reimbursement arrangements. Government and commercial payors’ implementation of value-based purchasing requirements could have a material adverse effect on our business, financial condition and results of operations.

The ACA resulted in the establishment of various demonstration projects and Medicaid programs under which states may apply to test new or existing approaches to payment and delivery of Medicaid benefits. For example, on May 29, 2018, CMS issued a notice indicating its intention to re-launch a home health agency pre-claim review demonstration project, now called the Review Choice Demonstration for Home Health Services. Compliance with this process could result in increased administrative costs or delays in reimbursement for home health services in states subject to the demonstration. Other alternative payment models, such as bundled payment arrangements, may be presented by the government and commercial payors to control costs that subject our company to financial risk. We cannot predict at this time what effect alternative payment models may have on our company. If we perform at a level below the outcomes demonstrated by our competitors, fail to satisfy quality data reporting requirements, are unable to

 

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meet or exceed quality performance standards under any applicable value-based purchasing program, or otherwise fail to effectively provide or coordinate the efficient delivery of quality healthcare services, our reputation in the industry may be negatively impacted, we may receive reduced reimbursement amounts and we may owe repayments to payors, which could materially adversely impact our business, financial condition and results of operations.

We may be similarly impacted by increased enrollment of Medicare and Medicaid beneficiaries in managed care plans, shifting away from traditional fee-for-service models. Under a managed Medicare plan, also known as Medicare Advantage, the federal government contracts with private health insurers to provide Medicare benefits and the insurers may choose to offer supplemental benefits. Approximately two-fifths of all Medicare beneficiaries were enrolled in a Medicare Advantage plan in 2020, a figure that continues to grow. Beginning in 2019, CMS allowed Medicare Advantage plans to offer certain personal care services as a supplemental benefit. Enrollment in managed Medicaid plans is also growing, as states are increasingly relying on MCOs to deliver Medicaid program services as a strategy to control costs and manage resources. Managed care contracts typically permit the payor to terminate the contract without cause, on very short notice, typically 60 days, which can provide payors leverage to reduce volume or obtain favorable pricing. We cannot assure you that we will be successful in our efforts to be included in managed plan networks, that we will be able to secure or maintain favorable contracts with all or some of the MCOs, that our reimbursement under these programs will remain at current levels, that the authorizations for services will remain at current levels or that our profitability will remain at levels consistent with past performance. In addition, operational processes may not be well-defined as a state transitions Medicaid recipients to managed care. For example, membership, new referrals and the related authorization for services to be provided may be delayed, which may result in delays in service delivery to consumers or in payment for services rendered. Difficulties with operational processes associated with new managed care contracts may negatively affect our revenue, cash flow and profitability for services provided.

Changes in the case mix of patients, as well as payor mix and payment methodologies, and decisions and operations of third-party organizations may have a material adverse effect on our business, financial condition and results of operations.

The sources and amounts of our revenue are determined by a number of factors, including the mix of patients and third-party payors, the rates of reimbursement or payments among payors, and decisions and operations of third-party organizations. Changes in the case mix of the patients, payment methodologies, or payor mix among third-party payor, Medicare, and Medicaid may significantly affect our results of operations and cash flows. In particular, any significant decrease in our population of high-acuity patients could have a material adverse effect on our business, financial condition and results of operations.

Our ability to provide services may also be impacted by actions of third-party organizations, such as assisted living facilities choosing to bring pharmacy services in-house or hospitals following CMS’s guidelines for providing care outside of a traditional hospital setting. Increasing consolidation in the payor and supplier structure, including vertical integration efforts among insurers, providers and suppliers, may limit our ability to negotiate favorable terms and conditions in our contracts and otherwise intensify competitive pressure. For example, MCOs and other third-party payors continue to consolidate, which enhances their ability to influence the delivery and cost structure of health care services. Consequently, the health care needs of patients in the United States are increasingly served by a smaller number of MCOs. These organizations generally enter into service agreements with a limited number of providers. Our business, financial condition and results of operations could be materially adversely affected if these organizations terminate us as a provider, engage our competitors as a preferred or exclusive provider and/or limit the patients eligible for our services.

Our business is reliant on federal and state spending, budget decisions and continuous governmental operations which may fluctuate under different political conditions.

Adverse developments in the United States could lead to a reduction in federal government expenditures, including governmentally funded programs in which we participate. In addition, if at any time the federal

 

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government is not able to meet its debt payments unless the federal debt ceiling is raised, and legislation increasing the debt ceiling is not enacted, the federal government may stop or delay making payments on its obligations, including funding for government programs, such as Medicare and Medicaid. Further, any failure by the Congress to complete the federal budget process and fund government operations may result in a shutdown, potentially causing us to incur substantial costs without reimbursement under the Medicare program. For example, the failure of the 2011 Joint Select Committee to meet its Deficit Reduction goal resulted in an automatic reduction in Medicare home health and hospice payments of 2% beginning April 1, 2013, though this reduction has been temporarily suspended through December 31, 2021 as a result of the COVID-19 pandemic. Congress continues to discuss deficit reduction measures, leading to a high degree of uncertainty regarding potential reforms to governmental healthcare programs. The Medicare program is frequently mentioned as a target for spending cuts and within the Medicare program the home health and hospice benefits are often specifically targeted for cuts and a lowering of the Medicare caps. Historically, state budget pressures have resulted in reductions in state spending, and given that Medicaid outlays are a significant component of state budgets, we can expect continuing cost containment pressures on Medicaid outlays for our services. Weak economic conditions also could adversely affect the budgets of individual states and of the federal government. This could result in attempts to reduce or eliminate payments for federal and state healthcare programs, and could result in an increase in taxes and assessments on our activities.

Given competing national priorities, we are unable to predict the outcome and impact on our business of any changes in healthcare policy relating to the future funding of the Medicare and Medicaid programs. Further, Medicare, Medicaid and/or private payor rates for home and community provider solutions and pharmacy services may not continue to be based on current methodologies or remain comparable to present levels. Any future healthcare legislation or regulation impacting these rates may materially adversely affect our business.

Changes in drug utilization and/or pricing, PBM contracts and Medicare Part D/Medicaid reimbursement may negatively impact our profitability.

The profitability of our Pharmacy Solutions segment is dependent upon the utilization of prescription and non-prescription pharmaceuticals. Our revenues, operating results and cash flows may decline if the utilization of drug and/or infusion therapies is reduced or physicians cease writing prescriptions for such therapies, including due to:

 

   

increased safety risk profiles or regulatory restrictions;

 

   

manufacturing or other supply issues;

 

   

certain products being withdrawn by their manufacturers or transitioned to over-the-counter products;

 

   

FDA actions restricting the supply or increasing the cost of products;

 

   

the introduction of new and successful prescription drugs or lower-priced generic alternatives to existing brand name products; or

 

   

inflation in the price of brand name drugs.

In addition, increased utilization of generic drugs has resulted in pressure to decrease reimbursement payments to facility-based, hospice, retail and specialty pharmacies for generic drugs, causing a reduction in our margins on sales of generic drugs. Contracts and fee schedules in the prescription drug industry, including our contracts with various payors and fee schedules under state Medicaid programs, generally use certain published benchmarks, including Average Wholesale Price, or AWP, or Wholesale Acquisition Cost, or WAC, to establish pricing for prescription drugs. Future changes to the use of AWP, WAC or to other published pricing benchmarks used to establish drug pricing, including changes in the basis for calculating reimbursement by federal and state health care programs and/or other payors, could impact the reimbursement we receive from Medicare and Medicaid programs, the reimbursement we receive from our PBM, clients and other payors and/or our ability to negotiate rebates and/or discounts with drug manufacturers and wholesalers. A failure or inability to fully offset

 

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any increased prices or costs or to modify our operations to mitigate the impact of such increases could have a material adverse effect on our operating results. Additionally, any future changes in drug prices could be significantly different than our projections. We cannot predict the effect of these possible changes on our businesses.

Our reimbursement under Medicare Part D, as well as our reimbursement from certain private third-party payors, is determined pursuant to agreements that we negotiate with those payors or their PBM representatives or group purchasing organizations, or GPOs. Similarly, our reimbursement from skilled nursing and rehabilitation facilities for drugs is determined pursuant to our agreements with them. Certain of these agreements are terminable upon prior notice by the other party. We cannot provide assurance that we will be able to replace terminated or expired agreements on terms as favorable as our existing agreements or at all. The termination or modification of these agreements could adversely affect our reimbursement from these sources, which would have a material adverse effect on our results of operations. Additionally, the proportion of our Medicare Part D business serviced under specific agreements may change over time based upon beneficiary choice, reassignment of beneficiaries to different Medicare Part D Plans, Medicare Part D Plan consolidation or other factors, which could also adversely affect our revenue. Many payors seek to limit the number of providers that supply pharmaceuticals to their enrollees in order to build volume that justifies their discounted pricing. From time to time, payors with whom we have relationships require that we bid against our competitors to keep their business. As a result of this bidding process, we may not be retained, and even if we are retained, the prices at which we are able to retain the business may be reduced. If we are not an approved provider selected by a GPO, affiliated hospitals and other members may be less likely to purchase our products. Should a GPO negotiate a sole source or bundling contract covering a future or current competitor, we may be precluded from making sales to members of that GPO for the duration of the contractual arrangement.

Furthermore, Medicare Part D has resulted in increased utilization of prescription medications and puts pressure on our gross margin rates in our Pharmacy Solutions segment due to regulatory and competitive pressures. As a result of the ACA and changes to the retiree drug subsidy rules, clients of our PBM business could decide to discontinue providing prescription drug benefits to their Medicare-eligible members. To the extent this occurs, the adverse effects of increasing customer migration into Medicare Part D may outweigh the benefits we realize from growth of our Medicare Part D products. For example, in October 2020, the HHS released a final rule requiring health insurers to disclose drug pricing and cost-sharing information. The public disclosure of insurer- or PBM-negotiated price concessions may result in drug manufacturers lowering discounts or rebates, impacting the ability to negotiate drug prices. In November 2020, the U.S. Department of Health and Human Services, or the HHS, released the Rebate Rule, which eliminates the regulatory safe harbor from prosecution under the Anti-Kickback Statute for rebates from pharmaceutical companies to PBMs in Medicare Part D and in Medicaid MCOs, replacing it with two far narrower safe harbors designed to directly benefit patients with high out-of-pocket costs and to change the way PBMs are compensated. The new safe harbors are (i) for rebates which are passed on to the patient at the point of sale and (ii) for flat service fee payments made to PBMs which cannot be tied to the list prices of drugs. The Pharmaceutical Care Management Association which represents PBMs, has filed a suit in an effort to block the Rebate Rule, claiming that the Rebate Rule would lead to higher premiums in Medicare Part D and was adopted in an unlawful manner. The Biden Administration has delayed the effective date of portions of the Rebate Rule to January 1, 2023, and HHS is currently reviewing the final regulation. It is unclear whether the Rebate Rule will be modified by the current Administration, whether pharmaceutical companies will respond by reducing list prices, whether list prices in the private market may also be reduced, and what the resulting impact will be to PBMs or us.

Changes in our relationships with pharmaceutical suppliers, including changes in drug availability or pricing, could adversely affect our business and financial results.

We have contractual relationships with pharmaceutical manufacturers, wholesalers and distributors to purchase the pharmaceuticals that we dispense. In order to have access to these pharmaceuticals, and to be able to participate in the launch of new pharmaceuticals, we must maintain a good working relationship with these

 

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suppliers. Most of the manufacturers we contract directly with have the right to cancel their supply contracts with us without cause and after giving only minimal notice. In addition, these agreements may allow the manufacturers to distribute through channels other than us. Certain of these agreements also allow pricing and other terms to be adjusted periodically for changing market conditions or required service levels. We may be unable to renew contracts with our suppliers on favorable terms or at all. Any changes to these relationships, including, but not limited to, the loss of a supplier relationship or changes in pricing, could have an adverse effect on our business and financial results. Many products dispensed by our pharmacies are manufactured with ingredients that are susceptible to supply shortages. Our suppliers are independent entities subject to their own operational and financial risks that are outside our control. If our current suppliers were to stop selling drugs to us or delay delivery, including as a result of supply shortages, production disruptions, quality issues, closing or bankruptcies of our suppliers, or for other reasons, we may be unable to procure alternatives from other suppliers in a timely and efficient manner and on acceptable terms, or at all. Should a supply disruption result in the inability to obtain pharmaceutical solutions necessary for patient care, our business, financial condition and results of operations could be negatively impacted.

Some pharmaceutical manufacturers, wholesalers and/or distributors attempt to limit the number of preferred pharmacies that may market certain of their products. We cannot provide assurance that we will be selected and retained as a preferred pharmacy or can remain a preferred pharmacy to market these products. We cannot provide assurance that we will be able to compete effectively with other providers to dispense each of our core products. Consolidation within the drug manufacturing industry and other external factors may enhance the ability of suppliers to sustain or increase pricing of drugs and diminish our ability to negotiate reduced drug acquisition costs. Any inability to offset increased brand name or generic drug acquisition costs or to modify our activities to lessen the financial impact of such increased costs could have a significant adverse effect on our operating results. We receive certain discounts, rebates and other price concessions from suppliers. There can be no assurance that any changes in legislation or regulations, or the interpretation or application of current law, that would eliminate or significantly reduce the discounts, rebates and other price concessions that we receive from suppliers or that would otherwise impact payment available for drugs under federal or state healthcare programs will not have a material adverse impact on our business, financial condition and results of operations.

The pipeline of new drugs includes many products that over the long term may replace older, more expensive therapies. As a result of such older drugs losing patent protection and being replaced by generic substitutes, new and less expensive delivery methods (such as when an infusion or injectable drug is replaced with an oral drug) or additional products may be added to a therapeutic class, thereby increasing price competition in that therapeutic category. Much of the branded and generic drug product that we dispense is manufactured in whole or in substantial part outside of the United States and imported by our suppliers. As a result, significant changes in tax or trade policies, tariffs or trade relations between the United States and other countries, such as the imposition of unilateral tariffs on imported products, could result in significant increases in our costs, restrict our access to suppliers, depress economic activity, and have a material adverse effect on our business, financial condition and results of operations. In addition, other countries may change their business and trade policies and such changes, as well as any negative sentiments towards the United States in response to increased import tariffs and other changes in U.S. trade regulations, could adversely affect our businesses.

Our business relies on the continual recruitment and retention of nurses, pharmacists, therapists, caregivers, direct support professionals and other qualified personnel, including senior management.

We compete with other healthcare providers for our employees, including but not limited to, clinicians, nurses, nurse practitioners, physician assistants, caregivers, direct care staff, counselors, therapists, pathologists, psychologists, pharmacists, other pharmacy professionals and providers for our mobile network, as well as senior management. Competition for skilled personnel is intense, and the process of locating and recruiting qualified personnel with the combination of the skills, experience and licenses necessary to meet the requirements of their job responsibilities can be difficult and lengthy. Various states in which we operate have established minimum staffing requirements or may establish minimum staffing requirements in the future. While we seek to comply

 

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with all applicable staffing requirements, the regulations in this area are complex and we may experience compliance issues from time to time. Failure to comply with such minimum staffing requirements may result in one or more facilities failing to meet the conditions of participation under relevant federal and state healthcare programs and the imposition of fines or other sanctions. In addition, private litigation involving these matters also has become more common. Moreover, a portion of the staffing costs we incur is funded by states through Medicaid program appropriations or otherwise. If states do not appropriate sufficient additional funds to pay for any additional operating costs resulting from such minimum staffing requirements, our profitability may be materially adversely affected.

Our ability to satisfy such staffing requirements will, among other things, depend upon our ability to attract and retain qualified healthcare professionals. If we are unable to attract and retain qualified personnel, we may be unable to provide our services, the quality of our services may decline and we could lose patients and referral sources, which could have a material adverse effect on our business, financial condition and results of operations. The loss of one or more of the members of the executive management team or the inability of a new management team to successfully execute our strategies may adversely affect our business. Our ability to attract and retain qualified personnel depends on several factors, including our ability to provide these personnel with attractive assignments and competitive salaries and benefits. During the COVID-19 pandemic, our ability to attract and retain qualified personnel may also depend on our ability to appropriately protect these personnel from exposure to the virus. We cannot be assured we will succeed in any of these areas. From time to time and particularly in recent years, the lack of availability of medical personnel, including qualified nurses, has been a significant operating issue for us and other healthcare providers in certain local and regional markets. Further, because we generally recruit our personnel from the local area where the relevant facility is located, the availability in certain areas of suitably qualified personnel can be limited.

If the demand exceeds the supply of available and qualified personnel, we and our competitors may be forced to offer higher compensation and other benefits to attract and retain them. Even if we were to offer higher compensation and other benefits, there can be no assurance that these individuals will choose to join or continue to work for us. Furthermore, the competitive market for this labor force has created turnover as many seek to take advantage of the available positions, each offering new and more attractive wage and benefit packages. We may be required to hire more expensive temporary personnel or increase our recruiting and marketing costs relating to labor, and the use of temporary or agency staff could also heighten the risk of one experiencing an adverse patient incident. In addition to the wage pressures inherent in this environment, the cost of training new employees amid the turnover rates may cause added pressure on our operating results. Recently, the enhanced unemployment benefits offered by several states have suppressed the opportunity to attract a new pool of qualified personnel in such states. If we expand our operations into geographic areas where healthcare providers historically have unionized or unionization occurs in our existing geographic areas, negotiating collective bargaining agreements may have a negative effect on our ability to timely and successfully recruit qualified personnel and on our financial results. If we are unable to retain existing employees or attract additional employees, or we experience an unexpected loss of leadership, we could experience a material adverse effect on our business, financial condition and results of operations.

We are subject to federal, state and local laws and regulations that govern our employment practices, including minimum wage, living wage, and paid time-off requirements. Failure to comply with these laws and regulations, or changes to these laws and regulations that increase our employment-related expenses, could adversely impact our operations.

We are subject to applicable rules and regulations relating to our relationship with our employees, including occupational safety and health requirements, wage and hour and other compensation requirements, break requirements, health benefits, unemployment, providing leave, sick pay and overtime, proper classification of workers as employees or independent contractors, immigration status and equal employment opportunity laws. These laws and regulations can vary significantly among jurisdictions and can be highly technical. Costs and expenses related to these requirements are a significant operating expense and may increase as a result of, among

 

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other things, changes in federal, state or local laws or regulations, or the interpretation thereof, requiring employers to provide specified benefits or rights to employees, increases in the minimum wage and local living wage ordinances, increases in the level of existing benefits or the lengthening of periods for which unemployment benefits are available. We may not be able to offset any increased costs and expenses. We have a substantial number of hourly employees who are paid wage rates based on or approximating the applicable federal, state or local minimum wage, and the high proportion of hourly employees makes our business sensitive to minimum wage laws at both the state and federal levels. Furthermore, any failure to comply with these laws requirements, including even a seemingly minor infraction, can result in significant penalties which could harm our reputation and have a material adverse effect on our business. In addition, federal, state and local proposals to introduce a system of mandated health insurance and flexible work time, provide for higher minimum wages, paid time off and other similar initiatives could, if implemented, adversely affect our operations.

In addition, certain individuals and entities, known as excluded persons, are prohibited from receiving payment for their services rendered to Medicaid, Medicare and other federal and state healthcare program beneficiaries. If we inadvertently hire or contract with an excluded person, or if any of our current employees or contractors becomes an excluded person in the future without our knowledge, we may be subject to substantial civil penalties, including up to $20,000 for each item or service furnished by the excluded person to a federal or state healthcare program beneficiary, an assessment of up to three times the amount claimed and exclusion from federal healthcare programs.

Our results of operations fluctuate on a quarterly basis.

Our financial condition and results of operations and other key metrics have fluctuated on a quarterly basis in the past and may continue to fluctuate in the future due to a variety of factors, including census, script volume, reimbursement rates, drug purchasing costs, labor availability and pricing, volume fluctuations in broader healthcare and provider markets that are upstream of our care settings and the potential timing of delayed or leading payor reimbursement rate changes based on budget seasons, as well as purchasing cost fluctuations depending on when core contracts renew or escalate. In addition, we have experienced and expect to continue to experience fluctuations in our quarterly results of operations due to the seasonal nature of our business. As a result, historical period-to-period comparisons of our results of operations are not necessarily indicative of future period-to-period results, impacting comparability of our quarterly results year-over-year.

Our business may be harmed by labor relation matters.

We are subject to a risk of work stoppages and other labor relations matters because our hourly workforce in some states is highly unionized. We have numerous agreements with various different unions, which are renegotiated from time to time. We may also negotiate Memoranda of Understanding to amend these collective bargaining agreements when we receive increases in our rates from various state agencies. Upon expiration of these collective bargaining agreements, we may not be able to negotiate labor agreements on satisfactory terms with these labor unions. A strike, work stoppage or other slowdown could result in a disruption of our operations and/or higher ongoing labor costs, which could adversely affect our business.

Because we are limited in our ability to control reimbursement rates received for our services, our business could be materially adversely affected if we are not able to maintain or reduce our costs to provide such services.

We receive fixed payments at predetermined reimbursement rates established through federal and state legislation from Medicare and Medicaid, our most significant payors, for our services. Consequently, our profitability largely depends upon our ability to manage the costs of providing these services. We cannot be assured that reimbursement payments under Medicare and Medicaid will be sufficient to cover the costs allocable to patients eligible for reimbursement pursuant to these programs. Commercial payors such as managed care organizations and private health insurance programs generally reimburse us for the services rendered to insured

 

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patients based upon contractually determined rates. Additionally, private payor rates are difficult for us to negotiate as such payors are under pressure to reduce their own costs. In addition, our profitability may be adversely affected by any efforts of our suppliers to shift healthcare costs by increasing the net prices on the products we obtain from them. Increases in operating costs, such as labor and supply costs, without a compensating increase in reimbursement rates, could have a material adverse effect on our business. In addition, cost pressures resulting from the use of more expensive forms of palliative care, including drugs and drug delivery systems, could negatively impact our profitability. As a result, we have sought to manage our costs in order to achieve a desired level of profitability including, but not limited to, centralization of various processes, the use of technology and management of the number of employees utilized. If we are not able to continue to streamline our processes and reduce our costs, our business, financial condition and results of operations could be materially adversely affected.

Delays in collection or non-collection of our accounts receivable, particularly during the business integration process, could adversely affect our business, financial condition and results of operations.

Prompt billing and collection of receivables from patients and third-party payors are important factors in our liquidity, and our business is characterized by delays from the time we provide services to the time we receive reimbursement or payment for these services. Having a diversified payor mix requires expertise and compliance across multiple complex coding, billing and revenue recognition functions. We bill numerous and varied payors, and they typically have different billing requirements that must be satisfied prior to receiving payment for services rendered. Reimbursement is typically conditioned on our documenting the level and the necessity of service provided and correctly applying administrative and billing codes. Coding of services can be complex. Incorrect or incomplete documentation and billing information could result in non-payment for services rendered and could lead to allegations of billing fraud. This could subsequently lead to civil and criminal penalties, including but not limited to exclusion from government healthcare programs. Reimbursement and procedural issues often require us to resubmit claims multiple times and respond to multiple administrative requests before payment is remitted, increasing the age of accounts receivable. Billing and collection of our accounts receivable are further subject to the complex regulations that govern Medicare and Medicaid reimbursement and rules imposed by third-party payors, which are continuously evolving. Our inability to bill and collect on a timely basis pursuant to these regulations and rules could subject us to payment delays that could have a material adverse effect on our business, financial condition and results of operations. In addition, timing delays in billings and collections may cause working capital shortages. It is possible that Medicare, Medicaid, documentation support, system problems or other provider issues or industry trends, particularly with respect to newly acquired entities for which we have limited operational experience, may extend our collection period, which may materially adversely affect our working capital, and our working capital management procedures may not successfully mitigate this risk.

The timing of payments made under the Medicare and Medicaid programs is subject to governmental budgetary constraints, which may result in an increased period of time between submission of claims and subsequent payment under specific programs, most notably under the Medicare and Medicaid managed care programs, which in many cases pay claims significantly slower than traditional Medicare or state Medicaid programs. This delay is a result of more complicated authorization, billing and collecting processes under Medicare and Medicaid managed care programs. In addition, we may experience delays in reimbursement as a result of the failure to receive prompt approvals related to change of ownership applications for acquired or other facilities. Further, our billing systems require significant technology investment and, as a result of marketplace demands, we need to continually invest in our billing systems. We may experience delays in reimbursement caused by our or other third parties’ information system failures. Changes in laws and regulations could further complicate our billing and increase our billing expense.

A change in our estimates of collectability or a delay in collection of accounts receivable could adversely affect our results of operations and liquidity. The estimates are based on a variety of factors, including the length of time receivables are past due, significant one-time events, contractual rights, client funding and/or political

 

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pressures, discussions with clients and historical experience. A delay in collecting our accounts receivable, or the non-collection of accounts receivable, including, without limitation, in connection with our transition and integration of acquired companies, could have a material negative impact on our results of operations and liquidity and could be required to record impairment charges in our consolidated financial statements.

If we fail to manage our growth effectively, we may be unable to execute our business plan, maintain high levels of service and satisfaction or adequately address competitive challenges.

We have experienced, and may continue to experience, rapid growth and organizational change, which has placed, and may continue to place, significant demands on our management and our operational and financial resources. Additionally, our organizational structure may become more complex as we expand our operational, financial and management controls, as well as our reporting systems and procedures as a public company. We may require significant capital expenditures and the allocation of valuable management resources to grow and evolve in these areas. We must effectively increase our headcount, ensure our personnel have the necessary licenses and competencies and continue to effectively train and manage our employees. We will be unable to manage our business effectively if we are unable to alleviate the strain on resources caused by growth in a timely and successful manner. If we fail to effectively manage our anticipated growth and change or fail to ensure that the level of care and services provided by our employees complies with regulatory and contractual requirements, the quality of our services may suffer, which could negatively affect our brand and reputation, harm our ability to attract and retain patients, customers, referral sources and employees and lead to the need for corrective actions.

In addition, as we expand our business, it is important that we continue to maintain high levels of patient service and satisfaction. If we are unable to continue to provide high quality healthcare that meets the regulatory requirements and generates high levels of patient satisfaction, our reputation, as well as our business, results of operations and financial condition would be adversely affected.

Our growth strategy is partially dependent upon our ability to identify and successfully complete acquisitions, joint ventures and other strategic initiatives. Any failure by us to manage or integrate acquisitions, divestitures and other significant transactions successfully may have a material adverse effect on our business, financial condition and results of operations.

Acquisitions are a key strategic advantage and value creation driver for us. We regularly evaluate opportunities to acquire other companies and have undertaken, and may in the future undertake, strategic and accretive acquisitions, including our recent acquisitions of Abode and OPPC. We face competition for acquisition and joint venture candidates, which may limit the number of acquisition and joint venture opportunities available to us or lead to the payment of higher prices for our acquisitions and joint ventures. In addition, changes in federal laws or regulations may materially adversely impact our ability to acquire businesses. For example, CMS has adopted a regulation known as the “36 Month Rule” that is applicable to home health agency acquisitions, which subject to certain exceptions, prohibits buyers of home health agencies that either enrolled in Medicare or underwent a change in ownership fewer than 36 months prior to the acquisition date, from assuming the Medicare billing privileges of the acquired home health agency. Instead, the acquired home health agencies must enroll as new providers with Medicare which may cause significant Medicare billing delays. As a result, the 36 Month Rule may further increase competition for acquisition targets that are not subject to the rule. We cannot assure you that we will successfully identify suitable acquisition candidates, obtain financing for such acquisitions, if necessary, consummate such potential acquisitions or efficiently integrate any acquired entities or successfully expand into new markets as a result of our acquisitions. If we are unable to successfully execute on such a strategy in the future, our future growth could be limited.

We believe that there are risks related to acquiring companies. Such risks include overpaying for acquisitions, losing key employees, strategic partnerships or patients of acquired companies, failing to effectively integrate acquired companies, the assumption of liabilities and exposure to unforeseen liabilities of acquired operations, and failing to achieve potential synergies or remove transition, integration or non-recurring costs. In addition, our due diligence review of acquired businesses may not successfully identify all potential issues. Further, following completion of an acquisition, we may not be able to maintain the growth rate, levels of

 

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revenue, earnings or operating efficiency that we and the acquired business have achieved or might achieve separately. Historically, we have funded acquisitions primarily through our credit facilities and/or cash on hand, and there is no guarantee that we will be able to obtain financing for any future acquisition on favorable terms, if at all. Furthermore, in certain circumstances, we could be required to pay or be involved in disputes relating to termination fees or liquidated damages if an acquisition is not consummated, the payment of which could have a material adverse effect on our business, financial condition or results of operations.

Upon consummation of an acquisition, the integration process could divert the attention of management, and any difficulties or problems encountered in the transition process could have a material adverse effect on our business, financial condition or results of operations. In particular, the integration process may temporarily redirect resources previously focused on reducing cost of services, resulting in lower gross profits in relation to revenues. The process of combining companies could cause the interruption of, or a loss of momentum in, the activities of the respective businesses, which could have an adverse effect on their combined operations. Additionally, in some acquisitions, we may have to renegotiate, or risk losing, one or more third-party payor contracts. We may also be unable to immediately collect the accounts receivable of an acquired entity while we align the payors’ payment systems and accounts with our own systems, and may have difficulties in recouping partial episode payments and other types of misdirected payments for services from previous owners. Certain transactions can require licensure changes which, in turn, result in disruptions in payment for services.

We may also make strategic divestitures from time to time. With respect to any divestiture, we may encounter difficulty finding potential acquirers or other divestiture options on favorable terms. Any divestiture could affect our profitability as a result of the gains or losses on such sale of a business or service, the loss of the operating income resulting from such sale or the costs or liabilities that are not assumed by the acquirer that may negatively impact profitability subsequent to any divestiture. We may also recognize impairment charges as a result of a divesture.

If we are unable to provide consistently high quality of care, our business will be adversely impacted.

Providing quality patient care is fundamental to our business. Clinical quality is becoming increasingly important within our industries. Effective October 2012, Medicare began to impose a financial penalty upon hospitals that have excessive rates of patient readmissions within 30 days from hospital discharge. We believe this regulation provides a competitive advantage to home health providers who can differentiate themselves based upon quality, particularly by achieving low patient acute care hospitalization readmission rates and by implementing disease management programs designed to be responsive to the needs of patients served by referring hospitals. We are focused intently upon improving our patient outcomes, particularly our patient acute care hospitalization readmission rates. Additionally, Medicare has established consumer-facing websites, Home Health Compare and Hospice Compare, that present data regarding our performance on certain quality measures compared to state and national averages. If we should fail to achieve or exceed these averages, it may affect our ability to generate referrals, which could have a material adverse effect upon our business, consolidated financial condition and results of operations.

Many of our service users have complex medical conditions or special needs, are vulnerable and often require a substantial level of care and supervision. There is a risk that one or more service users could be harmed by one or more of our employees or workforce members, either intentionally, through negligence or by accident. Further, individuals cared for by us have in the past engaged, and may in the future engage, in behavior that results in harm to themselves, our employees or to one or more other individuals, including members of the public. If one or more of our facilities experiences an adverse patient incident or is found to have failed to provide appropriate patient care, an admissions hold, loss of accreditation, license revocation or other adverse regulatory action could be taken against us. Any such patient incident or adverse regulatory action could result in governmental investigations, judgments or fines and have a material adverse effect on our business, financial condition and results of operations. In addition, we have been and could become the subject of negative publicity or unfavorable media attention, whether warranted or unwarranted, that could have a significant, adverse effect

 

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on the trading price of our common stock or adversely impact our reputation and how our referral sources and payors view us.

If we fail to provide or maintain a reputation for providing high quality or cost-effective care, or are perceived to provide lower quality or less cost-effective care than our competitors within the same geographic area, or if patients of our home and community health services and/or pharmacy services perceive that they could receive higher quality or more cost-effective services from other providers, our ability to attract and retain patients and customers could be adversely affected, which could have a material adverse effect upon our business, consolidated financial condition and results of operations. We believe that the perception of our quality of care by potential patients or their families seeking our services is influenced by a variety of factors, including physician and other healthcare professional referrals, community information and referral services, electronic media, newspapers and other print, and results of patient surveys, recommendations from family and friends, and published quality care statistics compiled by CMS or other industry data.

If we are unable to maintain our corporate reputation, or there is adverse publicity, including negative information on social media, or changes in public perception of our services, our business may suffer.

Our success depends on our ability to maintain our corporate reputation, including our reputation for providing quality patient care and for compliance with applicable Medicare and Medicaid requirements or other laws to which we are subject, among governmental authorities, physicians, hospitals, discharge planning departments, case managers, nursing homes, rehabilitation centers, advocacy groups, patients and their families, other referral sources and the public. For example, while we believe that the services we provide are of high quality, if our “quality measures,” which are published annually online by CMS, are deemed to be not of the highest value, our reputation could be negatively affected. Adverse publicity surrounding any aspect of our business, including our failure to provide proper care, litigation, changes in public perception of our services or government investigations of our operations could negatively affect our overall reputation, the willingness of other providers and organizations to refer patients to us, of patients to use our services and our ability to retain agreements or obtain new agreements. Increased government scrutiny may also contribute to an increase in compliance costs. Any of these events could have a negative effect on our business, financial condition and operating results.

There has been a marked increase in the use of social media platforms and similar channels that provide individuals with access to a broad audience of consumers and other interested persons. The availability of information on social media platforms is virtually immediate, as is its effect. Many social media platforms immediately publish the content their subscribers and participants post, often without filters or checks on accuracy of the content posted. The opportunity for dissemination of information, including inaccurate information, is potentially limitless. Information about our business and/or services may be posted on such platforms at any time. Negative views regarding our services may continue to be posted in the future, and are out of our control. Regardless of their accuracy or authenticity, such information and views may be adverse to our interests and may harm our reputation and brand. The harm may be immediate without affording an opportunity for redress or correction. Such negative publicity also could adversely affect the size, engagement, activity and loyalty of our customer base or the effectiveness of word-of-mouth marketing, and result in decreased revenue, or require us to expend additional funds for marketing efforts. Ultimately, the risks associated with any such negative publicity cannot be eliminated or completely mitigated and may materially adversely affect our business, financial condition and results of operations.

If our existing customers do not continue with or renew their contracts with us, renew at lower fee levels, decline to purchase additional services from us or reduce the services received from us pursuant to those contracts, it could have a material adverse effect on our business, financial condition and results of operations.

Our agreements with our customers are generally in effect for specific time periods. However, certain of our Pharmacy Solutions segment contracts are terminable without cause upon advance written notice, giving those

 

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customers leverage to demand more favorable pricing, or seek services from another provider. Additionally, many contracts in our workforce services line of business are subject to a competitive bid or re-bid process pursuant to federal, state, and/or local procurement laws. In all of our lines of business, our ability to renew or retain our agreements depends on our quality of service and reputation, but may also be affected by other factors over which we have little or no control, such as government appropriations and changes in provider eligibility requirements. Additionally, failure to satisfy any of the numerous technical renewal requirements in connections with our proposals for agreements could result in a proposal being rejected even if it contains favorable pricing terms. Failure to obtain, renew, or retain agreements with customers may negatively impact our business, financial condition, and results of operations. We can give no assurance that our existing agreements will be renewed on commercially reasonable terms or at all.

Our business depends on our ability to effectively invest in, implement improvements to and properly maintain the uninterrupted operation and data integrity of our information technology and other business systems.

Our business is highly dependent on maintaining effective and secure information systems, including those maintained by us and those maintained and provided by third-party service providers (for example, “software-as-a-service” and cloud solutions), as well as the integrity and timeliness of the data we use to serve our patients, support employees and operate our business. Our business also supports the use of electronic visit verification, or EVV, to collect visit submission information such as service type, visit start time and end time, and care plan tasks for our home and community based care services. We use mobile devices to capture time in and time out, mileage and travel time, as well as the completed care plan tasks with client verification. Our ability to effectively manage our business and coordinate the provision and billing of our services and prompt, accurate documentation of the care and services we provide depends significantly on the reliability and capacity of these systems. We rely on these providers to provide continual operation, as well as maintenance, enhancements, and security of any protected and/or confidential data (including personal information). To the extent that our EVV and other vendors fail to support these processes, our internal operations could be negatively affected. Our systems, and those of our third-party service providers, are vulnerable to damages, failures, malfunctions, outages or other interruptions which could be caused by a number of factors such as power outages or damages, telecommunications problems, data corruption, software errors, human error, computer viruses, defects and other errors, physical or electronic break-ins, theft, design defects, network failures, security breaches, cyber-attacks, acts of war or terrorist attacks, fire, flood and natural disasters. A system failure, outage or other interruption may also cause the corruption or loss of important, confidential and/or protected data (including personal information). Furthermore, our third-party providers’ existing safety systems, data backup, access protection, user management, information technology emergency planning and other security measures may not be sufficient to prevent data loss or long-term network outages.

In addition, we may have to upgrade our existing information technology systems from time to time in order for such systems to withstand the increasing needs of our expanding business. We rely on certain hardware, telecommunications and software vendors to maintain and periodically upgrade many of these systems so that we can continue to support our business. Costs and potential problems and interruptions associated with the implementation of new or upgraded systems and technology or with maintenance or adequate support of existing systems could disrupt or reduce the efficiency of our operations. Further, upgrading and expanding our information technology infrastructure could require significant investment of additional resources and capital, which may not always be available or available on favorable terms. We also depend on our information technology staff. If we cannot meet our staffing needs in this area, we may not be able to fulfill our technology initiatives while continuing to provide maintenance on existing systems. Any material disruption, outage or slowdown of our systems or those of our third-party providers, including those caused by our or their failure to successfully upgrade our or their systems, and our or their inability to convert to alternate systems in an efficient and timely manner could have a material adverse effect on our business, financial condition and results of operations.

Additionally, operations that we acquire must be integrated into our various information systems in an efficient and effective manner. For certain aspects, we rely upon third-party service providers to assist us with

 

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those activities. If we are unable to integrate and transition any acquired business into our information systems, due to our failures or any failure of our third-party service providers, we could incur unanticipated expenses, suffer disruptions in service, experience regulatory issues, and lose revenue from the operation of such business.

Security breaches, loss of data and other disruptions could compromise sensitive business or patient information, cause a loss of confidential patient data, employee data, personal information, or prevent access to critical information and expose us to liability, litigation and federal and state governmental inquiries and damage our reputation and brand.

In the ordinary course of our business, we collect, process, use, transmit, share, disclose, create, receive, maintain, transmit, and store, or collectively, Process, personal information (which may also be referred to as personal data, personally identifiable information, and/or non-public personal information), including protected health information, or PHI, relating to our patients, employees, referral sources, payors and others. We also Process, and contract with third-party service providers to Process, other sensitive, confidential and/or proprietary information. We use third-party service providers for important aspects of the Processing of personal information and other confidential and sensitive data and information, and therefore rely on third parties to manage functions that have material cybersecurity risks. Because of the sensitivity of the such personal information and other sensitive data and information that we and our service providers Process, the security of our technology platform and other aspects of our services, including those provided or facilitated by our third-party service providers, are critical to our operations and business strategy. Our patients, employees, payors and referral sources have a high expectation that we will adequately protect their information, including personal information, from cyberattacks or other security breaches, and may have claims against us if we are unable to do so. We may also have exposure to regulatory investigations and other compliance risks in the event of a cyberattack or other security breach. We have been subject to HHS investigations with respect to data privacy and security incidents involving PHI in the past, and there can be no assurance that we will not be subject to such HHS investigations in the future. Our patients, employees, payors and referral sources may have contractual rights of indemnification against us in the event that their personal or proprietary business information is accessed, disclosed, lost, used or compromised as a result of a breach of our information systems. In such an event, these parties may also seek to terminate our contracts with them.

Our systems and those of our third-party service providers and business partners may be vulnerable to data or security breaches, cyberattacks (including ransomware), acts of vandalism, computer viruses, misplaced or lost data, human errors or other similar events. While we have safeguards in place designed to defend our systems against intrusions and attacks and to protect our data, we cannot be certain that these measures are sufficient to counter all current and emerging technology threats. If unauthorized parties gain access to our networks or data, or those of our employees, third-party service providers or business partners, they may be able to access, steal, publish, delete, use in an unauthorized manner or modify confidential and sensitive information, including personal information, trade secrets or other confidential information, intellectual property, and proprietary business information. In addition, employees may intentionally or inadvertently cause data or security breaches that result in destruction, loss, alteration, unauthorized disclosure of or access to such information. Further, the techniques used to obtain unauthorized access, disable or degrade service, or sabotage systems change frequently and are often difficult to detect. Threats to our systems and associated third-party systems can originate from human error, fraud or malice on the part of employees or third parties or simply from accidental technological failure. Computer viruses and other malware can be distributed and could infiltrate our systems or those of associated third parties. Because the techniques used to circumvent security systems can be highly sophisticated, change frequently, are often not detected until launched against a target and may originate from less regulated and remote areas around the world, we, and our third-party service providers, may be unable to effectively detect or proactively address all possible techniques or implement adequate preventive measures for all situations. The administrative, physical and technological safeguards we or our third-party service providers implement to address these risks may not address applicable laws and regulations or address situations that could lead to increased privacy or security risks. The businesses we have acquired, or may acquire in the future, may not have in place all of the required safeguards and may have experienced breaches or security incidents. It may

 

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take significant time and expense to integrate such businesses to our policies and procedures. To the extent we terminate contracts with our third-party service providers, we may not be able to ensure that the relevant personal information of our patients and employees is maintained in compliance with the required safeguards. In the normal course of business, we are and have been the target of malicious cyberattack attempts and have experienced other security incidents. To date, such identified security events have not been material or significant to us, including to our reputation or business operations, or had a material financial impact, but there can be no assurance that present or future cyber-attacks will not be material or significant.

Any such cyberattack or threat, including those that result in data or security breaches, could result in costly investigations, litigation, government enforcement actions, civil or criminal penalties, fines, operational changes or other response measures, loss of patient and customer confidence in our security measures, loss of business partners, and negative publicity that could adversely affect our brand, reputation, business, financial condition and results of operations. In particular, any such interruption in access, compromise, use, improper access, acquisition, disclosure or other loss of information, including personal information, could result in legal claims or proceedings and/or liability or penalties under laws and regulations that protect the privacy, confidentiality, or security of personal information, including the Health Insurance Portability and Accountability Act of 1996, as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and their implementing regulations, or collectively, HIPAA, the California Consumer Privacy Act, or CCPA, and other state data privacy, security, or consumer protection laws, including state breach notification laws. These laws often provide for civil penalties for violations, as well as a private right of action for data breaches that may increase data breach litigation. Any delay in identifying such breaches or incidents or in providing timely notification of such incidents may lead to increased harm and increased penalties.

In addition, denial of service or other cyberattacks could be launched against us for a variety of purposes, including to interfere with our services or create a diversion for other malicious activities. Our defensive measures may not prevent unplanned downtime, or the unauthorized access, acquisition, disclosure or use of confidential, sensitive data, and/or personal information. We may be required to expend significant capital and other resources to protect against security breaches, to safeguard the privacy, security, and confidentiality of personal information and other sensitive data and information, to investigate, contain, remediate, and mitigate actual or potential security breaches and security incidents, and/or to report security breaches and security incidents to patients, customers, employees, regulators, media, credit bureaus, and other third parties in accordance with applicable law and to offer complimentary credit monitoring, identity theft protection, and similar services where required by law or otherwise appropriate. While we maintain cyber errors and omissions insurance coverage that covers certain aspects of cyber risks, these losses may not be adequately covered by insurance or other contractual rights available to us. We may also be subject to potential increases in insurance premiums, resulting in increased costs or loss of revenue, and such insurance coverage may not continue to be available to us in adequate amounts or on satisfactory terms, if at all.

We are subject to risks related to credit card payments and other payment methods.

We currently accept credit cards and debit cards. As a result, we pay interchange and other related acceptance and transaction processing fees, which may increase over time and raise our operating costs and lower profitability.

We are also subject to evolving Payment Card Industry, or PCI, and network operating rules, including data security rules, certification requirements and rules governing electronic funds transfers. For example, we are subject to Payment Card Industry Data Security Standards, issued by the PCI Security Standards Council, which contain compliance guidelines and standards with regard to our security surrounding the physical and electronic storage, processing and transmission of individual cardholder data, including regular audit to maintain compliance. As our business evolves and expands, and if we offer new payment options to consumers, we may be subject to additional regulations, compliance requirements, fraud, and other risks, in addition to new assessments that involve costs above what we currently pay for compliance. By accepting debit cards for

 

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payment, we are also subject to compliance with American National Standards Institute data encryption standards and payment network security operating guidelines. Additionally, the Fair and Accurate Credit Transactions Act requires systems that print payment card receipts to employ personal account number truncation so that the customer’s full account number is not viewable on the slip. Failure to be PCI compliant or to meet other payment card standards may result in the imposition of financial penalties or the allocation by the card brands of the costs of fraudulent charges to us. In addition, if we (or a third-party processing payment card transactions on our behalf) suffer a security breach affecting payment card information, we may have to pay onerous and significant fines, penalties, and assessments arising out of the major card brands’ rules and regulations, contractual indemnifications, or liability contained in merchant agreements and similar contracts, and we may lose our ability to accept payment cards for payment for our services, which could materially impact our operations and financial performance.

In addition, we rely on third-party payment processors to process the payments made by our customers. If our third-party payment processors terminate their relationships with us or refuse to renew their agreements with us on commercially reasonable terms, we would need to find an alternate payment processor and may not be able to secure similar terms or replace such payment processors in an acceptable time frame. Further, the software and services provided by our third-party payment processors may contain errors or vulnerabilities, be compromised, experience outages, or not meet our expectations. If any of these events were to occur, our business, financial condition, and results of operations could be materially and adversely affected.

We occasionally receive payments made with fraudulent data which result in customer-initiated disputes (charge-backs). Under current credit and debit card practices, we may be liable for fraudulent transactions and be required by card issuers to pay charge-back fees. Charge-backs result not only in our loss of fees earned with respect to the payment, but also leave us liable for the underlying money transfer amount. If our charge-back rate becomes excessive, card brands and associations also may require us to pay fines or refuse to process our transactions. In addition, we may be subject to additional fraud risk if third-party service providers or our employees fraudulently use our customer information for their own gain or facilitate the fraudulent use of such information. As a result, we may suffer losses as a result of orders placed with fraudulent data even if the associated financial institution approved payment of the orders. If we are unable to detect or control credit and debit card fraud, our liability for these transactions could harm our business, financial condition, and results of operations.

We may be subject to substantial malpractice or other similar claims.

The nature of our business subjects us to inherent risk of wrongful death, personal injury, product liability, professional malpractice and other potential claims, liabilities and substantial damage awards. In addition, the pharmaceutical products we dispense could become subject to contamination, product tampering, mislabeling, recall or other damage. In addition, errors in the compounding, dispensing and packaging of drugs and consuming drugs in a manner that is not prescribed could lead to serious injury or death. Healthcare providers have become subject to an increasing number of legal actions alleging malpractice or related legal theories in recent years, many of which involve large monetary claims and significant defense costs. In general, we coordinate care for high-need, medically complex individuals through employed clinicians, caregivers and pharmacists, including registered nurses, limited practice nurses, licensed therapists, certified nursing assistants, home health aides, therapy assistants, direct care staff and other similar professionals. From time to time, we are subject to claims alleging that we did not properly treat or care for a patient, that we failed to follow internal or external procedures that resulted in death or harm to a patient or that our employees mistreated our consumers, resulting in death or harm. We are also subject to claims arising out of accidents involving vehicle collisions brought by patients whom we are transporting, from employees driving to or from home visits or other affected individuals. We cannot be certain that a provider will not incur tort liability in treating one of our patients. The clinicians, caregivers and other healthcare professionals we employ could be considered our agents and, as a result, we could be held liable for their acts, omissions, malpractice and/or negligence and may be subject to mass tort actions and/or class actions. Moreover, in light of the COVID-19 pandemic, we could be liable if our

 

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COVID-19 screening, monitoring and/or safety protocols are deemed inadequate to stop the transmission of the COVID-19 virus from our providers to our patients. We cannot predict the effect that any claims of this nature, regardless of their ultimate outcome, could have on our business or reputation or on our ability to attract and retain patients and employees. While we maintain liability coverage that we believe is appropriate given the nature and breadth of our operations, any claims against us in excess of insurance limits, or multiple claims requiring us to pay deductibles, as well as the potential impact on our brand or reputation as a result of being involved in any legal proceedings, could have a material adverse impact on our business, results of operations and financial condition.

We are exposed to various risks related to governmental inquiries, regulatory actions and whistleblower lawsuits that could adversely affect our operating results. Our insurance may not cover all claims against us.

Regulatory agencies may initiate administrative proceedings alleging violations of statutes and regulations arising from our services, or reimbursement of those services, and seek to impose monetary penalties on us. We could be required to pay substantial amounts to respond to and defend against regulatory investigations, and if we do not prevail, damages or penalties arising from these administrative proceedings. We are subject to lawsuits under the federal False Claims Act and other federal and state statutes designed to combat fraud and abuse in our industries, as well as civil investigative demands related to our operations. Additionally, there can be no assurance that we will not be subject to claims or litigation related to the authorization or denial of claims for payment of benefits, or to allegations that we have engaged in fee splitting, which may be prohibited under state laws, or to allegations that we engage in the corporate practice of medicine or the delivery of medical services. Moreover, we could also be subject to potential litigation associated with compliance with various laws and governmental regulations at the federal or state levels, such as those relating to the protection of older adults and persons with disabilities or those related to employment, health, safety, security and other regulations under which we operate. We are currently subject to class actions, employee-related claims, and other lawsuits and proceedings in connection with our operations, including, but not limited to, those related to alleged violations of federal and state wage and hour laws, wrongful discharge, retaliation, and illegal discrimination. These claims, lawsuits, and proceedings are in various stages of adjudication or investigation and involve a wide variety of claims and potential outcomes.

Responding to lawsuits brought against us and governmental inquiries can often be expensive, time-consuming and disruptive to normal business operations. Moreover, the results of complex legal proceedings and governmental inquiries are difficult to predict. Unfavorable outcomes from these claims, lawsuits and governmental inquiries could adversely affect our business, financial condition and results of operations and we could incur substantial monetary liability and/or be required to change our business practices. Any claims made against us, regardless of their merit or eventual outcome, could damage our reputation and business and our ability to attract and retain patients, customers, strategic partnerships and employees.

We maintain general liability insurance to provide coverage to us and our subsidiaries against these litigation claims and potential litigation risks. However, we cannot assure you claims will not be made in the future in excess of the limits of our insurance, nor can we assure you that any such claims, if successful and in excess of such limits, will not have a material adverse effect on our business, financial condition and results of operations. We cannot assure you that the insurance we maintain will satisfy claims made against us or that insurance coverage will continue to be available to us at commercially reasonable rates, in adequate amounts or on satisfactory terms, if at all.

Our current insurance program may expose us to unexpected costs and negatively affect our business, financial condition and results of operations, particularly if we incur losses not covered by our insurance or if claims or losses differ from our estimates.

Although our insurance coverage reflects deductibles, self-insured retentions, limits of liability and similar provisions that we believe are reasonable based on our operations, the coverage under our insurance programs

 

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may not be adequate to protect us in all circumstances. Our insurance policies contain exclusions and conditions that could have a materially adverse impact on our ability to receive indemnification thereunder, as well as customary sub-limits for particular types of losses. Additionally, insurance companies that currently insure companies in our industries may cease to do so, may change the coverage provided, or may substantially increase premiums in the future. Changes in our annual insurance costs and self-insured retention limits depend in large part on the insurance market, and insurance coverage may not continue to be available to us at commercially reasonable rates, in adequate amounts or on satisfactory terms, if at all. In addition, we self-insure for various risks, including employment class actions, False Claims Act actions, adverse regulatory actions, commercial contractual or commercial tort actions, and intellectual property actions. The incurrences of losses and liabilities that exceed our available coverage, therefore, could have a material adverse effect on our business, financial condition and results of operations.

We utilize historical data to estimate our reserves for our insurance programs. Unanticipated changes in any applicable actuarial assumptions and management estimates underlying our liabilities for these losses could result in materially different expenses than expected under these programs, which could have a material adverse effect on our financial condition and results of operations. In addition, if we experience a greater number of these losses than we anticipate, it could have a material adverse effect on our business, financial condition and results of operations.

Factors outside of our control, including those listed, could require us to record an asset impairment of goodwill.

Because we have grown in part through acquisitions, goodwill and intangible assets, net represent a significant portion of our assets. We monitor the recoverability of our indefinite-lived intangible assets, which include our trademarks and tradenames, and evaluate goodwill and indefinite-lived intangible assets annually, or more frequently if indicators of impairment exist in interim periods, to determine if impairment has occurred. We also review the carrying value of our goodwill and intangible assets, both indefinite- and definite-lived, for impairment whenever events or changes in circumstances indicate that the carrying value of such assets may not be fully recoverable. Such indicators are based on market conditions and the operational performance of our business. If the testing performed indicates that impairment has occurred, we are required to record a non-cash impairment charge for the difference between the carrying value of the intangible assets or goodwill and the fair value of the intangible assets or the goodwill, respectively, in the period the determination is made. The testing of goodwill and intangible assets for impairment requires us to make estimates that are subject to significant assumptions about our future revenues, profitability, cash flow, fair value of assets and liabilities and weighted average cost of capital, as well as other assumptions. Changes in these estimates, or changes in actual performance compared with these estimates, may affect the fair value of intangible assets or goodwill, which may result in an impairment charge. If as part of our review of goodwill and intangibles for impairment, we were required to write down all or a significant part of our goodwill and/or intangible assets, our financial condition and results of operations could be materially adversely affected.

Inclement weather, natural disasters, acts of terrorism, riots, civil insurrection or social unrest, looting, protests, strikes or street demonstrations may impact our ability to provide services.

Inclement weather, natural disasters, acts of terrorism, riots, civil insurrection or social unrest, looting, protests, strikes or street demonstrations may prevent our employees from providing authorized services. We are not paid for authorized services that are not delivered due to these events. Furthermore, prolonged disruptions as a result of such events in the markets in which we operate, could disrupt our relationships with patients, caregivers and employees and referral sources located in affected areas and, in the case of our corporate office, our ability to provide administrative support services, including billing and collection services. Future inclement weather, natural disasters, acts of terrorism, riots, civil insurrection or social unrest, looting, protests, strikes or street demonstrations may adversely affect our reputation, business, financial condition and results of operations.

 

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We may be unable to adequately protect our intellectual property rights, which could harm our business.

We rely on a combination of intellectual property laws, internal procedures and nondisclosure agreements to protect our intellectual property and proprietary rights. We believe our trademarks are valuable assets. However, our intellectual property rights may not be sufficient to distinguish our services from those of our competitors and to provide us with a competitive advantage. For example, from time to time, third parties may use names, logos, and slogans similar to ours, may apply to register trademarks or domain names similar to ours, and may infringe or otherwise violate our intellectual property rights. Our intellectual property rights may not be successfully asserted against such third parties or may be invalidated, circumvented, or challenged. Asserting or defending our intellectual property rights could be time consuming and costly and could distract management’s attention and resources. If we are unable to prevent our competitors from using names, logos, slogans, and domain names similar to ours, consumer confusion could result, the perception of our brands and services could be negatively affected, and our revenue and profitability could suffer as a result. Failure to protect our intellectual property and proprietary rights could have an adverse effect on our business.

KKR Stockholder and Walgreen Stockholder control us and their interests may conflict with yours in the future.

Immediately following this offering, KKR Stockholder and Walgreen Stockholder will collectively beneficially own approximately     % of the voting power of our common stock (or approximately     % if the underwriters exercise in full their over-allotment option). As a result, KKR Stockholder and Walgreen Stockholder will be able to control the election and removal of our directors and thereby determine our corporate and management policies, including potential mergers or acquisitions, payment of dividends, asset sales, amendment of our certificate of incorporation or bylaws and other significant corporate transactions for so long as KKR Stockholder and its affiliates and/or Walgreen Stockholder and its affiliates retain significant ownership of us. KKR Stockholder, Walgreen Stockholder and their respective affiliates may also direct us to make significant changes to our business operations and strategy, including with respect to, among other things, new service offerings, employee headcount levels and initiatives to reduce costs and expenses. This concentration of our ownership may delay or deter possible changes in control of the Company, which may reduce the value of an investment in our common stock. So long as KKR Stockholder and its affiliates and/or Walgreen Stockholder and its affiliates continue to own, directly or indirectly, a significant amount of our voting power, even if such amount is less than 50%, they will continue to be able to strongly influence or effectively control our decisions, and each of KKR Stockholder and Walgreen Stockholder has the right to nominate individuals to our board of directors under the existing stockholders agreement. See “Certain Relationships and Related Party Transactions—Stockholders Agreement.”

In the ordinary course of their business activities, KKR Stockholder, Walgreen Stockholder and their respective affiliates may engage in activities where their interests conflict with our interests or those of our stockholders. Our second amended and restated certificate of incorporation will provide that any of KKR Stockholder, Walgreen Stockholder, any of their respective affiliates or any director who is not employed by us or his or her affiliates will not have any duty to refrain from engaging, directly or indirectly, in the same business activities or similar business activities or lines of business in which we operate. KKR Stockholder, Walgreen Stockholder and their respective affiliates also may pursue acquisition opportunities that may be complementary to our business and, as a result, those acquisition opportunities may not be available to us. In addition, KKR Stockholder, Walgreen Stockholder and their respective affiliates may have an interest in pursuing acquisitions, divestitures and other transactions that, in their judgment, could enhance their investment, even though such transactions might involve risks to you.

In addition, KKR Stockholder, Walgreen Stockholder and their respective affiliates will be able to determine the outcome of all matters requiring stockholder approval and will be able to cause or prevent a change of control of the Company or a change in the composition of our board of directors and could preclude any acquisition of the Company. This concentration of voting control could deprive you of an opportunity to receive

 

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a premium for your shares of common stock as part of a sale of the Company and ultimately might affect the market price of our common stock.

Risks Related to Our Regulatory Framework

We conduct business in a heavily regulated industry, and changes in regulations, the enforcement of these regulations, or violations of regulations may result in increased costs or sanctions that reduce our revenues and profitability.

The federal government and the states in which we operate regulate our industries extensively. The laws and regulations governing our operations, along with the conditions of participation and conditions of payment, in various government programs, impose certain requirements on the way in which we do business, the services we offer, and our interactions with providers and consumers. The extensive federal and state regulations affecting the healthcare industry include, but are not limited to, regulations relating to licensure, certification and enrollment, billing and coding, eligibility for, necessity of and provision of services, conduct of operations, allowable costs, prices for services, adequacy and quality of services, facility staffing requirements, facility accreditation, qualifications and licensure of staff, environmental and occupational health and safety, and the confidentiality and security of health-related information. In particular, various fraud and abuse laws, including the Anti-Kickback Statute, Stark Law, and the Federal False Claim Act, prohibit certain business practices and relationships that might affect the provision and cost of healthcare services reimbursable under Medicare and Medicaid, including the payment or receipt of remuneration for the referral of patients whose care will be paid for by Medicare or other governmental programs. We are also subject to laws requiring the registration and regulation of pharmacies; laws governing the dispensing of pharmaceuticals and controlled substances; laws regulating the protection of the environment and health and safety matters, including those governing exposure to, and the management and disposal of, hazardous substances; laws regarding food and drug safety, including those of the Food and Drug Administration, or FDA, and the Drug Enforcement Administration, or DEA. We are required to hold valid DEA and state-level licenses, meet various security and operating standards, and comply with the federal and various state controlled substance acts and related regulations governing the sale, dispensing, disposal, holding and distribution of controlled substances. Compliance with these regulations is expensive, and these costs may increase in the future.

Federal and state governments continue to pursue intensive enforcement policies resulting in a significant number of investigations, inspections, audits, citations of regulatory deficiencies, and other regulatory sanctions, including demands for refund of alleged overpayments, terminations from the Medicare and Medicaid programs, bans on Medicare and Medicaid payments for new admissions, admission moratoriums, and civil monetary penalties or criminal penalties. We expect audits under the CMS Recovery Audit Contractor, or RAC, program, the CMS Targeted Probe and Educate, or TPE, program, the Unified Program Integrity Contractors, or UPIC, program and other federal and state audits evaluating the medical necessity of services to further intensify the regulatory environment surrounding the healthcare industry, as third-party firms engaged by CMS and others conduct extensive pre and post-payment audits of claims data as well as medical and other records in order to identify improper payments to healthcare providers under the Medicare and Medicaid programs. The DEA, FDA and state regulatory authorities have broad enforcement powers, including the ability to seize or recall products. If we fail to comply with the extensive laws, regulations and prohibitions applicable to our businesses, we could become ineligible or disqualified to provide services or receive government program reimbursement, suffer suspension or revocation of our licenses, cancellation of our agreements, civil or criminal penalties and/or damage to our reputation, lose billing privileges, be barred from re-enrollment in governmental payor programs, or be required to repay amounts received or to make significant changes to our operations. We may also become subject to corporate integrity agreement(s) or monitoring by regulatory agencies. In addition, we could be forced to expend considerable resources responding to investigations, audits or other enforcement actions related to these laws, regulations or prohibitions. Failure of our staff to satisfy applicable licensure requirements, or of our home and community health services and pharmacy services operations to satisfy applicable licensure and certification requirements, could have a material adverse effect on our business, financial condition and results of operations.

 

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On March 9, 2020, the HHS Office of the National Coordinator for Health Information Technology, or ONC, and CMS promulgated final rules aimed at supporting seamless and secure access, exchange, and use of electronic health information, or EHI, by increasing innovation and competition by giving patients and their healthcare providers secure access to health information and new tools, allowing for more choice in care and treatment. The final rules are intended to clarify and operationalize provisions of the 21st Century Cures Act, or Cures Act, regarding interoperability and “information blocking,” and create significant new requirements for health care industry participants. Information blocking is defined as any activity that is likely to interfere with, prevent, or materially discourage access, exchange, or use of EHI, where a health information technology developer, health information network or health information exchange knows or should know that such practice is likely to interfere with access to, exchange or use of EHI. The new rules create significant new requirements for health care industry participants, and require certain electronic health record technology to incorporate standardized application programming interfaces, or APIs, to allow individuals to securely and easily access structured EHI using smartphone applications. The ONC will also implement provisions of the Cures Act requiring that patients can electronically access all of their EHI (structured and/or unstructured) at no cost. Finally, to further support access and exchange of EHI, the final ONC rule implements the information blocking provisions of the Cures Act and identifies eight “reasonable and necessary activities” as exceptions to information blocking activities, as long as specific conditions are met.

We are unable to predict the future course of federal and state regulation or legislation, including Medicare and Medicaid statutes and regulations, or the intensity of federal and state enforcement actions. Changes in the regulatory framework, including those associated with healthcare reform, and sanctions from various enforcement actions could have a material adverse effect on our business, financial condition and results of operations.

In the U.S., we conduct business in a heavily regulated industry and if we fail to comply with these laws and government regulations, we could incur fines and penalties or be required to make significant changes to our operations or experience adverse publicity, any or all of which could have a material adverse effect on our business, financial condition, and results of operations.

The U.S. healthcare industry is heavily regulated and closely scrutinized by federal, state and local governments. Comprehensive statutes and regulations govern our relationships with physicians and other healthcare providers, the manner in we provide and bill for services and collect reimbursement from governmental programs and private payors, our relationships with drug manufacturers, our marketing activities and other aspects of our operations. Of particular importance are:

 

   

the federal Anti-Kickback Statute, which prohibits the knowing and willful offer, payment, solicitation or receipt of any bribe, kickback, rebate or other remuneration for referring an individual, in return for ordering, leasing, purchasing or recommending or arranging for or to induce the referral of an individual or the ordering, purchasing or leasing of items or services covered, in whole or in part, by any federal healthcare program, such as Medicare and Medicaid. A person or entity does not need to have actual knowledge of the statute or specific intent to violate it to have committed a violation;

 

   

the federal physician self-referral law, commonly referred to as the Stark Law, which, subject to limited exceptions, prohibits physicians from referring Medicare or Medicaid patients to an entity for the provision of certain “designated health services” if the physician or a member of such physician’s immediate family has a direct or indirect financial relationship (including an ownership interest or a compensation arrangement) with the entity, and prohibit the entity from billing Medicare or Medicaid for such designated health services;

 

   

the federal False Claims Act, which imposes civil and criminal liability on individuals or entities that knowingly submit false or fraudulent claims for payment to the government or knowingly making, or causing to be made, a false statement in order to have a false claim paid, including qui tam or whistleblower suits. There are many potential bases for liability under the FCA. The government has

 

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used the FCA to prosecute Medicare and other government healthcare program fraud such as coding errors, billing for services not provided, and providing care that is not medically necessary or that is substandard in quality. In addition, the government may assert that a claim including items or services resulting from a violation of the federal Anti-Kickback Statute or Stark Law constitutes a false or fraudulent claim for purposes of the False Claims Act;

 

   

the criminal healthcare fraud provisions of HIPAA, and related rules that prohibit knowingly and willfully executing a scheme or artifice to defraud any healthcare benefit program or falsifying, concealing or covering up a material fact or making any material false, fictitious or fraudulent statement in connection with the delivery of or payment for healthcare benefits, items or services. Similar to the Anti-Kickback Statute, a person or entity does not need to have actual knowledge of the statute or specific intent to violate it to have committed a violation;

 

   

reassignment of payment rules that prohibit certain types of billing and collection practices in connection with claims payable by the Medicare or Medicaid programs;

 

   

similar state law provisions pertaining to anti-kickback, self-referral and false claims issues, some of which may apply to items or services reimbursed by any payor, including patients and commercial insurers. These statutes and regulations generally prohibit the payment or receipt of remuneration to induce or in exchange for a referral, and prohibit physicians from referring patients to an entity with which the physicians have a financial relationship, thus limiting the types of payments that can be made between healthcare providers and other parties who may influence referrals to those providers. Many of these statutes and regulations have not been interpreted to the extent of their federal analogues, and therefore are not clear in their scope and application;

 

   

laws that regulate debt collection practices;

 

   

a provision of the Social Security Act that imposes criminal penalties on healthcare providers who fail to disclose, or refund known overpayments;

 

   

federal and state laws that prohibit providers from billing and receiving payment from Medicare and Medicaid for services unless the services are medically necessary, adequately and accurately documented, and billed using codes that accurately reflect the type and level of services rendered;

 

   

federal and state laws that require licenses to dispense pharmaceuticals, including state laws that restrict operations by non-resident pharmacies, which may affect our ability to operate in some states; and

 

   

federal and state laws and policies that require healthcare providers to maintain licensure, certification or accreditation to enroll and participate in the Medicare and Medicaid programs, and to report certain changes in their operations to the agencies that administer these programs.

Because of the breadth of these laws and the narrowness of the statutory exceptions and safe harbors available, it is possible that some of our business activities could be subject to challenge under one or more of these laws. Achieving and sustaining compliance with these laws may prove costly. Failure to comply with these laws and other laws can result in civil and criminal penalties such as fines, damages, overpayment, recoupment, imprisonment, loss of enrollment status and exclusion from the Medicare and Medicaid programs. Our failure to accurately anticipate the application of these laws and regulations to our business or any other failure to comply with regulatory requirements could create liability for us and negatively affect our business. Any action against us for violation of these laws or regulations, even if we successfully defend against it, could cause us to incur significant legal expenses, divert our management’s attention from the operation of our business and result in adverse publicity.

Many states have CON laws or other regulatory provisions that may adversely impact our ability to expand into new markets and thereby limit our ability to grow and increase revenue.

 

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Many states have enacted CON laws that require prior state approval to offer new or expanded healthcare services or open new healthcare facilities or expand services at existing facilities. In such states, expansion by existing providers or entry into the market by new providers is permitted only where a given amount of unmet need exists, resulting from population increases, a reduction in competing providers or a lack of providers. These states ration the entry of new providers or services and the expansion of existing providers or services in their markets through a CON process, which is periodically evaluated and updated as required by applicable state law. The process is intended to promote comprehensive healthcare planning, assist in providing high-quality healthcare at the lowest possible cost and avoid unnecessary duplication by ensuring that only those healthcare facilities, services and operations that are needed will be built and opened or expanded.

Our costs of obtaining a CON in any new CON state in which we seek to operate could be significant, and we cannot assure you that we will be able to obtain the CON or other required approvals in the future. Our failure or inability to obtain a required CON, license or any necessary approvals could adversely affect our ability to expand into new markets and to expand our services and facilities in existing markets. Furthermore, if a CON or other prior approval upon which we relied to invest in a facility were to be revoked or lost through an appeal process, we may not be able to recover the value of our investment. Failure to obtain a CON may result in a facility’s ineligibility to receive reimbursement under the Medicare or Medicaid programs, the revocation of a facility’s license or imposition of civil or criminal penalties, any of which could harm our business.

CMS and state Medicaid agencies may, for a period of time, impose a moratorium against additional Medicaid enrollment for a particular type of service, upon a determination that a moratorium is necessary to prevent fraud, waste or abuse, or to limit an over-abundance of a type of Medicaid provider within a state. In addition, states may impose moratoriums relating to state Medicaid program, licensure and other matters, such as number of beds . A moratorium in any state in which we seek to, or currently, operate may prevent us from introducing, acquiring or disposing of, operations in that state, respectively, which may impair our future expansion, acquisition or divestiture opportunities in some states.

If we are unable to effectively adapt to changes in the healthcare industry, including changes to laws and regulations regarding or affecting U.S. healthcare reform, our business may be harmed.

In recent years, the Congress and certain state legislatures have considered and passed a large number of laws intended to result in significant changes to the healthcare industry, which could result in major changes in the healthcare delivery and reimbursement system on a national and state level, including changes directly impacting the reimbursement systems for our services. In March 2010, the ACA was signed into law and changed how healthcare services are delivered and reimbursed through the expansion of public and private health insurance coverage, reduction of growth in Medicare and Medicaid program spending, and the establishment and expansion of programs that tie reimbursement to quality and integration. Efforts to substantially modify provisions of the ACA have resulted in federal court reviews of such efforts, and the U.S. Supreme Court rejected the latest constitutional challenge to the ACA’s requirement to obtain minimum essential health insurance coverage, or the individual mandate, on June 17, 2021. The ultimate outcomes of efforts to expand the ACA, substantially amend its provisions, or change funding for the ACA is unknown. Though we cannot predict what, if any, reform proposals will be adopted, healthcare reform and legislation may have a material adverse effect on our business, financial condition and results of operations.

Moreover, healthcare reform initiatives have also resulted in changes to, or the adoption of, federal and state laws and regulations relating to the regulation of PBMs, drug pricing or purchasing and purchase discount and rebate arrangements with drug manufacturers, which could reduce discounts or rebates and affect our relationships with drug manufacturers. In addition to the rules promulgated by HHS, there have also been judicial decisions impacting the pharmacies and PBMs. For example, in December 2020, the U.S. Supreme Court upheld an Arkansas law that, among other things, mandates a particular pricing methodology, establishes an appeals process for a pharmacy when the reimbursement is below the pharmacy’s acquisition cost, permits a pharmacy to reverse and rebill if they cannot procure the drug from its wholesaler at a price equal to or less than the reimbursement rate, prohibits a PBM from reimbursing a pharmacy less than the amount it reimburses an affiliate

 

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on a per unit basis, and permits a pharmacy to decline to dispense if the reimbursement is lower than the pharmacy’s acquisition cost. It is unclear how these rules and decisions will impact pharmaceutical companies, pharmacies, and PBMs.

In addition, CMS has indicated that it intends to increase flexibility in state Medicaid programs, including by expanding the scope of waivers under which states may implement Medicaid expansion provisions, impose different eligibility or enrollment restrictions, or otherwise implement programs that vary from federal standards. CMS administrators have also signaled interest in changing Medicaid payment models. Other industry participants, such as private payors, may also introduce financial or delivery system reforms. We are unable to predict the nature and success of such initiatives. We cannot predict with certainty what impact any federal and state healthcare reforms will have on us, but such changes could impose new and/or more stringent regulatory requirements on our activities, which could adversely affect our business, financial condition, and results of operations.

If we are found to have violated HIPAA, or any other applicable privacy and security laws and regulations, as well as contractual obligations, we could be subject to sanctions, fines, damages and other additional civil or criminal penalties, which could increase our liabilities, harm our reputation and have a material adverse effect on our business, financial condition and results of operation.

Numerous federal, state and foreign laws, rules and regulations, as well as contractual obligations, govern the Processing of confidential, sensitive and personal information, including certain patient health information, such as patient records. Existing laws and regulations are constantly evolving, and new laws and regulations that apply to our business are being introduced at every level of government in the United States. In many cases, these laws and regulations apply not only to third-party transactions, but also to transfers of information between or among us, our affiliates and other parties with whom we conduct business. These laws and regulations may be interpreted and applied differently over time and from jurisdiction to jurisdiction, and it is possible that they will be interpreted and applied in ways that may have a material adverse effect on our business. The regulatory framework for data privacy and security worldwide is continuously evolving and developing and, as a result, interpretation and implementation standards and enforcement practices are likely to remain uncertain for the foreseeable future.

For example, HIPAA establishes a set of national privacy and security standards in the United States for the protection of PHI by health plans, healthcare clearinghouses, and certain healthcare providers, referred to as covered entities, and the business associates with whom such covered entities contract for services that involve the use or disclosure of PHI, including certain subcontractors of such business associates. HIPAA requires healthcare providers like us to develop and maintain policies and procedures with respect to PHI that is used or disclosed, including the adoption of administrative, physical, and technical safeguards to protect such information. In particular, HIPAA requires us to develop and maintain policies and procedures governing PHI that is used or disclosed, and to implement administrative, physical and technical safeguards to protect PHI, including PHI maintained, used and disclosed in electronic form. These safeguards include employee training, identifying business associates with whom covered entities need to enter into HIPAA-compliant contractual arrangements, called business associate agreements, and various other measures. Ongoing implementation and oversight of these measures involves significant time, effort and expense and we may have to dedicate additional time and resources to ensure compliance with HIPAA requirements.

HIPAA further requires covered entities to notify affected individuals “without unreasonable delay and in no case later than 60 calendar days after discovery of the breach” if their unsecured PHI is subject to an unauthorized access, use or disclosure, though many states require shorter breach notification timeframes. If a breach affects 500 patients or more, covered entities must report it to HHS and local media without unreasonable delay (and in no case later than 60 days after discovery of the breach), and HHS will post the name of the entity on its public website. If a breach affects fewer than 500 individuals, the covered entity must log it and notify HHS at least annually. HIPAA also implemented the use of standard transaction code sets and standard

 

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identifiers that covered entities must use when submitting or receiving certain electronic healthcare transactions, including activities associated with the billing and collection of healthcare claims.

Penalties for failure to comply with a requirement of HIPAA vary significantly depending on the failure and could include requiring corrective actions, resolution agreements, and/or imposing civil monetary or criminal penalties. HIPAA also authorizes HHS to conduct audits of HIPAA compliance and state attorneys general to file suit under HIPAA on behalf of state residents. Courts can award damages, costs and attorneys’ fees related to violations of HIPAA in such cases. While HIPAA does not create a private right of action allowing individuals to sue us in civil court for HIPAA violations, its standards have been used as the basis for a duty of care claim in state civil suits such as those for negligence or recklessness in the misuse or breach of PHI. Litigation with those affected could increase our liabilities, harm our reputation and have a material adverse effect on our business, financial condition and results of operations.

Numerous other federal and state laws protect the confidentiality, privacy, availability, integrity and security of PHI. For example, various states, such as California and Massachusetts, have implemented privacy laws and regulations, such as the California Confidentiality of Medical Information Act, that impose restrictive requirements regulating the use and disclosure of personally identifiable information, including PHI. In many cases, these laws are more restrictive than, and may not be preempted by, HIPAA and may be subject to varying interpretations by courts and government agencies, creating complex compliance issues and potentially exposing us to additional expense, adverse publicity and liability. We also expect that there will continue to be new laws, regulations and industry standards concerning privacy, data protection and information security proposed and enacted in various jurisdictions. For example, the CCPA went into effect on January 1, 2020, and established a new privacy framework for covered businesses such as ours. Further, in November 2020, California voters passed the California Privacy Rights and Enforcement Act of 2020, or CPRA, which further expands the CCPA with additional data privacy compliance requirements that may impact our business, and establishes a regulatory agency dedicated to enforcing those requirements. It remains unclear how various provisions of the CCPA and CPRA will be interpreted and enforced. In addition, on March 2, 2021, Virginia enacted the Virginia Consumer Data Protection Act, or CDPA, a comprehensive privacy statute that shares similarities with the CCPA, CPRA, and legislation proposed in other states. The CPRA and CDPA may require us to incur additional costs and expenses in an effort to comply before the laws becomes effective on January 1, 2023. Other states also have or are in the process of imposing similar privacy obligations. Recent laws such as the Biometric Information Privacy Act in Illinois have also restricted the use of biometric information. Such laws and regulations require us to continuously review our data Processing practices and policies, may cause us to incur substantial costs with respect to compliance, and could require us to adapt our products and solutions, which may reduce their utility to our customers.

Similar laws have been proposed in other states and at the federal level and if passed, such laws may have potentially conflicting requirements that would make compliance challenging. Such changes may also require us to modify our products and features, and may limit our ability to make use of the data that we collect, may require additional investment of resources in compliance programs, impact strategies and the availability of previously useful data and could result in increased compliance costs and/or changes in business practices and policies. New legislation proposed or enacted in various other states will continue to shape the data privacy environment nationally.

Additionally, all 50 U.S. states and the District of Columbia have enacted breach notification laws that may require us to notify patients, employees or regulators in the event of unauthorized access to or disclosure of personal or confidential information experienced by us or our service providers. These laws are not consistent, and compliance in the event of a widespread data breach is difficult and may be costly. Moreover, states have been frequently amending existing laws, requiring attention to changing regulatory requirements. We also may be contractually required to notify patients or other counterparties of a security breach. Although we may have contractual protections with our service providers, any actual or perceived security breach could harm our reputation and brand, expose us to potential liability or require us to expend significant resources on data security

 

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and in responding to any such actual or perceived breach. Any contractual protections we may have from our service providers may not be sufficient to adequately protect us from any such liabilities and losses, and we may be unable to enforce any such contractual protections. In addition to government regulation, privacy advocates and industry groups have and may in the future propose self-regulatory standards from time to time. These and other industry standards may legally or contractually apply to us, or we may elect to comply with such standards.

Further, in Canada, the Personal Information Protection and Electronic Documents Act, or PIPEDA, and similar provincial laws may impose obligations with respect to Processing personal information. PIPEDA requires companies to obtain an individual’s consent when collecting, using or disclosing that individual’s personal information. Individuals have the right to access and challenge the accuracy of their personal information held by an organization, and personal information may only be used for the purposes for which it was collected. If an organization intends to use personal information for another purpose, it must again obtain that individual’s consent.

Additionally, we make public statements about our use and disclosure of personal information through our privacy policies, information provided on our website and press statements. Although we endeavor to comply with our public statements and documentation, we may at times fail to do so or be alleged to have failed to do so. The publication of our privacy policies and other statements that provide promises and assurances about data privacy and security can subject us to potential government or legal action if they are found to be deceptive, unfair or misrepresentative of our actual practices. Moreover, from time to time, concerns may be expressed about whether our services compromise the privacy of patients and others. Any concerns about our data privacy and security practices, even if unfounded, could damage the reputation of our businesses, discourage potential patients from our services and have a material adverse effect on our business.

Complying with these various laws, rules, regulations and standards, and with any new laws or regulations changes to existing laws, could cause us to incur substantial costs that are likely to increase over time, require us to change our business practices in a manner adverse to our business, divert resources from other initiatives and projects, and restrict the way products and services involving data are offered, all of which may have a material adverse effect on our business. For example, we have incurred and expect to continue to incur additional costs to comply with the CCPA and other similar regulations. However, in the future we may be unable to make such changes and modifications to our business practices in a commercially reasonable manner, or at all. Given the rapid development of cybersecurity and data privacy laws, we expect to encounter inconsistent interpretation and enforcement of these laws and regulations, as well as frequent changes to these laws and regulations which may expose us to significant penalties or liability for non-compliance, the possibility of fines, lawsuits (including class action privacy litigation), regulatory investigations, criminal or civil sanctions, audits, adverse media coverage, public censure, other claims, significant costs for remediation and damage to our reputation, or otherwise have a material adverse effect on our business and operations. Any inability to adequately address data privacy or security-related concerns, even if unfounded, or to comply with applicable laws, regulations, standards and other obligations relating to data privacy and security, could result in additional cost and liability to us, damage our relationships with patients and have a material adverse effect on our business.

We face and are currently subject to reviews, audits and investigations under our licenses and/or contracts with federal and state government agencies and other payors, and these reviews, audits and investigations could have adverse findings that may negatively impact our business.

As a result of our participation in the Medicare and Medicaid programs, we face and are currently subject to various governmental reviews, audits, and investigations to verify our compliance with these programs and applicable laws and regulations. An increasing level of governmental and private resources are being devoted to the investigation of allegations of fraud and abuse in the Medicare and Medicaid programs, and federal and state regulatory authorities are taking an increasingly strict view of the requirements imposed on healthcare providers by the Social Security Act, the Medicare and Medicaid programs, and other applicable laws. We are routinely subject to audits under various government programs, including the RAC program, the TPE program and the

 

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UPIC program, in which CMS engages third-party firms to conduct extensive pre and post-payment reviews of claims data and medical and other records to identify potential improper payments to healthcare providers under the Medicare program.

In addition, each of our facilities and agencies must comply with required conditions of participation in the Medicare program. If we fail to meet the conditions of participation at a facility, we may receive a notice of deficiency from the applicable state surveyor. If that facility then fails to institute an acceptable plan of correction to remediate the deficiency within the correction period provided by the state surveyor, that care center could be terminated from the Medicare program or subjected to alternative sanctions. CMS may impose temporary management, direct a plan of correction, direct training or impose payment suspensions and civil monetary penalties, in each case, upon providers who fail to comply with the conditions of participation. Termination of one or more of our facilities from the Medicare program for failure to satisfy the program’s conditions of participation, or the imposition of alternative sanctions, could disrupt operations, require significant attention by management, or have a material adverse effect on our reputation, business, financial condition and results of operations.

In addition, we, like other healthcare providers, are subject to ongoing investigations by the U.S. Department of Health and Human Services Office of Inspector General, the United States Department of Justice, or DOJ, and State Attorneys General into the billing of services provided to Medicare and Medicaid patients, including whether such services were properly documented and billed, whether services provided were medically necessary, and general compliance with conditions of participation and conditions of payment in the Medicare and Medicaid programs. Private payors such as third-party insurance and managed care entities also often reserve the right to conduct audits. If billing errors are identified in the sample of reviewed claims, the billing error can be extrapolated to all claims filed which could result in a larger overpayment than originally identified in the sample of reviewed claims. Our costs to respond to and defend any such reviews, audits and investigations are significant and are likely to increase in the current enforcement environment. These audits and investigations may require us to refund or retroactively adjust amounts that have been paid under the relevant government program or from other payors. Further, an adverse review, audit or investigation could result in other adverse consequences, particularly if the underlying conduct is found to be pervasive or systemic. These consequences include: (1) state or federal agencies imposing significant fines, penalties and other sanctions on us; (2) loss of our right to participate in the Medicare or Medicaid programs or one or more third-party payor networks; (3) indemnity claims asserted by patients and others for which we provide services; and (4) damage to our reputation in various markets, which could adversely affect our ability to attract patients and employees. If they were to occur, these consequences could have a material adverse effect on our business, financial condition and results of operations.

Quality reporting requirements may negatively impact Medicare reimbursement.

We are subject to certain reporting requirements, and if we fail to comply with those requirements, our future Medicare reimbursement could be impacted. In particular, the ACA directed the Secretary of HHS to establish quality reporting requirements for hospice programs. Failure to submit required quality data will result in a 2% reduction to the market basket percentage increase for that year. This quality reporting program is currently “pay-for-reporting,” meaning it is the act of submitting data that determines compliance with program requirements. Similarly, in the Calendar Year 2015 Home Health Final Rule, CMS proposed to establish a new “Pay-for-Reporting Performance Requirement” with which provider compliance with quality reporting program requirements can be measured. Home health agencies that do not submit quality measure data to CMS are subject to a 2% reduction in their annual home health payment update percentage. Currently, home health agencies are required to report prescribed quality assessment data for a minimum of 90% of all patients. The Improving Medicare Post-Acute Care Transformation Act of 2014, or the IMPACT Act, requires the submission of standardized data by home health agencies and other providers. Specifically, the IMPACT Act requires, among other significant activities, the reporting of standardized patient assessment data with regard to quality measures, resource use, and other measures. Failure to report data as required will subject providers to a 2% reduction in market basket prices then in effect.

 

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There can be no assurance that we will continue to meet quality reporting requirements in the future which may result in us seeing a reduction in its Medicare reimbursements. We could also incur meaningful additional expenses in an effort to comply with additional and changing quality reporting requirements.

Risks Related to Our Indebtedness

Our high level of indebtedness requires that we dedicate a substantial portion of our cash flows to debt service payments and reduces the funds that would otherwise be available for other general corporate purposes and other business opportunities, which could adversely affect our operating performance, growth, profitability and financial condition, which in turn could make it more difficult for us to generate cash flow sufficient to satisfy all of our obligations under our indebtedness.

As of June 30, 2021, we had approximately $2,984.7 million outstanding under the First Lien Term Loan Facility and approximately $450.0 million outstanding under the Second Lien Facility. As of June 30, 2021, we had no borrowings outstanding under the Revolving Credit Facility, with an available borrowing capacity under the Revolving Credit Facility of approximately $320.0 million, and $54.1 million of letters of credit outstanding under the LC Facility.

Our overall level of indebtedness requires that we dedicate a substantial portion of our cash flows to debt service payments. The First Lien Term Loan Facility requires quarterly principal and periodic cash interest payments through March 5, 2026 and the Second Lien Facility requires periodic cash interest payments through March 5, 2027. The Revolving Credit Facility requires periodic cash interest payments on outstanding amounts through March 5, 2024.

Our substantial indebtedness reduces the funds that would otherwise be available for operations, future business opportunities and payments of our debt obligations and limits our ability to:

 

   

obtain additional financing, if necessary, for working capital and operations, or such financing may not be available on favorable terms;

 

   

make needed capital expenditures;

 

   

make strategic acquisitions or investments or enter into joint ventures;

 

   

react to changes or withstand a future downturn in our business, our industries or the economy in general;

 

   

meet budget targets and forecasts of future results;

 

   

engage in business activities, including future opportunities that may be in our interest; and

 

   

react to competitive pressures or compete with competitors with less debt.

These limitations could adversely affect our operating performance, growth, profitability and financial condition, which would make it more difficult for us to generate cash flow sufficient to satisfy our obligations under our indebtedness.

Our ability to make scheduled payments on our debt obligations also depends on our financial condition, results of operations and capital resources, which are subject to, among other things: the business, financial, economic, industry, competitive, regulatory and other factors discussed in these risk factors, and on other factors, some of which are beyond our control, including: the level of capital expenditures we make, including those for acquisitions, if any; our debt service requirements; fluctuations in our working capital needs; our ability to borrow funds and access capital markets; and restrictions on debt service payments and our ability to make working capital borrowings for debt service payments contained in our debt instruments.

 

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If we are unable to generate sufficient cash flow to permit us to make scheduled service payments on our debt, then we will be in default and holders of that debt and potentially certain of our other debt could declare all outstanding principal and interest to be due and payable. If our existing indebtedness were to be accelerated, there can be no assurance that we would have, or be able to obtain, sufficient funds to repay such indebtedness in full. In addition, upon the occurrence and continuance of an event of a default, the lenders under the Revolving Credit Facility could terminate their further commitments to loan money and our secured lenders under the First Lien Facilities and the Second Lien Facility could foreclose against the assets securing their borrowings, and we could be forced into bankruptcy or liquidation.

Despite our high level of indebtedness, we may still be able to incur substantially more debt, which could further increase the risks to our financial condition described above.

Despite our high level of indebtedness, we may be able to incur significant additional indebtedness in the future, including off-balance sheet financings, trade credit, contractual obligations and general and commercial liabilities. Although the credit agreements governing the First Lien Facilities and the Second Lien Facility contain restrictions on the incurrence of additional indebtedness, these restrictions are subject to a number of qualifications and exceptions, and the additional indebtedness incurred in compliance with these restrictions could be substantial. These restrictions also will not prevent us from incurring obligations that do not constitute indebtedness, and additionally we have further borrowing capacity under the Revolving Credit Facility. As of June 30, 2021, we had no borrowings outstanding under the Revolving Credit Facility, and an available borrowing capacity under the Revolving Credit Facility of approximately $320.0 million.

We may be able to increase the commitments under the Revolving Credit Facility by up to $370.0 million, plus an additional amount, subject to certain conditions, which borrowings would be secured indebtedness. We may also be able to increase the capacity under the First Lien Term Loan Facility and the Second Lien Facility by up to $370.0 million, collectively, plus an additional amount, subject to certain conditions, which borrowings would be secured indebtedness. The addition of new debt to our current debt levels could further exacerbate the related risks to our financial condition that we now face.

If we are unable to generate sufficient cash to service all of our indebtedness, we may be forced to take other actions to fund the satisfaction of our obligations under our indebtedness, which may not be successful.

If our cash flow is insufficient to fund our debt service obligations, we could face substantial liquidity problems and could be forced to reduce or delay investments and capital expenditures or to dispose of material assets or operations, raise additional debt or equity capital or restructure or refinance our indebtedness. However, we may not be able to implement any such alternative measures on commercially reasonable terms or at all and, even if successful, those alternative actions may not allow us to meet our scheduled debt service obligations. Even if new financing were available, it may be on terms that are less attractive to us than our then existing indebtedness or it may not be on terms that are acceptable to us. In addition, the credit agreements governing the First Lien Facilities and the Second Lien Facility restrict our ability to dispose of assets and use the proceeds from those dispositions and may also restrict our ability to raise debt or equity capital to be used to repay other indebtedness when it becomes due. Thus, we may not be able to consummate those dispositions or to obtain proceeds in an amount sufficient to meet any debt service obligations then due.

If we cannot generate sufficient cash flow to permit us to make scheduled payments on our debt, then we will be in default and holders of that debt could declare all outstanding principal and interest to be due and payable. If our existing indebtedness were to be accelerated, there can be no assurance that we would have, or be able to obtain, sufficient funds to repay such indebtedness in full. In addition, in the event of a default, the lenders under the Revolving Credit Facility could terminate their further commitments to loan money and our secured lenders under the First Lien Facilities and the Second Lien Facility could foreclose against the assets securing their borrowings and we could be forced into bankruptcy or liquidation.

 

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The terms of our outstanding indebtedness may restrict our current and future operations, particularly our ability to respond to changes or to take certain actions.

The credit agreements governing the First Lien Facilities and the Second Lien Facility contain restrictive covenants that impose significant operating and financial restrictions on us and may limit our ability to engage in acts that may be in our best interest, including restrictions on our ability to:

 

   

incur additional indebtedness and guarantee indebtedness;

 

   

pay dividends or make other distributions in respect of, or repurchase or redeem, capital stock;

 

   

prepay, redeem or repurchase certain debt;

 

   

make loans, investments and other restricted payments;

 

   

sell or otherwise dispose of assets;

 

   

incur liens;

 

   

enter into transactions with affiliates;

 

   

alter the businesses we conduct;

 

   

enter into agreements restricting our subsidiaries’ ability to pay dividends; and

 

   

consolidate, merge or sell all or substantially all of our assets.

Additionally, at certain times, the Revolving Credit Facility requires maintenance of a certain minimum fixed charge coverage ratio. See “Description of Certain Indebtedness—Covenants.” Our ability to comply with the covenants and restrictions contained in our credit agreements may be affected by events beyond our control. If market or other economic conditions deteriorate, our ability to comply with these covenants and restrictions may be impaired.

A breach of the covenants under one of these agreements could result in an event of default under the applicable indebtedness, which, if not cured or waived, could have a material adverse effect on our business, results of operations and financial condition. Such a default, if not cured or waived, may allow the creditors to accelerate the related debt principal and/or related interest payments and may result in the acceleration of any other debt to which a cross-acceleration or cross-default provision applies. If our existing indebtedness were to be accelerated, there can be no assurance that we would have, or be able to obtain, sufficient funds to repay such indebtedness in full. In addition, an event of default under the credit agreements governing the First Lien Facilities and the Second Lien Facility would permit the lenders under our Revolving Credit Facility to terminate all commitments to extend further credit under that facility. Furthermore, if we were unable to repay the amounts due and payable under the First Lien Facilities and the Second Lien Facility, those lenders could proceed against the collateral granted to them to secure that indebtedness, and we could be forced into bankruptcy or liquidation.

Our variable rate indebtedness subjects us to interest rate risk, which could cause our debt service obligations to increase significantly.

Borrowings under the First Lien Facilities and the Second Lien Facility are at variable rates of interest and expose us to interest rate risk. If interest rates increase, our debt service obligations on the variable rate indebtedness will increase even though the amount borrowed will remain the same, and our net income and operating cash flows, including cash available for servicing our indebtedness, will correspondingly decrease.

London Interbank Offered Rate, or LIBOR, is an average interest rate, determined by the ICE Benchmark Administration, that banks charge one another for the use of short-term money. In addition, the terms of many investments, financings or other transactions in the U.S. and globally have been historically tied to LIBOR, which functions as a reference rate or benchmark for various commercial and financial contracts. The

 

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United Kingdom’s Financial Conduct Authority, or FCA, has announced plans to discontinue supporting LIBOR and transition away from LIBOR by the end of 2021. However, subsequent announcements by the FCA, the LIBOR administrator and other regulators indicate that it is possible that certain LIBOR tenors may continue beyond 2021 and the most widely used LIBOR tenors may continue until mid-2023. There remains uncertainty regarding the future use of LIBOR and the nature of any replacement rate, and any potential effects of the transition away from LIBOR. Various financial industry groups have begun planning for that transition and certain regulators and industry groups have taken actions to establish alternative reference rates (e.g., the Secured Overnight Financing Rate, which measures the cost of overnight borrowings through repurchase agreement transactions collateralized with U.S. Treasury securities and is intended to replace U.S. dollar LIBOR with certain adjustments). The transition process may involve, among other things, an increase in volatility or illiquidity of markets for instruments that currently rely on LIBOR. Various pending legislation, including in the U.S. Congress and the New York state legislature, may affect the transition of LIBOR-based instruments as well by permitting trustees and calculation agents to transition instruments with no LIBOR transition language to an alternative reference rate selected by such agents. It is uncertain whether such legislative proposals will be signed into law. Any such effects, as well as other unforeseen effects, could have a material adverse effect on our First Lien Facilities, the Second Lien Facility or our future debt linked to such a “benchmark” and our ability to service debt that bears interest at floating rates of interest. In addition, the overall financial market may be disrupted as a result of the phase-out or replacement of LIBOR. Disruption in the financial market could have a material adverse effect on our business, financial condition and results of operations.

If the financial institutions that are lenders under the Revolving Credit Facility fail to extend credit under the facility or reduce the borrowing base, our liquidity and results of operations may be adversely affected.

One of our sources of liquidity is the Revolving Credit Facility. Each financial institution that is a lender under the Revolving Credit Facility is responsible on a several but not joint basis for providing a portion of the loans to be made under the facility. If any participant or group of participants with a significant portion of the commitments under the Revolving Credit Facility fails to satisfy its or their respective obligations to extend credit under the facility and we are unable to find a replacement for such participant or participants on a timely basis (if at all), our liquidity may be adversely affected.

In addition, the lenders under the Revolving Credit Facility may reduce the borrowing base under the facility in certain circumstances, which could adversely impact our liquidity and results of operations.

Our high level of indebtedness may hinder our ability to negotiate favorable terms with our suppliers, which could negatively impact our operating performance and, thus, could make it more difficult for us to generate cash flow sufficient to satisfy all of our obligations under our indebtedness.

Our high level of indebtedness may adversely affect our credit profile or rating, which may adversely affect our ability to negotiate favorable trade terms from our current or future suppliers, including pricing, payment, delivery, inventory, transportation, defective and marketing allowances and other terms, and may increase our need to support merchandise purchases with letters of credit. We may also be unable to negotiate favorable trade terms for our current or future service and non-merchandise vendors, including vendors that assist us in critical aspects of the business such as transportation and logistics, supplies, professional services, insurance and risk management, procurement, marketing and advertising, online operations and information technology. This could negatively impact the profitability of our business and our ability to effectively compete against competitors. Thus, our high level of indebtedness could adversely affect the profitability of our business, which could make it more difficult for us to generate cash flow sufficient to satisfy our obligations under our indebtedness.

General Risk Factors

We will be a “controlled company” within the meaning of the rules of Nasdaq and the rules of the SEC and, as a result, qualify for, and intend to rely on, exemptions from certain corporate governance requirements.

 

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You will not have the same protections afforded to stockholders of other companies that are subject to such requirements.

After completion of this offering and the application of net proceeds therefrom, KKR Stockholder and Walgreen Stockholder will collectively beneficially own approximately     % of the voting power of common stock (or approximately     % if the underwriters exercise in full their over-allotment option). As a result, we will be a “controlled company” within the meaning of the corporate governance standards of Nasdaq. Under these rules, a company of which more than 50% of the voting power is held by an individual, group or another company is a “controlled company” and may elect not to comply with certain corporate governance requirements, including the requirement that:

 

   

a majority of our board of directors consist of “independent directors” as defined under the rules of Nasdaq;

 

   

our director nominees be selected, or recommended for our board of directors’ selection, by a nominating/governance committee comprised solely of independent directors; and

 

   

the compensation of our executive officers be determined, or recommended to our board of directors for determination, by a compensation committee comprised solely of independent directors.

Following this offering, we intend to utilize these exemptions. As a result, we may not have a majority of independent directors, our compensation committee and nominating and governance committee may not consist entirely of independent directors. Accordingly, you may not have the same protections afforded to stockholders of companies that are subject to all of the corporate governance requirements of Nasdaq.

We will incur increased costs and become subject to additional regulations and requirements as a result of becoming a public company, and our management will be required to devote substantial time to new compliance matters, which could lower our profits or make it more difficult to run our business.

As a public company, we will incur significant legal, regulatory, finance, accounting, investor relations, insurance, and other expenses that we have not incurred as a private company, including costs associated with public company reporting requirements and costs of recruiting and retaining non-executive directors. We also have incurred and will incur costs associated with the Sarbanes-Oxley Act, and the Dodd-Frank Wall Street Reform and Consumer Protection Act, or the Dodd-Frank Act, and related rules implemented by the SEC and Nasdaq. The expenses incurred by public companies generally for reporting and corporate governance purposes have been increasing. We expect these rules and regulations to increase our legal and financial compliance costs and to make some activities more time-consuming and costly, although we are currently unable to estimate these costs with any degree of certainty. Our management will need to devote a substantial amount of time to ensure that we comply with all of these requirements, diverting the attention of management away from revenue-producing activities. These laws and regulations also could make it more difficult or costly for us to obtain certain types of insurance, including director and officer liability insurance, and we may be forced to accept reduced policy limits and coverage or incur substantially higher costs to obtain the same or similar coverage. These laws and regulations could also make it more difficult for us to attract and retain qualified persons to serve on our board of directors, our board committees or as our executive officers. Furthermore, if we are unable to satisfy our obligations as a public company, we could be subject to delisting of our common stock and the Units, fines, sanctions and other regulatory action and potentially civil litigation.

Failure to comply with requirements to design, implement and maintain effective internal controls could have a material adverse effect on our business and stock price. We currently have a material weakness in our internal control over financial reporting.

As a privately-held company, we were not required to evaluate our internal control over financial reporting in a manner that meets the standards of publicly traded companies required by Section 404(a) of the Sarbanes-Oxley Act, or Section 404.

 

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As a public company, we will have significant requirements for enhanced financial reporting and internal controls. The process of designing and implementing effective internal controls is a continuous effort that requires us to anticipate and react to changes in our business and the economic and regulatory environments and to expend significant resources to maintain a system of internal controls that is adequate to satisfy our reporting obligations as a public company. If we are unable to establish or maintain appropriate internal financial reporting controls and procedures, it could cause us to fail to meet our reporting obligations on a timely basis, result in material misstatements in our consolidated financial statements and harm our results of operations. In addition, we will be required, pursuant to Section 404, to furnish a report by management on, among other things, the effectiveness of our internal control over financial reporting in the second annual report following the completion of this offering. This assessment will need to include disclosure of any material weaknesses identified by our management in our internal control over financial reporting. The rules governing the standards that must be met for our management to assess our internal control over financial reporting are complex and require significant documentation, testing and possible remediation. Testing and maintaining internal controls may divert our management’s attention from other matters that are important to our business.

In connection with the implementation of the necessary procedures and practices related to internal control over financial reporting, we may identify deficiencies that we may not be able to remediate in time to meet the deadline imposed by the Sarbanes-Oxley Act for compliance with the requirements of Section 404. In addition, we may encounter problems or delays in completing the remediation of any deficiencies identified by our independent registered public accounting firm in connection with the issuance of their attestation report.

In connection with the preparation and audits of our consolidated financial statements as of and for the years ended December 31, 2020 and 2019, a material weakness was identified in our internal control over financial reporting. A material weakness is a deficiency, or a combination of deficiencies, in internal control over financial reporting, such that there is a reasonable possibility that a material misstatement of our annual or interim financial statements will not be prevented or detected on a timely basis. Specifically, there were material adjustments identified in our calculations of right of use assets and lease liabilities in connection with our adoption of ASU 2016-02, Leases, and the related 2020 and 2019 lease activity. These adjustments are appropriately reflected in our 2020 and 2019 consolidated financial statements. The material weakness resulted from the lack of properly designed controls with sufficient precision to review and identify lease input errors associated with calculating our right of use assets and lease liabilities.

We have begun taking measures, and plan to continue to take measures, to remediate this material weakness. These measures include design changes to our controls related to leases as well as adopting additional oversight controls and procedures. However, the implementation of these measures may not fully address this material weakness in our internal control over financial reporting, and, if so, we would not be able to conclude that it has been fully remedied. If our efforts to remediate this material weakness are not successful, the material weakness may reoccur or related material weakness could occur in the future.

Our testing, or the subsequent testing (if required) by our independent registered public accounting firm, may reveal deficiencies in our internal control over financial reporting that are deemed to be material weaknesses in addition to the material weakness described above. Any material weaknesses could result in a material misstatement of our annual or quarterly consolidated financial statements or disclosures that may not be prevented or detected. If we are unable to successfully remediate our existing or any future material weaknesses in our internal control over financial reporting, or if we identify any additional material weaknesses, the accuracy and timing of our financial reporting may be adversely affected, we may be unable to maintain compliance with securities law requirements regarding timely filing of periodic reports in addition to Nasdaq listing requirements.

We may not be able to conclude on an ongoing basis that we have effective internal control over financial reporting in accordance with Section 404 or our independent registered public accounting firm may not issue an unqualified opinion. If either we are unable to conclude that we have effective internal control over financial reporting or our independent registered public accounting firm is unable to provide us with an unqualified report,

 

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investors could lose confidence in our reported financial information, which could have a material adverse effect on the trading price of our common stock.

There has been no prior public market for our common stock and there may not develop or continue an active, liquid trading market for shares of our common stock, which may cause shares of our common stock to trade at a discount from the initial offering price and make it difficult to sell the shares of common stock you purchase.

Prior to this offering, there has not been a public trading market for shares of our common stock. We cannot predict the extent to which investor interest in us will lead to the development of a trading market or how active and liquid that market may become. If an active and liquid trading market does not develop or continue, you may have difficulty selling your shares of our common stock at an attractive price or at all. If you purchase shares of our common stock in this offering, you will pay a price that was not established in a competitive market. Instead, the initial public offering price per share of common stock will be determined by agreement between us and the representatives of the underwriters, and may not be indicative of the price at which shares of our common stock will trade in the public market after this offering. The market price of our common stock may decline below the initial offering price and you may not be able to sell your shares of our common stock at or above the price you paid in this offering, or at all. The lack of an active market may impair your ability to sell your shares at the time you wish to sell them or at a price you consider reasonable. The lack of an active market may also reduce the fair market value of your shares. Furthermore, an inactive market may also impair our ability to raise capital by selling shares of our common stock.

Our stock price may change significantly following this offering, and you may not be able to resell shares of our common stock at or above the price you paid or at all, and you could lose all or part of your investment as a result.

Even if a trading market develops, the market price of our common stock may be highly volatile and could be subject to wide fluctuations. You may not be able to resell your shares at or above the initial public offering price due to a number of factors such as those listed in “—Risks Related to Our Business” and the following:

 

   

results of operations that vary from the expectations of securities analysts and investors;

 

   

results of operations that vary from those of our competitors;

 

   

changes in expectations as to our future financial performance, including financial estimates and investment recommendations by securities analysts and investors;

 

   

changes in economic conditions for companies in our industries;

 

   

changes in market valuations of, or earnings and other announcements by, companies in our industries;

 

   

declines in the market prices of stocks generally, particularly those of companies in our industries;

 

   

additions or departures of key management personnel;

 

   

strategic actions by us or our competitors;

 

   

announcements by us or our competitors of significant contracts, price reductions, new services, acquisitions, dispositions, joint marketing relationships, joint ventures, other strategic relationships or capital commitments;

 

   

changes in our market share;

 

   

changes in general economic or market conditions or trends in our industries or the economy as a whole;

 

   

changes in business or regulatory conditions;

 

   

future sales of our common stock or other securities;

 

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investor perceptions of or the investment opportunity associated with our common stock relative to other investment alternatives;

 

   

changes in the way we are perceived in the marketplace, including due to negative publicity or campaigns on social media to boycott certain of our services, our business or our industries;

 

   

the public’s response to press releases or other public announcements by us or third parties, including our filings with the SEC;

 

   

changes or proposed changes in laws or regulations or differing interpretations or enforcement thereof affecting our business;

 

   

announcements relating to litigation or governmental investigations;

 

   

guidance, if any, that we provide to the public, any changes in this guidance or our failure to meet this guidance;

 

   

the development and sustainability of an active trading market for our common stock;

 

   

changes in accounting principles; and

 

   

other events or factors, including those resulting from informational technology system failures and disruptions, epidemics, pandemics, natural disasters, war, acts of terrorism, civil unrest or responses to these events.

Furthermore, the stock market may experience extreme volatility that, in some cases, may be unrelated or disproportionate to the operating performance of particular companies. These broad market and industry fluctuations may adversely affect the market price of our common stock, regardless of our actual operating performance. In addition, price volatility may be greater if the public float and trading volume of our common stock is low.

In the past, following periods of market volatility, stockholders have instituted securities class action litigation against various issuers. If we were to become involved in securities litigation, it could have a substantial cost and divert resources and the attention of executive management from our business regardless of the outcome of such litigation, which may adversely affect the market price of our common stock.

Investors in this offering will suffer immediate and substantial dilution.

The initial public offering price per share of common stock will be substantially higher than our as adjusted net tangible book value per share immediately after this offering. As a result, you will pay a price per share of common stock that substantially exceeds the per share book value of our tangible assets after subtracting our liabilities. Upon the issuance and sale of                  shares of our common stock by us at an assumed initial public offering price of $         per share, which is the midpoint of the estimated price range set forth on the cover page of this prospectus, you will incur immediate and substantial dilution in an amount of $         per share of common stock. If the underwriters exercise their over-allotment option, you will experience additional dilution. See “Dilution.”

You may be diluted by the future issuance of additional common stock in connection with our incentive plans, acquisitions or otherwise.

After this offering we will have approximately                  shares of common stock authorized but unissued (or                  shares if the underwriters exercise in full their over-allotment option). Our second amended and restated certificate of incorporation to become effective immediately prior to the consummation of this offering will authorize us to issue these shares of common stock, options and other equity awards relating to common stock for the consideration and on the terms and conditions established by our board of directors in its sole discretion, whether in connection with acquisitions or otherwise. We have reserved shares for issuance under our

 

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2017 Stock Plan and our 2021 Incentive Plan. See “Executive Compensation—Equity Incentive Plans.” Any common stock that we issue, including under our 2017 Stock Plan, our 2021 Incentive Plan or other equity incentive plans that we may adopt in the future, would dilute the percentage ownership held by the investors who purchase common stock in this offering. In the future, we may also issue our securities in connection with investments or acquisitions. The number of shares of our common stock issued in connection with an investment or acquisition could constitute a material portion of our then-outstanding shares of our common stock. Any issuance of additional securities in connection with investments or acquisitions may result in additional dilution to you.

In addition, concurrently with this offering, we are offering                Units, plus an additional                 Units if the underwriters in that offering exercise their over-allotment option to purchase additional Units in full. Unless settled earlier as described below, each purchase contract that is a component of a Unit being will settle automatically on the mandatory settlement date into between                and                shares of our common stock, subject to certain anti-dilution adjustments. Based on the assumed initial public offering price of $        per share, which is the midpoint of the estimated price range set forth on the cover page of this prospectus, and assuming the maximum number of shares issuable upon automatic settlement of such purchase contracts, up to                shares of common stock (or up to                shares if the underwriters in the Concurrent Offering exercise in full their option to purchase additional Units) are issuable upon settlement of the purchase contracts, subject to certain anti-dilution adjustments. See “Tangible Equity Units Offering.”

Any of these issuances may dilute your ownership interest in us and any of these events or the perception that these settlements and/or issuances could occur may have an adverse impact on the price of our common stock. See “Dilution.”

The Units may adversely affect the market price of our common stock.

The market price of our common stock is likely to be influenced by the Units. For example, the market price of our common stock could become more volatile and could be depressed by:

 

   

investors’ anticipation of the potential resale in the market of a substantial number of additional shares of our common stock received upon settlement of the purchase contracts that are a component of the Units;

 

   

possible sales of our common stock by investors who view the Units as a more attractive means of equity participation in us than owning shares of our common stock; and

 

   

hedging or arbitrage trading activity that may develop involving the Units and our common stock.

Our ability to raise capital in the future may be limited.

Our business and operations may consume resources faster than we anticipate. In the future, we may need to raise additional funds through the issuance of new equity securities, debt or a combination of both. Additional financing may not be available on favorable terms or at all. If adequate funds are not available on acceptable terms, we may be unable to fund our capital requirements. If we issue new debt securities, the debt holders would have rights senior to holders of our common stock to make claims on our assets and the terms of any debt could restrict our operations, including our ability to pay dividends on our common stock. If we issue additional equity securities or securities convertible into equity securities, existing stockholders will experience dilution and the new equity securities could have rights senior to those of our common stock. Because our decision to issue securities in any future offering will depend on market conditions and other factors beyond our control, we cannot predict or estimate the amount, timing or nature of our future offerings. Thus, you bear the risk of our future securities offerings reducing the market price of our common stock and diluting their interest.

 

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Because we have no current plans to pay cash dividends on our common stock, you may not receive any return on investment unless you sell your common stock for a price greater than that which you paid for it.

We have no current plans to pay cash dividends on our common stock. The declaration, amount and payment of any future dividends will be at the sole discretion of our board of directors, and will depend on, among other things, general and economic conditions, our results of operations and financial condition, our available cash and current and anticipated cash needs, capital requirements, contractual, legal, tax and regulatory restrictions and implications on the payment of dividends by us to our stockholders or by our subsidiaries to us, including restrictions under our credit agreements and other indebtedness we may incur, and such other factors as our board of directors may deem relevant. See “Dividend Policy.” As a result, you may not receive any return on an investment in our common stock unless you sell our common stock for a price greater than your purchase price.

BrightSpring Health Services, Inc. depends on its subsidiaries for cash to fund its operations and expenses, including future dividend payments, if any, and to meet its debt obligations.

Our operations are conducted through our subsidiaries and our ability to generate cash to meet our debt service obligations (including the amortizing notes that are components of the Units) or to make future dividend payments, if any, is highly dependent on the earnings of, and the receipt of funds from, our subsidiaries via dividends or intercompany loans. We do not currently expect to declare or pay dividends on our common stock for the foreseeable future; however, to the extent that we determine in the future to pay dividends on our common stock, the agreements governing our indebtedness may restrict the ability of our subsidiaries to pay dividends or otherwise transfer assets to us. In addition, Delaware law may impose requirements that may restrict our ability to pay dividends to holders of our common stock.

Future sales or issuances, or the perception of future sales or issuances, by us or our existing stockholders in the public market following this offering, or the settlement of the purchase contracts, could cause the market price for our common stock to decline.

The sale or issuance of substantial amounts of shares of our common stock or other securities convertible or exchangeable into shares of our common stock in the public market, or the settlement of the purchase contracts that are a component of the Units, or the perception that such sales or issuances could occur, including sales by our existing stockholders, could harm the prevailing market price of shares of our common stock. These sales or issuances, or the possibility that these sales or issuances may occur, also might make it more difficult for us to sell equity securities in the future at a time and at a price that we deem appropriate.

Upon completion of this offering, we will have a total of                  shares of our common stock outstanding, or                  shares if the underwriters exercise in full their option to purchase additional shares of our common stock. We will also have outstanding                Units, or                 Units if the underwriters in the Concurrent Offering exercise in full their option to purchase additional Units, which will settle into up to                shares of our common stock, or                  shares if the underwriters in the Concurrent Offering exercise in full their option to purchase additional Units, based on the assumed initial public offering price of $        per share, which is the midpoint of the estimated price range set forth on the cover page of this prospectus, and assuming the maximum number of shares issuable upon automatic settlement of such purchase contracts, subject to certain anti-dilution adjustments. All of the shares of our common stock sold in this offering, the Units and the shares of common stock issuable upon settlement of the Units will be freely tradable without restriction or further registration under the Securities Act, except that any shares held by our affiliates, as that term is defined under Rule 144 of the Securities Act, or Rule 144, including our directors, executive officers and other affiliates (including our existing stockholders), may be sold only in compliance with the limitations described in “Shares Eligible for Future Sale.”

The remaining outstanding                  shares of common stock held by our existing stockholders after this offering, representing approximately     % of the total outstanding shares of our common stock following this offering (or approximately     % if the underwriters exercise in full their over-allotment option), will be “restricted securities” within the meaning of Rule 144 and subject to certain restrictions on resale. Restricted

 

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securities may be sold in the public market only if they are registered under the Securities Act or are sold pursuant to an exemption from registration such as Rule 144, as described in “Shares Eligible for Future Sale.”

We, our directors and executive officers, and substantially all of our stockholders will sign lock-up agreements with the underwriters that will, subject to certain customary exceptions, restrict the sale of the shares of our common stock and certain other securities held by them for 180 days following the date of this prospectus. The representatives of the underwriters may, in their sole discretion and at any time without notice, release all or any portion of the shares or securities subject to any such lock-up agreements. See “Underwriting (Conflicts of Interest)” for a description of these lock-up agreements.

Upon the expiration of the lock-up agreements described above, all of such shares will be eligible for resale in a public market pursuant to Rule 144, subject to our compliance with the public information requirement and, in the case of shares held by our affiliates, to volume, manner of sale and other limitations under Rule 144. We expect that certain of our existing stockholders will be considered an affiliate upon the expiration of the lock-up period based on their expected share ownership, as well as their board nomination rights (if applicable). Certain other of our stockholders may also be considered affiliates at that time.

In addition, pursuant to the existing registration rights agreement, KKR Stockholder and Walgreen Stockholder each has the right, subject to certain conditions, to require us to register the sale of their shares of our common stock under the Securities Act. See “Certain Relationships and Related Party Transactions—Registration Rights Agreement.” By exercising their registration rights and selling a large number of shares, KKR Stockholder and Walgreen Stockholder could cause the prevailing market price of our common stock to decline. Certain of our existing stockholders have “piggyback” registration rights with respect to future registered offerings of our common stock. Following completion of this offering, the shares covered by registration rights would represent approximately     % of our total common stock outstanding (or approximately     % if the underwriters exercise in full their over-allotment option). Registration of any of these outstanding shares of common stock would result in such shares becoming freely tradable without compliance with Rule 144 upon effectiveness of the registration statement. See “Shares Eligible for Future Sale.”

We intend to file one or more registration statements on Form S-8 under the Securities Act to register shares of our common stock or securities convertible into or exchangeable for shares of our common stock issued pursuant to our existing 2017 Stock Plan and our 2021 Incentive Plan to be adopted in connection with this offering. Any such Form S-8 registration statements will automatically become effective upon filing. Accordingly, shares registered under such registration statements will be available for sale in the open market. We expect that the initial registration statement on Form S-8 will cover                  shares of our common stock.

As restrictions on resale end, or if the existing stockholders exercise their registration rights, the market price of our shares of common stock could drop significantly if the holders of these restricted shares sell them or are perceived by the market as intending to sell them. These factors could also make it more difficult for us to raise additional funds through future offerings of our shares of common stock or other securities.

If securities analysts do not publish research or reports about our business or if they downgrade our stock or our sector, our stock price and trading volume could decline.

The trading market for our common stock will rely in part on the research and reports that industry or financial analysts publish about us or our business. We do not control these analysts. Furthermore, if one or more of the analysts who do cover us downgrade our stock or our industries, or the stock of any of our competitors, or publish inaccurate or unfavorable research about our business, or if our operating results do not meet their expectations, the price of our stock could decline. If one or more of these analysts ceases coverage of the Company or fails to publish reports on us regularly, we could lose visibility in the market, which in turn could cause our stock price or trading volume to decline.

 

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Our management may spend the proceeds of this offering and the Concurrent Offering in ways with which you may disagree or that may not be profitable.

Although we anticipate using the net proceeds from this offering and the Concurrent Offering as described under “Use of Proceeds,” we will have broad discretion as to the application of the net proceeds received by us and could use them for purposes other than those contemplated by this offering and the Concurrent Offering. You may not agree with the manner in which our management chooses to allocate and spend the net proceeds. Our management may use the proceeds for corporate purposes that may not increase our profitability or otherwise result in the creation of stockholder value. In addition, pending our use of the proceeds, we may invest the proceeds primarily in instruments that do not produce significant income or that may lose value.

Anti-takeover provisions in our organizational documents could delay or prevent a change of control.

Certain provisions of our second amended and restated certificate of incorporation and amended and restated bylaws may have an anti-takeover effect and may delay, defer or prevent a merger, acquisition, tender offer, takeover attempt, or other change of control transaction that a stockholder might consider in its best interest, including those attempts that might result in a premium over the market price for the shares held by our stockholders.

These provisions will provide for, among other things:

 

   

a classified board of directors, as a result of which our board of directors will be divided into three classes, with each class serving for staggered three-year terms;

 

   

the ability of our board of directors to issue one or more series of preferred stock;

 

   

advance notice requirements for nominations of directors by stockholders and for stockholders to include matters to be considered at our annual meetings;

 

   

certain limitations on convening special stockholder meetings;

 

   

the removal of directors only for cause and only upon the affirmative vote of the holders of at least 6623% of the shares of common stock entitled to vote generally in the election of directors if KKR Stockholder, Walgreen Stockholder and their respective affiliates cease to beneficially own, in the aggregate, at least 40% of shares of common stock entitled to vote generally in the election of directors; and

 

   

that certain provisions may be amended only by the affirmative vote of at least 6623% of shares of common stock entitled to vote generally in the election of directors if KKR Stockholder, Walgreen Stockholder and their respective affiliates cease to beneficially own, in the aggregate, at least 40% of shares of common stock entitled to vote generally in the election of directors.

These anti-takeover provisions could make it more difficult for a third party to acquire us, even if the third party’s offer may be considered beneficial by many of our stockholders. As a result, our stockholders may be limited in their ability to obtain a premium for their shares. See “Description of Capital Stock.”

Our board of directors will be authorized to issue and designate shares of our preferred stock in additional series without stockholder approval.

Our amended and restated certificate of incorporation will authorize our board of directors, without the approval of our stockholders, to issue                  shares of our preferred stock, subject to limitations prescribed by applicable law, rules and regulations and the provisions of our amended and restated certificate of incorporation, as shares of preferred stock in series, to establish from time to time the number of shares to be included in each such series and to fix the designation, powers, preferences and rights of the shares of each such series and the qualifications, limitations or restrictions thereof. The powers, preferences and rights of these additional series of preferred stock may be senior to or on parity with our common stock, which may reduce its value.

 

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Our amended and restated certificate of incorporation will provide, subject to limited exceptions, that the Court of Chancery of the State of Delaware will be the exclusive forum for substantially all disputes between us and our stockholders and the federal district courts will be the exclusive forum for Securities Act claims, which could limit our stockholders’ ability to bring a suit in a different judicial forum than they may otherwise choose for disputes with us or our directors, officers, team members or stockholders.

Our amended and restated certificate of incorporation will provide, subject to limited exceptions, that unless we consent to the selection of an alternative forum, the Court of Chancery of the State of Delaware will, to the fullest extent permitted by law, be the sole and exclusive forum for any (i) derivative action or proceeding brought on behalf of our company, (ii) action asserting a claim of breach of a fiduciary duty owed by any director, officer, or other employee or stockholder of our company to the Company or our stockholders, creditors or other constituents, (iii) action asserting a claim against the Company or any director or officer of the Company arising pursuant to any provision of the Delaware General Corporation Law, or the DGCL, or our amended and restated certificate of incorporation or our amended and restated bylaws or as to which the DGCL confers jurisdiction on the Court of Chancery of the State of Delaware, or (iv) action asserting a claim against the Company or any director or officer of the Company governed by the internal affairs doctrine; provided that, the exclusive forum provision will not apply to suits brought to enforce any liability or duty created by the Securities Exchange Act of 1934, as amended, or the Exchange Act, which already provides that such claims must be bought exclusively in the federal courts. Our amended and restated certificate of incorporation also provides that, unless we consent in writing to the selection of an alternative forum, the U.S. federal district courts will be the exclusive forum for the resolution of any actions or proceedings asserting claims arising under the Securities Act. While the Delaware Supreme Court has upheld the validity of similar provisions under the DGCL, there is uncertainty as to whether a court in another state would enforce such a forum selection provision. Our exclusive forum provision will not relieve us of our duties to comply with the federal securities laws and the rules and regulations thereunder, and our stockholders will not be deemed to have waived our compliance with these laws, rules and regulations.

Any person or entity purchasing or otherwise acquiring any interest in shares of our capital stock will be deemed to have notice of and consented to the forum provisions in our amended and restated certificate of incorporation. This choice of forum provision may limit a stockholder’s ability to bring a claim in a judicial forum that it finds favorable for disputes with us or any of our directors, officers, other team members or stockholders. There is also a risk that the exclusive forum provisions may result in increased costs for a stockholder to bring a claim. Alternatively, if a court were to find the choice of forum provision contained in our amended restated certificate of incorporation to be inapplicable or unenforceable in an action, we may incur additional costs associated with resolving such action in other jurisdictions, which could harm our business, results of operations and financial conditions.

If tax laws change, it could adversely affect our business, financial condition and results of operations.

We are subject to federal, state and local income taxes in the United States and in certain foreign jurisdictions in which we operate. Increases in income tax rates or other changes in tax laws in any particular jurisdiction could reduce our after-tax income from such jurisdictions and could adversely affect our business, financial condition or results of operations. The United States and other countries in which we have significant operations have recently made or are actively considering changes to existing tax laws. For example, in December 2017, the Tax Cuts and Jobs Act, or TCJA, was signed into law in the United States.

Additional changes in the U.S. tax regime or in how U.S. multinational corporations are taxed on foreign earnings, including changes in how existing tax laws are interpreted or enforced, could adversely affect our business, financial condition and results of operations. We cannot predict the outcome of any specific legislative proposals or amendments to existing treaties. Since we operate or have operations in the United States and in non-U.S. jurisdictions, our plans for expansion or our results of operations in such jurisdictions could be adversely affected if any adopted proposals resulted in an increase in our tax burden, costs of our tax compliance

 

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or otherwise adversely affected our results of operations and cash flows. There are no assurances that we will be able to implement effective tax planning strategies that are necessary to optimize our tax position following changes in tax laws in the United States and globally. Our effective tax rate and our results of operations may be impacted by any changes in tax laws.

 

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FORWARD-LOOKING STATEMENTS

This prospectus includes forward-looking statements that reflect our current views with respect to, among other things, our operations and financial performance. Forward-looking statements include all statements that are not historical facts. These forward-looking statements are included throughout this prospectus, including in the sections entitled “Summary,” “Risk Factors,” “Management’s Discussion and Analysis of Financial Condition and Results of Operations” and “Business” and relate to matters such as our industries, business strategy, goals and expectations concerning our market position, future operations, margins, profitability, capital expenditures, liquidity and capital resources and other financial and operating information. We have used the words “anticipate,” “assume,” “believe,” “continue,” “could,” “estimate,” “expect,” “intend,” “may,” “plan,” “potential,” “predict,” “project,” “future,” “will,” “seek,” “foreseeable,” the negative version of these words or similar terms and phrases to identify forward-looking statements in this prospectus.

The forward-looking statements contained in this prospectus are based on management’s current expectations and are not guarantees of future performance. The forward-looking statements are subject to various risks, uncertainties, assumptions or changes in circumstances that are difficult to predict or quantify. Our expectations, beliefs, and projections are expressed in good faith and we believe there is a reasonable basis for them. However, there can be no assurance that management’s expectations, beliefs and projections will result or be achieved. Actual results may differ materially from these expectations due to changes in global, regional or local economic, business, competitive, market, regulatory and other factors, many of which are beyond our control. We believe that these factors include but are not limited to those described under “Risk Factors” and the following:

 

   

we operate in a highly competitive industry;

 

   

if we are unable to maintain relationships with existing patient referral sources or establish new referral sources, our business, financial condition and results of operations could be materially adversely affected;

 

   

a pandemic, epidemic or outbreak of an infectious disease, including the ongoing outbreak of COVID-19, could adversely affect our business;

 

   

changes to Medicare and Medicaid rates or methods governing Medicare and Medicaid payments for our services could materially adversely affect our business;

 

   

cost containment initiatives of third-party payors, including post-payment audits, could adversely impact our business, financial condition and results of operations;

 

   

the implementation of alternative payment models and the transition of Medicaid and Medicare beneficiaries to managed care organizations may limit our market share and could adversely affect our revenues;

 

   

changes in the case mix of patients, as well as payor mix and payment methodologies, and decisions and operations of third-party organizations may have a material adverse effect on our business, financial condition and results of operations;

 

   

our business is reliant on federal and state spending, budget decisions and continuous governmental operations which may fluctuate under different political conditions;

 

   

changes in drug utilization and/or pricing, PBM contracts and Medicare Part D/Medicaid reimbursement may negatively impact our profitability;

 

   

changes in our relationships with pharmaceutical suppliers, including changes in drug availability or pricing, could adversely affect our business and financial results;

 

   

our business relies on the continual recruitment and retention of nurses, pharmacists, therapists, caregivers, direct support professionals and other qualified personnel, including senior management;

 

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we are subject to federal, state and local laws and regulations that govern our employment practices, including minimum wage, living wage, and paid time-off requirements; failure to comply with these laws and regulations, or changes to these laws and regulations that increase our employment-related expenses, could adversely impact our operations;

 

   

our results of operations fluctuate on a quarterly basis;

 

   

our business may be harmed by labor relation matters;

 

   

because we are limited in our ability to control reimbursement rates received for our services, our business could be materially adversely affected if we are not able to maintain or reduce our costs to provide such services;

 

   

delays in collection or non-collection of our accounts receivable, particularly during the business integration process, could adversely affect our business, financial condition and results of operations;

 

   

if we fail to manage our growth effectively, we may be unable to execute our business plan, maintain high levels of service and satisfaction or adequately address competitive challenges;

 

   

our growth strategy is partially dependent upon our ability to identify and successfully complete acquisitions, joint ventures and other strategic initiatives; any failure by us to manage or integrate acquisitions, divestitures and other significant transactions successfully may have a material adverse effect on our business, financial condition and results of operations;

 

   

if we are unable to provide consistently high quality of care, our business will be adversely impacted;

 

   

if we are unable to maintain our corporate reputation, or there is adverse publicity, including negative information on social media, or changes in public perception of our services, our business may suffer;

 

   

if our existing customers do not continue with or renew their contracts with us, renew at lower fee levels, decline to purchase additional services from us or reduce the services received from us pursuant to those contracts, it could have a material adverse effect on our business, financial condition and results of operations;

 

   

our business depends on our ability to effectively invest in, implement improvements to and properly maintain the uninterrupted operation and data integrity of our information technology and other business systems;

 

   

security breaches, loss of data and other disruptions could compromise sensitive business or patient information, cause a loss of confidential patient data, employee data, personal information , or prevent access to critical information and expose us to liability, litigation and federal and state governmental inquiries and damage our reputation and brand;

 

   

we are subject to risks related to credit card payments and other payment methods;

 

   

we may be subject to substantial malpractice or other similar claims;

 

   

we are exposed to various risks related to governmental inquiries, regulatory actions and whistleblower lawsuits that could adversely affect our operating results. Our insurance may not cover all claims against us;

 

   

our current insurance program may expose us to unexpected costs and negatively affect our business, financial condition and results of operations, particularly if we incur losses not covered by our insurance or if claims or losses differ from our estimates;

 

   

factors outside of our control, including those listed, could require us to record an asset impairment of goodwill; and

 

   

inclement weather, natural disasters, acts of terrorism, riots, civil insurrection or social unrest, looting, protests, strikes or street demonstrations may impact our ability to provide services.

 

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These factors should not be construed as exhaustive and should be read in conjunction with the other cautionary statements that are included in this prospectus. Should one or more of these risks or uncertainties materialize, or should any of our assumptions prove incorrect, our actual results may vary in material respects from those projected in these forward-looking statements.

Any forward-looking statement made by us in this prospectus speaks only as of the date of this prospectus and are expressly qualified in their entirety by the cautionary statements included in this prospectus. Factors or events that could cause our actual results to differ may emerge from time to time, and it is not possible for us to predict all of them. We may not actually achieve the plans, intentions or expectations disclosed in our forward-looking statements and you should not place undue reliance on our forward-looking statements. Our forward- looking statements do not reflect the potential impact of any future acquisitions, mergers, dispositions, joint ventures, investments or other strategic transactions we may make. We undertake no obligation to publicly update or review any forward-looking statement, whether as a result of new information, future developments or otherwise, except as may be required by any applicable securities laws.

 

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USE OF PROCEEDS

We estimate that we will receive net proceeds of approximately $         million (or approximately $         million, if the underwriters exercise in full their over-allotment option) from the sale of shares of our common stock in this offering, assuming an initial public offering price of $         per share, which is the midpoint of the estimated price range set forth on the cover page of this prospectus, and after deducting the underwriting discounts and commissions and estimated offering expenses payable by us. An increase (decrease) of 1,000,000 shares from the expected number of shares of common stock to be sold by us in this offering, assuming no change in the assumed initial public offering price per share, would increase (decrease) our net proceeds from this offering by $         million. A $1.00 increase (decrease) in the assumed initial public offering price would increase (decrease) the net proceeds to us from this offering by $         million, assuming the number of shares of common stock offered by us, as set forth on the cover page of this prospectus, remains the same and after deducting the underwriting discounts and commissions and estimated offering expenses payable by us.

We estimate that the net proceeds to us from the concurrent offering of the Units, if completed, after deducting estimated underwriting discounts and commissions and estimated offering expenses payable by us, will be approximately $            million (or $            million if the underwriters in the concurrent offering of the Units exercise in full their option to purchase additional Units). We intend to use proceeds from this offering and the concurrent offering of the Units to repay $             million outstanding aggregate amount under the Second Lien Facility, with any remainder to be used for general corporate purposes.

As of June 30, 2021, we had $450.0 million aggregate principal amount outstanding under the Second Lien Facility, maturing on March 5, 2027. As of June 30, 2021, our second lien term loans had an effective interest rate of 9.50%. For a further description of our Second Lien Facility, see “Description of Certain Indebtedness.”

 

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DIVIDEND POLICY

We currently expect to retain all future earnings for use in the operation and expansion of our business and have no current plans to pay dividends on our common stock. The declaration, amount and payment of any future dividends will be at the sole discretion of our board of directors, and will depend on, among other things, general and economic conditions, our results of operations and financial condition, our available cash and current and anticipated cash needs, capital requirements, contractual, legal, tax and regulatory restrictions and implications on the payment of dividends by us to our stockholders or by our subsidiaries to us, including restrictions under our credit agreements and other indebtedness we may incur, and such other factors as our board of directors may deem relevant. If we elect to pay such dividends in the future, we may reduce or discontinue entirely the payment of such dividends at any time. BrightSpring Health Services, Inc.’s operations are conducted through its subsidiaries. In the event that we do pay a dividend, we intend to cause our operating subsidiaries to make distributions to us in an amount sufficient to cover such dividend. Our subsidiaries are currently subject to certain restrictions and covenants under the credit agreements governing the First Lien Facilities and the Second Lien Facility, including limits on amounts of leverage, interest charges, distributions, dividends and capital expenditures. These restrictions and covenants may restrict the ability of those entities to make distributions to BrightSpring Health Services, Inc. See “Description of Certain Indebtedness.” Any additional financing arrangement we enter into in the future may include restrictive covenants that limit our subsidiaries’ ability to pay dividends to us. In addition, Delaware law may impose requirements that may restrict our ability to pay dividends to holders of our common stock.

 

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CAPITALIZATION

The following table sets forth our cash and cash equivalents and capitalization as of June 30, 2021:

 

   

on an actual basis; and

 

   

on an as adjusted basis after giving effect to the sale of                  shares of our common stock offered by us in this offering at an assumed initial public offering price of $         per share, which is the midpoint of the estimated price range set forth on the cover page of this prospectus, and the concurrent issuance of             Units, in each case after deducting the underwriting discounts and commissions and estimated offering expenses payable by us, and the application of the net proceeds to us therefrom as described under “Use of Proceeds.”

You should read this table in conjunction with the information contained in “Use of Proceeds,” “Management’s Discussion and Analysis of Financial Condition and Results of Operations” and “Description of Certain Indebtedness” as well as our audited consolidated financial statements and related notes and our unaudited condensed consolidated financial statements and related notes, each included elsewhere in this prospectus. Because the closing of this offering is not contingent upon the completion of the concurrent offering of the Units, you should not assume that the concurrent offering of the Units, including its component parts of the purchase contracts and the amortizing notes, as reflected in the applicable column below, will take place.

 

     As of June 30, 2021  
     Actual     As Adjusted(1)  
     (unaudited)     (unaudited)  

(In thousands, except par value)

    

Cash and cash equivalents

   $ 240,617     $                
  

 

 

   

 

 

 

Debt:

    

First Lien Facilities(2):

    

First Lien Term Loan Facility

     2,984,702    

Revolving Credit Facility

     —      

Second Lien Facility

     450,000    

Amortizing notes that are components of the Units (3)

     —      

Other

     11,066    
  

 

 

   

 

 

 

Total debt

   $ 3,445,768     $    
  

 

 

   

 

 

 

Shareholders’ equity:

    

Common stock, $0.01 par value per share,                  shares authorized,                  shares issued and outstanding, actual;                  shares authorized,                  shares issued and outstanding, as adjusted(1)(4)

     750,308    

Additional paid-in capital(1)(4)(5)

     20,769    

Accumulated deficit

     (36,616  

Accumulated other comprehensive income

     325    
  

 

 

   

 

 

 

Total shareholders’ equity

     734,786    
  

 

 

   

 

 

 

Total capitalization

   $ 4,180,554     $    
  

 

 

   

 

 

 

 

(1)

To the extent we change the number of shares of common stock sold by us in this offering from the shares we expect to sell or we change the initial public offering price from the assumed initial public offering price of $         per share, the midpoint of the estimated price range set forth on the cover page of this prospectus, or any combination of these events occurs, the net proceeds to us from this offering and each of additional paid-in capital, total shareholders’ equity and total capitalization may increase or decrease. A $1.00 increase (decrease) in the assumed initial public offering price of $         per share, which is the midpoint of the estimated price range set forth on the cover page in this offering, would increase (decrease) the net proceeds

 

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  that we receive in this offering and each of additional paid-in capital, total shareholders’ equity and total capitalization by approximately $        , assuming the number of shares offered by us remains the same as set forth on the cover page of this prospectus and after deducting the underwriting discounts and commissions and estimated offering expenses payable by us. An increase (decrease) of 1,000,000 shares in the expected number of shares to be sold by us in this offering, assuming no change in the assumed initial public offering price of $         per share, which is the midpoint of the estimated price range set forth on the cover page of this offering, would increase (decrease) our net proceeds from this offering and each of additional paid-in capital, total shareholders’ equity and total capitalization by approximately $         after deducting the underwriting discount and commissions and estimated offering expenses payable by us.
(2)

As of June 30, 2021, there were $54.1 million letters of credit outstanding under the LC Facility.

(3)

Each Unit will include an amortizing note, as described in “Tangible Equity Units Offering.” The exact amount of the principal amount of these amortizing notes will not be determined until the pricing of the concurrent offering of the Units. The amortizing note component of the Units represents the present value of the installment payments due under the amortizing note, calculated with the assumption that the total principal and interest components of the installment payment will equal        % of the $50.00 stated amount of the Units per annum. A 25-basis point increase in the assumed yield of        % per annum would be expected to result in a $        million increase to the amortizing note component and a corresponding decrease to the purchase contract component.

(4)

Each Unit will include a purchase contract, as described in “Tangible Equity Units Offering.” Share numbers and amounts do not reflect shares of our common stock issuable upon settlement of the purchase contracts.

(5)

We will account for the purchase contracts that are components of the Units as equity and will record the $        million initial fair value of these purchase contracts, net of the related underwriting discounts, commissions and offering expenses allocated to the purchase contracts, as additional paid-in capital. The exact amount of the initial fair value of these purchase contracts will not be determined until the pricing of the concurrent offering of the Units and our determination of the final offering expenses related thereto. The value assigned to the purchase contract component represents the difference in the stated value of the Units and the amount assigned to the amortizing note component.

 

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DILUTION

If you invest in our common stock in this offering, your ownership interest in us will be diluted to the extent of the difference between the initial public offering price per share of our common stock and the as adjusted net tangible book value per share of our common stock after giving effect to this offering. Dilution results from the fact that the per share offering price of the common stock is substantially in excess of the net tangible book value per share attributable to our existing stockholders.

Our net tangible book deficit as of June 30, 2021 was approximately $2,780.5 million, or $                 per share of our common stock. We calculate net tangible book deficit per share by taking the amount of our total tangible assets (including our operating lease right-of-use assets), reduced by the amount of our total liabilities, and then dividing that amount by the total number of shares of common stock outstanding.

After giving effect to (i) the sale by us of                  shares of common stock in this offering at an assumed initial public offering price of $         per share, which is the midpoint of the estimated price range set forth on the cover page of this prospectus, and (ii) the use of proceeds therefrom, after deducting the underwriting discounts and commissions and estimated offering expenses payable by us, our as adjusted net tangible book value as of June 30, 2021 would have been $         million, or $         per share of our common stock. This amount represents an immediate decrease in net tangible book deficit of $         per share of common stock to our existing stockholders and an immediate and substantial dilution in net tangible book value of $         per share of common stock to new investors purchasing shares in this offering.

The following table illustrates this dilution on a per share of common stock basis assuming the underwriters do not exercise their option to purchase additional shares of common stock in this offering:

 

Assumed initial public offering price per share of common stock

   $                

Net tangible book deficit per share of common stock as of June 30, 2021

  

Increase in net tangible book value per share of common stock attributable to investors in this offering

  

As adjusted net tangible book value per share of common stock after giving effect to this offering

  

Dilution per share of common stock to investors in this offering

   $    
  

 

 

 

Dilution is determined by subtracting as adjusted net tangible book value per share of common stock after the offering from the initial public offering price per share of common stock.

Each $1.00 increase or decrease in the assumed initial public offering price per share of common stock would increase or decrease, as applicable, the as adjusted net tangible book value by $         per share and the dilution to new investors in the offering by $         per share, assuming that the number of shares offered by us in this offering, as set forth on the cover page of this prospectus, remains the same. The as adjusted information discussed above is for illustrative purposes only. Our net tangible book value following the completion of the offering is subject to adjustment based on the actual offering price of our common stock and other terms of this offering determined at pricing.

 

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The following table summarizes, on the same as adjusted basis as of June 30, 2021, the total number of shares of common stock purchased from us, the total cash consideration paid to us and the average price per share of common stock paid by our existing stockholders and by new investors purchasing shares of common stock in this offering.

 

     Shares Purchased     Total Consideration     Average
Price Per
Share
 
     Number      Percent     Amount      Percent  
     (in thousands)  

Existing stockholders

                                $                             $                

New investors in this offering

               $                 $    

Total

               $                 $    

If the underwriters were to exercise in full their option to purchase                  additional shares of common stock in this offering, the percentage of shares of our common stock held by existing stockholders as of June 30, 2021 would be     % and the percentage of shares of our common stock held by new investors in this offering would be     %.

 

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MANAGEMENT’S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS

The following discussion analyzes our financial condition and results of operations and should be read in conjunction with our consolidated financial statements and related notes included elsewhere in this prospectus. This discussion contains forward-looking statements that involve risks and uncertainties. See “Forward-Looking Statements.” When reviewing the discussion below, you should keep in mind the substantial risks and uncertainties that characterize our business. Known material factors that could affect our financial performance and actual results, and could cause actual results to differ materially from those expressed or implied in any forward-looking statements included in this discussion or otherwise made by our management, are described in “Risk Factors.” Factors that could cause or contribute to such difference are not limited to those identified in “Risk Factors.” All statements in this discussion and analysis concerning our current and planned operations are modified by reference to our discussion of recent developments related to the COVID-19 pandemic, and our ability to carry out our current and planned operations are dependent on further developments associated with the COVID-19 pandemic.

Overview

We are a leading home and community-based healthcare services platform, focused on delivering complementary provider and pharmacy services to complex patients. We have a differentiated approach to care delivery, with a purpose-built and scaled model that addresses the three critical services that the highest-need and highest-cost patients require. With a focus on Senior and Specialty patients, which includes Behavioral populations, our platform provides clinical services, supportive care and pharmacy solutions in lower-cost home and community settings to Medicare, Medicaid and commercially-insured populations. We are an essential part of our nation’s health delivery network as a front-line provider of high-quality and cost-effective care to a large and growing number of people, who increasingly require a combination of specialized solutions to enable holistic health care management. Our presence spans all 50 states, we serve over 330,000 patients daily through our approximately 10,000 clinical providers and pharmacists, and our services make a profound impact in the lives and communities of the people we serve.

Our model focuses on delivering high-touch and coordinated services to medically-complex clients and patients, which is a large, growing and underserved population in the U.S. healthcare system. These high-need and high-cost Senior and Specialty patients comprise a market of over $1.5 trillion across our business lines. The chronic conditions and long-term health needs of these patients not only represent an outsized share of health care spend today, but also are expected to drive a disproportionate share of future expenditures. Americans with five or more chronic conditions make up 12% of the population and account for 41% of total health care spending, on average spending 14 times more on health services than those without chronic conditions. These patients require clinical services, supportive care and pharmacy solutions to achieve quality outcomes, but must often navigate disjointed and separately-administered health services. This can result in uncoordinated care delivery with adverse medical consequences, as compared to receiving timely, proximal and complete care support in the home and community that improves health and reduces cost.

We have built a significant presence and expertise in delivering complementary and high-touch daily healthcare services and programs to complex patients in their homes and in communities in order to address their multiple health needs and requirements more completely. Our provider health services consist of both clinical and supportive care that are customized to individual patient needs. Clinical services consist of Home Health and Hospice to Seniors, as well as Home-Based Primary Care, Rehab Therapy and nursing to Senior and Specialty populations, including Neuro and Behavioral patients. Supportive care consists of services that address activities of daily living and social determinants of health for both Senior and Specialty populations as well. Often in tandem with our provider services, we provide alternative site daily pharmacy solutions across many home and community settings, including Senior Living communities, Hospice sites of care, homes of Seniors who are on a significant number of medications, Neuro and Behavioral clients’ and patients’ homes, Home Infusion, and

 

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Specialty Pharmacy (primarily oncology), as well as providing pharmacy solutions to skilled nursing and rehabilitation facilities and hospitals. By providing a complementary and purpose-built suite of services, our care model is designed to address more patient needs and better integrate health services delivery to improve outcomes and patient experiences, while reducing overall costs.

BrightSpring, as it exists today, is the product of BrightSpring Health Holdings Corp. and its subsidiaries, which we acquired on March 5, 2019, and PharMerica Corporation and its subsidiaries, which we acquired on December 7, 2017. In this prospectus, we refer to the acquisition of BrightSpring Health Holdings Corp. and its subsidiaries as the BHS Acquisition. Under GAAP, BrightSpring Health Holdings Corp. and its subsidiaries have been consolidated prospectively since the acquisition date of March 5, 2019. Comparability of our results for periods prior to the date of the BHS Acquisition may accordingly be limited.

2020 Overview and Key Highlights

 

   

Provided approximately 120 million hours of care and delivered over 30 million prescriptions across all 50 states in the process of serving over 330,000 people a day.

 

   

Delivered strong and market-leading quality metrics and outcomes across the Company, which demonstrates the impact and value of our services.

 

   

Effectively managed through the COVID-19 pandemic utilizing comprehensive infection controls, securing PPE for our caregivers, and ensuring continuity of operations and care for our patients.

 

   

Continued investment in automation, data and analytics, process efficiencies, technology solutions, and human capital to enable further growth, as part of the Company’s ongoing continuous improvement program.

 

   

Expanded initiatives that further build out innovative clinical and care management programs intended to provide more holistic models of care for the highest-need, highest-risk and highest-cost populations.

 

   

Opened 29 de novo locations across our home health, hospice, rehab, personal care, community living, pediatric autism, home infusion, and long term specialty pharmacy businesses (including pre-acquisition openings by Abode and OPPC).

 

   

Completed and integrated 12 acquisitions (eight provider and four pharmacy) that leverage our scale, end market presence and organizational capabilities and build upon our track record of successful M&A.

 

   

Grew revenue by $1.1 billion, or 23.3%, to $5.6 billion with numerous businesses growing organically into the double-digits and growth bolstered by strategic and accretive acquisitions.

 

   

Increased operating income by $101.9 million, or 160.9%, net income by $92.2 million, EBITDA by $128.5 million, or 58.9%, and Adjusted EBITDA by $79.5 million, or 23.9%.

 

   

Delivered $222.6 million in cash flow from operations.

Our Service Offerings

We are the largest independent provider of home and community-based health services in the United States delivering both provider and pharmacy solutions. We believe that our high-quality and complementary health service offerings to complex Senior and Specialty populations address important patient and stakeholder needs. We enhance patient outcomes through the coordination of multiple related services that high-need, high-cost patients require, which represents a unique and holistic care delivery model. Our services are principally delivered in patient-preferred and lower-cost settings over long periods of time, given the chronic nature of the patient conditions that we address. We believe our breadth of service capabilities and proven outcomes position us as a provider of choice for patients, families, referral sources, customers, and payors. We deliver services through two reportable segments: Home and Community Health Provider Services, or Provider Services, and Pharmacy Solutions.

 

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The following table summarizes the revenues generated by each of our segments for the six months ended June 30, 2021 and 2020:

 

     For the Six Months Ended June 30,  
($ in millions)    2021     2020  
     Revenue      % of
Revenue
    Revenue      % of
Revenue
 

Provider Services

   $ 909.5        28.8   $ 826.0        30.6

Pharmacy Solutions

     2,082.8        65.9     1,748.5        64.8

Other

     168.1        5.3     123.6        4.6
  

 

 

    

 

 

   

 

 

    

 

 

 

Total revenues

   $ 3,160.4        100.0   $ 2,698.1        100.0
  

 

 

    

 

 

   

 

 

    

 

 

 

The following table summarizes the revenues generated by each of our segments for the most recent three years:

 

     For the Years Ended December 31,  
($ in millions)    2020     2019     2018  
     Revenue      % of
Revenue
    Revenue      % of
Revenue
    Revenue      % of
Revenue
 

Provider Services

   $ 1,683.8        30.2   $ 1,286.6        28.4   $ —          0.0

Pharmacy Solutions

     3,635.9        65.1     3,022.3        66.8     2,536.1        100.0

Other

     260.7        4.7     216.3        4.8     —          0.0
  

 

 

    

 

 

   

 

 

    

 

 

   

 

 

    

 

 

 

Total revenues

   $ 5,580.4        100.0   $ 4,525.2        100.0   $ 2,536.1        100.0
  

 

 

    

 

 

   

 

 

    

 

 

   

 

 

    

 

 

 

Home and Community Health Provider Services

In our Home and Community Health Provider Services segment, we provide a variety of impactful and valuable services to address chronic and complex patient conditions and help manage the whole-person health of our client and patients in their homes and communities. These services consist of both clinical and supportive care to over 30,000 Senior and Specialty populations today, with census for home health and hospices services having grown approximately 81.6% over the past year, and include the following:

Home Health Care

Our Home Health services provide patient-centric, highly skilled and compassionate clinical care primarily to Senior patients recovering from surgery or illness or living with chronic diseases. We serve an average daily census of approximately 9,000 across nine states through our over 1,600 home health skilled nurses and therapists. Our Home Health services include clinical care across a myriad of patient conditions and medication regimens, as well as innovative care management clinical programs that utilize care transitions, primary care, and physician specialist and hospital integration to coordinate health services and drive outcomes.

Our Hospice services provide physical, emotional and spiritual comfort and support primarily for Senior patients with terminal illnesses and their families. We serve an average daily census of over 4,000 patients across 15 states through our 1,500 hospice and palliative caregivers. Our hospice services span palliative nursing care, routine care, respite case, continuous care, social work, spiritual counseling, homemaker services, bereavement counseling, and other support including medical care, pain management and symptom alleviation. Our interdisciplinary hospice teams tailor unique and individualized plans for patients and their families based on a comprehensive understanding of their needs.

Our Personal Care services include supportive care and activities of daily living support that address social determinants of health, including dietary and nutrition management, fall risk management, transportation,

 

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cognitive and social engagement, skills building, companionship, and bathing and grooming, as well as professional nursing, medication support, Alzheimer’s/dementia care and other specialized chronic patient condition programs, respite care, other in-home programs, and geriatric care management. We serve over 18,000 patients monthly across 23 states through our network of 13,400 caregivers. Our services include short-term, transitional and long-term care that allows individuals to continue to live independently with improved safety and outcomes in their homes and communities.

Long-Term Specialty Care

Our Long-Term Specialty Care services provide both patient-centric clinical care and supportive care to Seniors, Behavioral, ABA, and NeuroRehab clients and patients living with age-related acute or chronic conditions, living with life-long indications (including I/DD and autism) or recovering from a catastrophic neuro event (ABI/TBI or stroke) requiring intensive therapy, respectively. These short, medium and long-term home and community-based services support individuals of all ages who need various forms of expert clinical care and therapy in addition to assistance with daily living due to serious medical issues they may have.

Our Rehab Therapy services provide specialized, highly-skilled and custom-designed rehabilitation services, including physical, speech and occupational therapy and ABA, for patients of all ages with a range of injuries and conditions, including brain and spinal cord injuries, stroke, pediatric neuro conditions and autism. We serve a daily average of over 4,800 patients both in their homes and in 30 clinics across 19 states through our network of 2,000 clinicians. Our custom-designed therapies span the continuum of care, including outpatient, in-home, transitional care, and longer-term residential.

In Community Living services, we serve over 11,000 patients across 27 states and delivered over 100 million hours of care in 2020 to clients with I/DD, autism and other cognitive and behavioral disorders. We offer a variety of programs, including group homes, supported living, behavioral therapy, short-term or medium-term transitional care, family living (host homes), vocational training, and case management.

As part of our goal to more fully engage the entire community of patients and provide the best choice of care, we also offer a variety of other innovative services including family and youth services and workforce development.

Pharmacy Solutions

We provide pharmacy services across many care settings, often in coordination with our Provider Services, and filled over 30 million prescriptions in 2020. We operate some of the largest pharmacy businesses in the United States, with services that include Senior Living Pharmacy, Behavioral Pharmacy, Hospice Pharmacy, In-Home Pharmacy, Home Infusion, and Specialty Pharmacy delivered to patients in homes and communities, as well as Hospital and Skilled Nursing and Rehabilitation Pharmacy for services delivered to facilities. We operate 178 pharmacies in total across all 50 states, with services to approximately 3,000 locations, more than 25,000 homes, and approximately 275,000 patients through over 5,200 unique payor contracts.

Pharmacy services are a universal need and ubiquitous connection point across medically complex populations and the overlapping patient services we provide across settings. Home and Community-Based Pharmacy and Facility-Based Pharmacy services to complex patients are extremely differentiated compared to retail pharmacy, with dramatically different and more challenging user needs and service requirements. High-need Senior and Specialty patients depend on closely managed daily medication regimens. As a result, medication appropriateness, accuracy and adherence are critical points of emphasis for managing chronic conditions, treating temporary episodes, and promoting the overall long-term health and well-being of patients.

Home and Community-Based Pharmacy

Our home and community-based pharmacy solutions ensure that medications are accessible in a timely manner for patients living in home and community-based residential settings that include senior living facilities

 

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(ALFs and ILFs), patient homes for in-home pharmacy, mostly patient homes for hospice pharmacy, home infusion and Specialty pharmacy, I/DD group homes, and rehab settings. We purchase, repackage and dispense prescription and non-prescription pharmaceuticals in accordance with physician orders and deliver medications throughout the day to individual patients and residents.

Our Senior Living Pharmacy platform is designed to provide a consistent, best in-class experience for multi-state senior living providers accompanied with local concierge support for individual communities and residents in their homes. We do this through centralized intake and order entry that yields a standardized operations model to drive efficiencies and consistency of experience in all markets for the senior living provider.

Our Hospice Pharmacy provides hospice pharmacy and pharmacy benefit management, or PBM, services for people and families primarily in their homes, as well as in some inpatient units and skilled nursing and rehabilitation facilities where hospice patients can also reside. We believe we are one of the largest independent hospice pharmacies in the United States and have a unique local pharmacy model that delivers same-day medications directly to people’s homes from our own controlled pharmacies, for better patient and hospice provider experiences.

Our In-Home Pharmacy program called Continue Care was built for Home Health and Personal Care patients, for patient discharges to home from skilled nursing and rehabilitation facilities or hospitals, or for partnering with payors with a focus on any high-risk patient (member) who is living in their home with chronic conditions and an intensive polypharmacy medication need and regimen (typically eight to 12 or more medications). Polypharmacy is now widely acknowledged and appreciated as the number one marker for the highest risk patients. We have developed our Continue Care program over the past year to uniquely and effectively serve these patients in their homes through both medication therapy and risk management and ongoing care support.

We believe our Behavioral Pharmacy (including serving I/DD group homes) platform is one of the largest I/DD specialty pharmacy providers in the United States, designed purposefully for behavioral populations and their specific needs. In this business we provide customized medication management to ensure regulatory compliance through specialized packaging, calendar cycle fill aids, customized labelling with bar codes and medication pass times to ensure adherence and the right dose at the right time, integration with 42 eMAR/EHR products to ensure medication administration documentation, and flexible delivery schedules tailored to client and agency schedules and activities.

Our Home Infusion business provides specialty infusion services in the home focused on pharmaceutical therapies that require expert administration, offering high-touch clinical services to patients. Infusion therapy services are a specialty form of pharmaceuticals that involve the intravenous administration of medications that treat a wide range of acute and chronic health conditions – infections, auto-immune illnesses, cancer pain, multiple sclerosis, hemophilia, and nutritional deficiencies.

Our Specialty Pharmacy business provides dispensing of specialty drugs, care management and other related services to patients, oncology practices, and hospitals. As the leading independent specialty oncology pharmacy in the United States, our services encompass clinical coordination and review, nursing support and patient education, compliance with appropriate oncology protocols, patient assistance with insurance access and outside funding, and timely delivery of medication.

Facility-Based Pharmacy

We make sure critical medications and therapies are accessible in a timely and optimized manner for patients in skilled nursing and rehabilitation facilities and hospitals, in the process providing value well beyond medication delivery through proprietary operational, clinical, cost, regulatory, and educational support programs for our customers. We purchase, repackage, dispense, and deliver prescription and non-prescription pharmaceuticals in accordance with

 

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physician orders, typically to customer locations within a radius of 100 miles or less of our pharmacy locations at least once each day. We provide 24-hour, seven-day per week on-call pharmacist services for emergency dispensing and/or consultation with the facility’s staff or the resident’s attending physician.

Locations of Operations

We are headquartered in Louisville, Kentucky with operations in all 50 states, Puerto Rico and Canada. We deliver a higher proportion of services in select regions with favorable demographics and regulatory environments.

We serve patients across approximately 7,000 offices, customer locations and group homes, as well as serving approximately 125,000 patients in their own homes, with co-location of our provider and pharmacy services in approximately 75% of our states.

Payor Mix

We are characterized by payor diversification across our platform. Our payors are principally federal, state and local governmental agencies, commercial insurance, private, and other payors. No payor represents more than 35% of our revenue in the aggregate in 2020 or for the six months ended June 30, 2021. Additionally, our Medicaid payors can be further broken down across 50 states with our top 10 Medicaid states representing 19% of total Company revenue. Our payor mix has become increasingly more diversified since 2018 primarily due to organic growth and acquisitions throughout our portfolio. The federal, state and local programs under which we operate are subject to legislative and budgetary changes that can influence reimbursement rates.

 

     For the Six Months Ended June 30,  
($ in millions)    2021     2020  
     Revenue      % of
Revenue
    Revenue      % of
Revenue
 

Medicare D

   $ 1,061.9        33.6   $ 918.7        34.1

Medicaid

     780.5        24.8     739.4        27.4

Commercial Insurance

     578.7        18.3     469.9        17.4

Medicare A

     364.2        11.5     240.0        8.9

Private & Other

     193.1        6.1     195.5        7.2

Department of Labor

     168.1        5.3     123.6        4.6

Medicare B

     13.9        0.4     11.0        0.4
  

 

 

    

 

 

   

 

 

    

 

 

 
   $ 3,160.4        100.0   $ 2,698.1        100.0
  

 

 

    

 

 

   

 

 

    

 

 

 

 

     For the Years Ended December 31,  
($ in millions)    2020     2019     2018  
     Revenue      % of
Revenue
    Revenue      % of
Revenue
    Revenue      % of
Revenue
 

Medicare D

   $ 1,903.7        34.1   $ 1,590.5        35.1   $ 1,357.7        53.6

Medicaid

     1,512.5        27.1     1,172.7        25.9     111.2        4.4

Commercial Insurance

     999.4        17.9     816.8        18.1     517.9        20.4

Medicare A

     494.3        8.9     412.8        9.1     444.2        17.5

Private & Other

     385.4        6.9     299.5        6.6     105.1        4.1

Department of Labor

     260.8        4.7     216.3        4.8     —          0.0

Medicare B

     24.3        0.4     16.6        0.4     —          0.0
  

 

 

    

 

 

   

 

 

    

 

 

   

 

 

    

 

 

 
   $ 5,580.4        100.0   $ 4,525.2        100.0   $ 2,536.1        100.0
  

 

 

    

 

 

   

 

 

    

 

 

   

 

 

    

 

 

 

We provide our services across all 50 states, Puerto Rico and Canada, with our top 10 states of operations comprising 57% of total Company revenue.

 

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Trends and Other Factors Affecting Business (Recent Developments)

Continued Growth of our Home and Community Health Provider Services Patient Population

We focus on delivering high-touch and coordinated services to medically-complex Senior and Specialty patients in the home and community-based settings in which they live. As the baby boomer population ages, Seniors, who comprise a significant majority of our patients, will represent a higher percentage of the overall population. The U.S. Census Bureau projects that the U.S. population aged 65 and over will grow substantially from 15.2% of the population in 2016 to 20.6% of the population by 2030, and the population size of people over age 85 is expected to double by 2036. We believe patients will increasingly seek treatment and referral sources and payors will increasingly support treatment in homes more often than in higher cost, less convenient, higher acuity settings. Home health care can reduce 365-day post-discharge costs by more than $6,000 per patient, and as healthcare spending rises, home health care can improve the continuity of care while reducing overall costs. In addition, advancements in medical technology have allowed providers to expand access points and the breadth of services available for delivery in the home.

The vast majority of patients we serve in our provider businesses are served in the home, and we have purposefully continued to expand our service offering and footprint to serve patients in the home. In addition, we have meaningfully expanded our footprint in Home Health and Hospice, building on Personal Care, to better serve Seniors and Specialty patients in the home. For example, our total average daily census for our Home Health Care was 31,152 and 26,428 in June 2021 and 2020, respectively, with census for home health and hospice services growing at 18% year over year. Our multiple and complementary service lines addressing these patient populations will increasingly provide care coordination opportunities and cross-referrals with opportunities to provide our holistic care services to patients across health settings and stages.

Continued Growth of our Home and Community-Based Pharmacy Solutions Businesses

We focus on providing accessible medications in a timely manner to our patients receiving pharmacy solutions in alternative site home and community-based settings. Our Senior Living, Hospice, In-Home, Behavioral, Home Infusion, and Specialty pharmacy businesses serve patients in their place of residence and homes. Our high-need Senior and Specialty patients depend on closely managed daily medication regimens that are supported by pharmacist and nurse consultants and accessible in a timely manner. According to industry reports, pharmacy solutions tailored for the home environment, such as home infusion services, will continue to grow faster than the overall pharmacy market. Each of the end markets to these home and community-based pharmacy services are growing at attractive rates, and lack of appropriate pharmacy medication management and non-adherence among complex and polypharmacy patients in homes are significant contributor to ER visits, hospitalizations and increased costs.

We have continued to expand our pharmacy capabilities to serve this need. Overall in our home and community-based pharmacy we have grown our census of patients served and prescriptions by 41% and 49%, respectively, over the past year. Our service lines in this pharmacy segment are one of the largest independent pharmacy providers or a leading pharmacy provider in their respective market, and we expect to continue to increase our share across these pharmacy markets. From 2018 to 2020 the unique number of exclusive or limited distribution drugs we dispense has increased by 55%, and the annual revenue impact has increased by nearly 125%, as a result of our leading customer service and pharmaceutical drug manufacturer relationships.

Our Ability to Build De Novo Locations

We have a proven ability to expand our presence by opening new locations – across both of our operating segments in Provider Services and Pharmacy Solutions – across multiple geographies and generating consistent ramp-up performance at the site level. We believe our platform can continue to scale nationally, adding density to key markets as a lever to facilitate further growth. The Company’s scale and platform of complementary segments and service lines provides us with access to more de novo opportunities to consider and prioritize.

 

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Since January 1, 2018, we have opened 75 de novo offices (branches/agencies) and clinics in new locations in 31 states across our home health, hospice, rehab (both home & community and outpatient), pediatric autism, personal care, community living (I/DD), home infusion, and specialty pharmacy businesses (including openings by Abode and OPPC prior to our acquisitions). Since beginning our de novo program in late 2018, we have accelerated the pace of our de novo openings, having opened eight in 2018, 22 in 2019, 30 in 2020 and 15 in the first six months of 2021. We typically identify and open new locations within proximity of an existing location as we expand in markets, regions and states. Our support resources internally in real estate, purchasing, IT, credentialing, payor contracting, HR, and sales and marketing, along with our project management office, help to support and manage de novos from start to opening. We expect to continue to selectively and strategically expand our footprint within the United States and extend our service offerings to our patients, and we believe de novo investments are a meaningful organic growth driver for the Company.

Our Ability to Facilitate Cross-Referrals

Our operating model is purpose-built to increasingly navigate patients across our various service offerings, leading to improved patient, family, physician, referral source, and payor experiences, better outcomes, and cross-referral revenue opportunities as patients receive multiple required services and progress through their continuum of care. Our performance is driven partly on our appeal with our patients to provide these cross-referrals – either in the same setting at the same time or across settings and stages of health – within our collection of provider services and pharmacy solutions.

We provide multiple provider and pharmacy services to approximately 18,000 patients today, and we believe that there are over 550,000 additional opportunities to deliver our services to our current patient and customer base through care coordination and our expanding geographic and service footprint. For example, we have approximately 94% pharmacy penetration across our Behavioral (I/DD) provider business, which generates an incremental $69 million of revenue annually for the Company, and hospice patients on the provider side receive their medications from us.

Cross-referral opportunities exist not only between our two provider and pharmacy segments, but also within the provider service lines and within the pharmacy service lines. Within the provider segment, patients often transition from home health to hospice and can receive supportive are services concurrent with home health and hospice. Within the pharmacy segment, our Continue Care program is also aimed at providing continuous medication risk and therapy management longitudinally post discharge from hospitals and skilled nursing customers.

Culture of Quality and Compliance and Consistent Operations Execution

Quality and compliance are an ongoing focus at the Company and a key part of our culture, and quality results underpin referral source relationships and volume. We invest over $200 million annually in people, training, auditing, signature programs, accreditations, advocacy, and technologies to support quality, compliance and safety, as part of our “Quality First” framework. We have demonstrated high marks for service levels, satisfaction scores, and quality metrics that are most often at industry leading levels. We receive 4.2 and 4.3 patient/family satisfaction scores (on a 5-point scale) in our Seniors Personal Care and Behavioral (I/DD) services. In our Pharmacy Solutions segment, we have over 99.99% order accuracy, 99.77% order completeness and 98.59% on-time delivery serving long-term care patients in senior living and skilled nursing, our Home Infusion services have received a 95.4% patient satisfaction score, with 99.9% dispensing accuracy, and 95.9% therapy completion, and our Specialty pharmacy has a 3.6 day average turnaround time on referrals, a 96.6% medication possession ratio, and a 90.1 “world class” NPS among patients, all of these being reasons why we have been awarded 102 exclusive or limited distribution oncology drugs by pharma manufacturers.

Operational excellence is also an ongoing focus at the Company, including how we collect and share key metrics, hold operational reviews, and implement continuous improvement initiatives across the organization.

 

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Led by a dedicated PMO team who shepherds and helps to monitor and manage key initiatives, we have realized approximately $35 million of savings in efficiency efforts. We have continued to make investments in automation, data and systems to support enhanced workflows, further scale and future growth across service lines, whether mobile EMRs and ERPs.

Stable Reimbursement Environment Across our Portfolio of Businesses

Our revenue is dependent upon our contracts and relationships with payors for our “must-serve” patient populations. We partner with a large and diverse set of payor groups nationally and in each of our markets to form provider networks and to lower the overall cost of care. We structure our payor contracts to help both providers and payors achieve their objectives in a mutually aligned manner. Maintaining, supporting and both deepening and increasing the number of these contracts and relationships, particularly as we continue to grow market share and enter new markets, is important for our long-term success.

We have observed relatively stable reimbursement rates from government and commercial payors in both our Home and Community Health Provider Services and Pharmacy Solutions businesses over a number of years, particularly for services provided to high-need, medically-complex populations. Due to the medical necessity of our services, which are lower cost than healthcare services provided in other settings and reduce ER, hospital and institutional utilization, we have a history of favorable reimbursement stability that delivered low-to-mid single digit rate increases across our lines of business over the past 10 years.

Aligning to Value-Based Care Reimbursement Models with Innovative Solutions

Our scale, depth and platform of diverse yet related services that all complex patients require position us at the forefront with government and commercial payors who are increasingly seeking ways to fund value-based reimbursement models. Such models are becoming more prevalent, and according to recent studies, 60% of U.S. healthcare payments made to providers in 2018 were linked to quality metrics. Our high-quality services that are delivered in patient and family-preferred settings at lower comparable costs are well-positioned for the long-term, as we continue to add wraparound care management capabilities and offerings to our core services. We believe our ability to enable more patients to move from the acute care setting to the home (and/or community clinics) represents a critical part of this industry transition effort, as we have demonstrated improved patient outcomes to payors while driving incremental revenue growth. We have a uniquely and comparatively large number of payor contracts across the organization today, which provide for relationships and opportunities for future partnerships.

Factors Affecting Results of Operations and Comparability

Acquisitions

In addition to organic growth, we have grown through acquisitions that have deepened and expanded our presence in current markets or facilitated entry into attractive adjacent markets.

During each of the years ended December 31, 2018, 2019 and 2020, we completed 12 acquisitions, excluding the 2019 BHS Acquisition, within the Provider Services and Pharmacy Solutions segments. Aggregate consideration, net of cash acquired, for these acquisitions was approximately $130.0 million, $187.5 million and $414.7 million, respectively. The 2018 acquisition totals include acquisitions completed by Provider Services prior to the BHS Acquisition. Select highlights of these acquisitions are as follows:

 

   

On March 5, 2019, we completed the BHS Acquisition for approximately $1,350.6 million, net of cash acquired. With the purchase of BrightSpring Health Holdings Corp. and its subsidiaries, we expanded our services to include all of the Provider Services segment along with Pharmacy Solutions expansion of reach to the I/DD population serviced within the Provider Services segment. This acquisition was foundational to strategically provide the complementary and diversified platform of health services that

 

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we offer today, all to the same Senior and Specialty populations across the Provider Services and Pharmacy Solutions segments. We funded this acquisition through debt, equity investment and available cash. We believe that the BHS Acquisition affects the comparability of results across all periods as the results of operations of BrightSpring Health Holdings Corp. and its subsidiaries are included from the date of the acquisition. We describe the nature of these impacts below in “—Results of Operations.”

 

   

On May 24, 2019, we completed the acquisition of ProPac Payless Pharmacy, or ProPac, for approximately $136.2 million. We funded this acquisition through the delayed draw term loan portion of our First Lien Facilities and available cash. With the purchase of ProPac, we expanded our Pharmacy Solutions operations primarily in the Pacific Northwest states and further expanded into the attractive senior living pharmacy market with leading customers. The addition of ProPac supported our strategy of utilizing our scale and operating discipline to drive cost synergies while expanding our reach in attractive pharmacy markets.

 

   

On September 30, 2020, we completed the acquisition of OPPC for approximately $190.0 million. We funded the acquisition primarily through incremental borrowing on our Revolving Credit Facility and available cash. With the purchase of OPPC, we expanded our pharmacy offerings in the attractive Hospice Pharmacy services market with value added to the OPPC platform through accelerating de novo hospice pharmacies in new target markets, leveraging our existing national pharmacy network to locally fulfill hospice drug prescriptions directly to patient homes in more markets, enhancing sales through our hospice provider relationships, and driving purchasing and cost savings in further leveraging our scale. We are also rolling out these hospice pharmacy services internally to hospice patients that we serve in our Provider Services segment.

 

   

On April 15, 2021, we completed the acquisition of Abode for approximately $750.0 million, net of an acquired Medicare Advanced payment liability of $25.0 million. We funded the acquisition through the incurrence of incremental term loans under our First Lien Facilities and available cash. With the purchase of Abode, we expanded our growing home health and hospice offerings with a leading and high-quality provider in 12 new states that complement our existing home health and hospice states, leveraging operating infrastructure that had previously been assembled at BrightSpring, further strengthening our clinical service offerings, driving hospice pharmacy revenue synergies (and home health pharmacy revenue synergies in the future), and better positioning us to acquire “tuck-in” home health and hospice companies in the future.

Impact of COVID-19 and CARES Act

On January 31, 2020, the Secretary of HHS declared a national public health emergency due to a novel coronavirus. In March 2020, the World Health Organization declared the outbreak of COVID-19, a disease caused by this novel coronavirus, a pandemic. This disease continues to spread throughout the United States and other parts of the world. The COVID-19 outbreak has adversely impacted economic activity and conditions worldwide, including workforces, liquidity, capital markets, consumer behavior, supply chains and macroeconomic conditions. After the declaration of a national emergency in the United States on March 13, 2020, in compliance with stay-at-home and physical distancing orders and other restrictions on movement and economic activity intended to reduce the spread of COVID-19, we altered numerous clinical, operational and business processes. While each of the states deemed healthcare services an essential business, allowing us to continue to deliver healthcare services to our patients, the effects of the pandemic have been wide-reaching. We have invested in equipment, technology and education that allows our workforce to provide continued support to our clinicians and caregivers who continue to care for our patients.

In recognition of the significant threat to the liquidity of financial markets posed by the COVID-19 pandemic, the Federal Reserve and Congress have taken dramatic actions to provide liquidity to businesses and the banking system in the United States. On March 27, 2020, the Coronavirus Aid, Relief, and Economic

 

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Security Act, or CARES Act, a sweeping stimulus bill intended to bolster the U.S. economy, was signed into law. The Paycheck Protection Program and Health Care Enhancement Act, or PPPHCE Act, and the Consolidated Appropriations Act, or CAA, both expansions of the CARES Act, were signed into law on April 24, 2020 and December 27, 2020, respectively. In total, the CARES Act, the PPPHCE Act and the CAA authorize $178.0 billion in funding to be distributed to health care providers through the Provider Relief Fund. This funding is intended to support healthcare providers by reimbursing them for healthcare-related expenses or lost revenues attributable to COVID-19.

We have taken precautions to protect the safety and well-being of our employees and patients by purchasing and delivering significant additional quantities of PPE and other medical supplies to branches, pharmacies and regional offices across the country. We had, and continue to have, success in sourcing our PPE from both traditional and non-traditional suppliers and while we have been fortunate to secure the necessary PPE supplies, we have incurred significantly higher per unit costs for such items from time to time, as compared to pre-pandemic costs.

Our primary COVID-related impacts have been in prescription drug volume with our skilled nursing and rehabilitation facility customers. During 2020, we experienced a script reduction of approximately 2.7 million scripts when compared with our pre-pandemic levels early in January and February 2020. These script volume impacts were due largely to industry declines in skilled nursing and rehabilitation facility occupancy rates. We believe that these COVID related effects had an impact of approximately $134.3 million reduction in revenue in our Pharmacy Solutions segment, when compared to pre-pandemic levels. During the six months ended June 30, 2021, we continued to experience script reductions when compared to our pre-pandemic levels early in January and February 2020, which equated to approximately 1.9 million scripts, and an estimated impact on revenue of approximately $(94.4) million. We took action quickly to reduce costs and mitigate the impact of these COVID-related declines. Additionally, due to the Company’s complementary diversification and mix of services we provide as a whole, we were able to continue to grow, despite the pandemic, and perform well in many of our other provider and pharmacy businesses, which helped to mitigate the impact of COVID-19 overall.

While we believe our patient and script volumes have started to recover throughout 2021, the following factors could potentially alter this outlook and negatively impact our recovery from the pandemic: vaccine distribution, the continued increase or decrease in the number of COVID-19 cases nationwide, any future or prolonged shelter-in-place orders, the return of our patients’ and families’ confidence in skilled nursing and rehabilitation facilities and in allowing our caregivers into their homes, our ability to attract and retain qualified caregivers as a result of COVID-19 concerns and supplemental governmental benefits, cost normalization around PPE, and our ability to readily access referrals from hospitals.

Potential negative impacts of COVID-19 on our results include lower revenue, higher salary and wage expenses due to increased market rate expectations of caregivers, and increased PPE supply costs. The impacts to revenue may consist of lower volumes due to interruption of the operations of our customers and referral sources, patient unwillingness to receive care in a skilled nursing and rehabilitation facility or accept services in their homes, and prolonged school closures and lower reimbursement rates due to any negative impacts to state Medicaid budgets as a result of the pandemic.

We continually review and adjust our operations to adapt to the changing COVID-19 environment. We have remained fully operational and have continued to provide our patients with critical services during the pandemic. COVID-19, and the challenges to communities and sheltering that were associated with it, highlighted how our services are a “lifeline” for patients in their homes, community settings and facilities, and the value of our services has never been more evident than during the past eighteen months through COVID-19. In addition, we plan to continue to execute on our strategic business plans to grow our services both organically and through acquisitions.

 

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CARES Act

The following portions of the CARES Act have impacted us in 2020 and into 2021:

Provider Relief Fund:

Beginning in April 2020, funds were distributed to health care providers who provide or provided diagnosis, testing, or care for individuals with possible or actual cases of COVID-19. The payments received under the Provider Relief Fund, or PRF, are subject to certain terms and conditions. Payments are to be used to prevent, prepare for, and respond to COVID-19. In April 2020, the Company received grants in an aggregate principal amount of $4.0 million, for which it did not apply, from the PRF as part of the automatic general distributions by HHS. The Company returned certain of these funds in 2020, while keeping approximately $3.9 million as we met the criteria to keep the funds based on lost revenues or incremental costs. In October 2020, the Company received grants in an aggregate principal amount of $18.7 million from the PRF, for which we applied. The Company did not recognize any income related to these Provider Relief Funds in 2020. During April 2021, the Company received grants in an aggregate principal amount of $19.3 million from the PRF, for which we applied. We expect to use certain of these funds for healthcare related expenses attributable to COVID-19 as well as any lost revenues attributable to COVID-19 that were unreimbursed by other sources through June 30, 2022, in accordance with the current guidance issued by HHS. We will return any unused funds following the statutory use period, currently set for varying time periods through late 2022. We are required to properly and fully document the use of such funds in reports to HHS. The Company’s ability to utilize and retain some or all of such funds will depend on the magnitude, timing, and nature of the impact of the COVID-19 pandemic. As of December 31, 2020, we had received $22.6 million in PRF payments. As of June 30, 2021, we had received a total of $41.9 million in cumulative PRF payments. For the year ended December 31, 2020 and for the six months ended June 30, 2021, we had recognized no amounts related to these funds in our consolidated statements of income. The unrecognized amount of $41.9 million is recorded in our accrued expenses in our consolidated balance sheet at June 30, 2021.

In order to receive and use PRF funds, the Company has certified to various terms and conditions, as required by the HHS, including but not limited to: (1) it provides or provided after January 31, 2020 diagnosis, testing or care for individuals with possible or actual cases of COVID-19, (2) that the PRF funds will only be used to prevent, prepare for and respond to COVID-19, (3) such PRF funds shall reimburse the Company only for health care related expenses or lost revenues that are attributable to COVID-19, (4) the Company will not use the PRF funds to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse and (5) the Company will submit reports as HHS determines are needed to ensure compliance with conditions that are imposed on PRF funds.

The rules and regulations associated with the implementation of the CARES Act, including the terms and conditions of the PRF, have not been finalized and remain subject to publication and change. HHS has issued interim and informal guidance in the form of “Fact Sheets” and “FAQs” to address questions regarding PRF funds usage for various financial structures and arrangements, vaccine distribution and administration, and other specific questions health care providers have submitted to HHS for clarification. The final rules and regulations may be materially different from our current understanding. Such changes in the final rules and regulations may materially affect our ability to utilize and retain the PRF payments and may change our accounting for the use of such funds. The Company believes that it is in compliance with all applicable terms and conditions, regulations and interim guidance regarding the receipt and usage of PRF funds.

Deferred payment of the employer portion of social security tax:

We were permitted to defer payments of the employer portion of social security tax for 2020, which will be payable in 50% increments, with the first due by December 31, 2021 and the second 50% due by December 31, 2022. This deferral increased our 2020 cash flow from operations by approximately $66.7 million. As of

 

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December 31, 2020 and June 30, 2021, we had deferred payment of approximately $66.7 million and $67.0 million, respectively, of social security tax in total, and this amount is reflected in current portion of deferred payroll tax liabilities and deferred payroll taxes in our consolidated balance sheet. The Company intends to pay its deferred portion of employer social security payroll taxes, as required by law, with $33.5 million in the fourth quarter of 2021 and the remaining in the fourth quarter of 2022.

Components of Our Consolidated Statement of Income (Loss)

Revenues. The Company recognizes the amount of revenue to which it expects to be entitled for the transfer of promised goods or services to customers. For transactions involving the transfer of goods, revenues are primarily recognized when the customer obtains control of the products sold, which is generally upon shipment or delivery, depending on the delivery terms specified in the sales agreement. For transactions exclusively involving provision of services, revenues are recognized over time based on an appropriate measure of progress.

Cost of Services and Cost of Goods. We classify expenses directly related to providing services and goods, including depreciation and amortization, as cost of services and cost of goods. Direct costs and expenses principally include cost of drugs, net of rebates, salaries and benefits for direct care and service professionals, contracted labor costs, insurance costs, transportation costs for clients requiring services, certain client expenses such as food, supplies and medicine, residential occupancy expenses, which primarily comprise rent and utilities, and other miscellaneous direct service or goods related expenses.

Selling, General and Administrative Expenses. Selling, general and administrative expenses consist of expenses incurred in support of our operations and administrative functions and include labor costs, such as salaries, bonuses, commissions, benefits and travel-related expenses, distribution expenses, facilities rental costs, third-party revenue cycle management costs and corporate support costs including finance, information technology, legal, human resources, procurement and other administrative costs.

Interest Expense, net. Interest expense includes the debt service costs associated with our various debt instruments, including our First Lien Facilities and Second Lien Facility. Interest expense also includes the amortization of deferred financing fees, which are amortized over the term of the respective credit agreement.

Income Tax Expense (Benefit). Our provision for income taxes is based on permanent book/tax differences and statutory tax rates in the various jurisdictions in which we operate. Significant estimates and judgments are required in determining the provision for income taxes.

 

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Results of Operations

Consolidated Results of Operations

Six Months Ended June 30, 2021 Compared to Six Months Ended June 30, 2020

The following table sets forth, for the periods indicated, our consolidated results of operations from our unaudited statements of income:

 

     For the Six Months Ended June 30,     Change  
($ in thousands)    2021     2020               
     Amount      % Revenues     Amount     % Revenues     Amount      %  

Revenues:

              

Products

   $ 2,082,765        65.9   $ 1,748,491       64.8   $ 334,274        19.1

Services

     1,077,662        34.1     949,643       35.2     128,019        13.5
  

 

 

    

 

 

   

 

 

   

 

 

   

 

 

    

 

 

 

Total revenues

     3,160,427        100.0     2,698,134       100.0     462,293        17.1
  

 

 

    

 

 

   

 

 

   

 

 

   

 

 

    

 

 

 

Cost of goods

     1,778,590        56.3     1,485,814       55.0     292,776        19.7

Cost of services

     790,893        25.0     700,875       26.0     90,018        12.8
  

 

 

    

 

 

   

 

 

   

 

 

   

 

 

    

 

 

 

Gross profit

     590,944        18.7     511,445       19.0     79,499        15.5

Selling, general and administrative expenses

     487,681        15.4     435,548       16.1     52,133        12.0
  

 

 

    

 

 

   

 

 

   

 

 

   

 

 

    

 

 

 

Operating income

     103,263        3.3     75,897       2.8     27,366        36.1

Interest expense, net

     78,656        2.5     72,359       2.7     6,297        8.7
  

 

 

    

 

 

   

 

 

   

 

 

   

 

 

    

 

 

 

Income before income taxes

     24,607        0.8     3,538       0.1     21,069        595.5

Income tax expense (benefit)

     6,114        0.2     (3,331     (0.1 )%      9,445        (283.5 )% 
  

 

 

    

 

 

   

 

 

   

 

 

   

 

 

    

 

 

 

Net income

     18,493        0.6     6,869       0.3     11,624        169.2

Net income attributable to noncontrolling interests

     463        0.0     123       0.0     340        276.4
  

 

 

    

 

 

   

 

 

   

 

 

   

 

 

    

 

 

 

Net income attributable to BrightSpring Health Services, Inc. and subsidiaries

   $ 18,030        0.6   $ 6,746       0.3   $ 11,284        167.3
  

 

 

    

 

 

   

 

 

   

 

 

   

 

 

    

 

 

 

Revenues

Revenue was $3,160.4 million for the six months ended June 30, 2021, as compared with $2,698.1 million for the six months ended June 30, 2020, an increase of $462.3 million or 17.1%. The increase primarily resulted from the following segment activity and factors:

 

   

an $83.5 million, or 3.1% growth on the six months ended June 30, 2020 consolidated revenue, increase in Provider Services revenue. See additional discussion in “—Segment Results of Operations” below; and

 

   

a $334.3 million, or 12.4% growth on the six months ended June 30, 2020 consolidated revenue, increase in Pharmacy Solutions revenue. See additional discussion in “—Segment Results of Operations” below.

 

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Cost of Services and Cost of Goods

Cost of services and cost of goods were $790.9 million and $1,778.6 million, respectively, for the six months ended June 30, 2021, as compared with $700.9 million and $1,485.8 million, respectively, for the six months ended June 30, 2020, an aggregate increase of $382.8 million or 17.5%. The increase primarily resulted from the following segment activity and factors:

 

   

a $51.0 million, or 2.3% growth on the six months ended June 30, 2020 consolidated cost of services and cost of goods, increase in Provider Services cost of services and cost of goods. See additional discussion in “—Segment Results of Operations” below; and

 

   

a $292.8 million, or 13.4% growth on the six months ended June 30, 2020 consolidated cost of services and cost of goods, increase in Pharmacy Solutions cost of services and cost of goods. See additional discussion in “—Segment Results of Operations” below.

Selling, General and Administrative Expenses

Selling, general and administrative expenses were $487.7 million for the six months ended June 30, 2021, as compared with $435.5 million for the six months ended June 30, 2020, an increase of $52.1 million or 12.0%. The increase primarily resulted from the following segment activity and factors:

 

   

a $27.2 million, or 6.2% growth on the six months ended June 30, 2020 consolidated selling, general and administrative expenses, increase in Provider Services selling, general and administrative expenses. See additional discussion in “—Segment Results of Operations” below; and

 

   

a $17.5 million, or 4.0% growth on the six months ended June 30, 2020 consolidated selling, general and administrative expenses, increase in Pharmacy Solutions selling, general and administrative expenses. See additional discussion in “—Segment Results of Operations” below.

Interest Expense

Interest expense was $78.7 million for the six months ended June 30, 2021, as compared with $72.4 million for the six months ended June 30, 2020, an increase of $6.3 million or 8.7%. The increase primarily resulted from the increase in outstanding debt as compared to the prior period.

Income Tax Expense (benefit)

Income tax expense was $6.1 million for the six months ended June 30, 2021, as compared with a benefit in the six months ended June 30, 2020 of $(3.3) million, an increase of $9.4 million. The benefit is the result of certain provisions in the CARES Act. The increase was primarily the result of an increase in segment EBITDA growth. See additional discussion on segment EBITDA in “—Segment Results of Operations” below.

Years Ended December 31, 2020, 2019 and 2018

The following table sets forth, for the periods indicated, our consolidated results of operations:

 

($ in thousands)   For the Years Ended December 31,      ’20 v ’19 Change     ’19 v ’18 Change  
    2020      2019(1)      2018(1)      Amount(1)      %(1)     Amount(1)      %(1)  

Revenues:

                  

Products

  $ 3,635,898      $ 3,022,334      $ 2,536,053      $ 613,564        20.3   $ 486,281        19.2

Services

    1,944,474        1,502,875        —          441,599        29.4     1,502,875        n.m.  
 

 

 

    

 

 

    

 

 

    

 

 

    

 

 

   

 

 

    

 

 

 

Total revenues

    5,580,372        4,525,209        2,536,053        1,055,163        23.3     1,989,156        78.4
 

 

 

    

 

 

    

 

 

    

 

 

    

 

 

   

 

 

    

 

 

 

Cost of goods

    3,099,365        2,564,669        2,160,144        534,696        20.8     404,525        18.7

Cost of services

    1,432,269        1,126,634        —          305,635        27.1     1,126,634        n.m.  
 

 

 

    

 

 

    

 

 

    

 

 

    

 

 

   

 

 

    

 

 

 

Gross profit

    1,048,738        833,906        375,909        214,832        25.8     457,997        121.8

 

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($ in thousands)   For the Years Ended December 31,      ’20 v ’19 Change     ’19 v ’18 Change  
    2020      2019(1)      2018(1)      Amount(1)      %(1)     Amount(1)      %(1)  

Selling, general and administrative expenses

    883,547        770,592        312,128        112,955        14.7     458,464        146.9 %. 
 

 

 

    

 

 

    

 

 

    

 

 

    

 

 

   

 

 

    

 

 

 

Operating income

    165,191        63,314        63,781        101,877        160.9     (467)        (0.7 )% 

Interest expense, net

    138,953        166,893        74,613        (27,940)        (16.7 )%      92,280        123.7
 

 

 

    

 

 

    

 

 

    

 

 

    

 

 

   

 

 

    

 

 

 

Income (loss) before income taxes

    26,238        (103,579)        (10,832)        129,817        n.m.       (92,747)        n.m.  

Income tax expense (benefit)

    5,087        (32,491)        (3,211)        37,578        (115.7)     (29,280)        n.m.  
 

 

 

    

 

 

    

 

 

    

 

 

    

 

 

   

 

 

    

 

 

 

Net income (loss)

    21,151        (71,088)        (7,621)        92,239        n.m.       (63,467)        n.m.  
                  

Net income attributable to noncontrolling interests

    341        1,293        —          (952)        (73.6)     1,293        n.m.  
 

 

 

    

 

 

    

 

 

    

 

 

    

 

 

   

 

 

    

 

 

 

Net income (loss) attributable to BrightSpring Health Services, Inc. and subsidiaries

  $ 20,810      $ (72,381)      $ (7,621)      $ 93,191        n.m.     $ (64,760)        n.m.  
 

 

 

    

 

 

    

 

 

    

 

 

    

 

 

   

 

 

    

 

 

 

 

(1)

The BHS Acquisition closed on March 5, 2019. Comparability of results for the years ended December 31, 2019 and 2018 are impacted as a result.

Year Ended December 31, 2020 Compared to Year Ended December 31, 2019

BrightSpring, as it exists today, is the product of an acquisition on March 5, 2019 of BrightSpring Health Holdings Corp. and its subsidiaries in the BHS Acquisition. Under GAAP, BrightSpring Health Holdings Corp. and its subsidiaries are consolidated prospectively since the acquisition date of March 5, 2019. As a result, there are an additional 63 days of BrightSpring Health Holdings Corp. and its subsidiaries in our consolidated financial statements in 2020, compared to 2019.

 

($ in thousands)    For the Years Ended December 31,  
     2020      2019     Change  

Revenues:

       

Products

   $ 3,635,898      $ 3,022,334     $ 613,564  

Services

     1,944,474        1,502,875       441,599  
  

 

 

    

 

 

   

 

 

 

Total revenues

     5,580,372        4,525,209       1,055,163  
  

 

 

    

 

 

   

 

 

 

Cost of goods

     3,099,365        2,564,669       534,696  

Cost of services

     1,432,269        1,126,634       305,635  
  

 

 

    

 

 

   

 

 

 

Gross profit

     1,048,738        833,906       214,832  

Selling, general and administrative expenses

     883,547        770,592       112,955  

Net income (loss)

   $ 21,151      $ (71,088   $ 92,239  

Adjusted EBITDA

   $ 412,028      $ 332,573     $ 79,455  

See “—Non-GAAP Financial Measures” below for a reconciliation of Adjusted EBITDA to net income (loss) for each of the periods presented in the table above.

The following discussion of our results of operations should be read in conjunction with the foregoing tables summarizing our consolidated results of operations.

Revenues

Revenue was $5,580.4 million for the year ended December 31, 2020, as compared with $4,525.2 million for the year ended December 31, 2019, an increase of $1,055.2 million or 23.3%. The increase primarily resulted from the following segment activity and factors:

 

   

a $319.6 million, or 7.1% growth on consolidated 2019 revenue, increase as a result of the BHS Acquisition; and

 

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a $735.6 million, or 16.3% growth on consolidated 2019 revenue, increase as a result of growth in our other businesses. See additional discussion in “—Segment Results of Operations” below.

Cost of Services and Cost of Goods

Cost of services and cost of goods were $1,432.3 million and $3,099.4 million, respectively, for the year ended December 31, 2020, as compared with $1,126.6 million and $2,564.7 million, respectively, for the year ended December 31, 2019, an aggregate increase of $840.3 million or 22.8%. The increase primarily resulted from the following segment activity and factors:

 

   

a $242.1 million, or 6.6% growth on consolidated 2019 cost of services and cost of goods, increase as a result of the BHS Acquisition; and

 

   

a $598.2 million, or 16.2% growth on consolidated 2019 cost of services and cost of goods, increase as a result of growth in our other businesses. See additional discussion in “—Segment Results of Operations” below.

Selling, General and Administrative Expenses

Selling, general and administrative expenses were $883.5 million for the year ended December 31, 2020, as compared with $770.6 million for the year ended December 31, 2019, an increase of $113.0 million or 14.7%. The increase primarily resulted from the following segment activity and factors:

 

   

a $56.3 million, or 7.3% growth on consolidated 2019 selling, general and administrative expenses, increase as a result of the BHS Acquisition;

 

   

a $121.2 million, or 15.7% growth on consolidated 2019 selling, general and administrative expenses, as a result of growth in our other businesses. See additional discussion in “—Segment Results of Operations” below; and

 

   

a $(64.6) million, or (8.4)% change to consolidated 2019 selling, general and administrative expenses, decrease as a result of acquisition-related transaction expenses associated with various acquisitions but primarily associated with the BHS Acquisition in 2019, including a $31.7 million debt extinguishment.

Interest Expense

Interest expense was $139.0 million for the year ended December 31, 2020, as compared with $166.9 million for the year ended December 31, 2019, a decrease of $27.9 million or 16.7%. The decrease primarily resulted from the favorable repricing and LIBOR rates on the outstanding First Lien Facilities in early Q1 of 2020 and resulted in decreased interest expense year over year of $27.9 million.

Income Tax Expense (Benefit)

Income tax expense was $5.1 million for the year ended December 31, 2020, as compared with a benefit in the year ended December 31, 2019 of $(32.5) million resulting in an increase of $37.6 million for the year. The increase was primarily the result of the decrease in acquisition-related costs of $64.7 million in 2020 compared to 2019, which were primarily incurred during the BHS Acquisition on March 5, 2019, as well as the increased interest expense during 2019 as compared to 2020 of $27.9 million.

 

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Year Ended December 31, 2019 Compared to Year Ended December 31, 2018

Under GAAP, BrightSpring Health Holdings Corp. and its subsidiaries are consolidated prospectively since the acquisition date of March 5, 2019, resulting in 302 days of BrightSpring Health Holdings Corp. and its subsidiaries in our consolidated financial statements in 2019.

 

($ in thousands)    For the Years Ended December 31,  
     2019     2018     Change  

Revenues:

      

Products

   $ 3,022,334     $ 2,536,053     $ 486,281  

Services

     1,502,875       —         1,502,875  
  

 

 

   

 

 

   

 

 

 

Total revenues

     4,525,209       2,536,053       1,989,156  
  

 

 

   

 

 

   

 

 

 

Cost of goods

     2,564,669       2,160,144       404,525  

Cost of services

     1,126,634       —         1,126,634  
  

 

 

   

 

 

   

 

 

 

Gross profit

     833,906       375,909       457,997  

Selling, general and administrative expenses

     770,592       312,128       458,464  

Net loss

   $ (71,088   $ (7,621   $ (63,467

Adjusted EBITDA

   $ 332,573     $ 163,819     $ 168,754  

See “—Non-GAAP Financial Measures” below for a reconciliation of Adjusted EBITDA to net loss for each of the periods presented in the table above.

The following discussion of our results of operations should be read in conjunction with the foregoing tables summarizing our consolidated results of operations.

Revenues

Revenue was $4,525.2 million for the year ended December 31, 2019, as compared with $2,536.1 million for the year ended December 31, 2018, an increase of $1,989.2 million or 78.4%. The increase primarily resulted from the following segment activity and factors:

 

   

a $1,595.6 million, or 62.9% growth on consolidated 2018 revenue, increase as a result of the BHS Acquisition (including 1.7% estimated growth in the BHS business since the acquisition date); and

 

   

a $393.6 million, or 15.5% growth on consolidated 2018 revenue, increase as a result of growth in our other businesses. See additional discussion in “—Segment Results of Operations” below.

Cost of Services and Cost of Goods

Cost of services and cost of goods were $1,126.6 million and $2,564.7 million, respectively, for the year ended December 31, 2019, as compared with $0.0 million and $2,160.1 million, respectively, for the year ended December 31, 2018, an aggregate increase of $1,531.2 million or 70.9%. The increase primarily resulted from the following segment activity and factors:

 

   

a $1,202.3 million, or 55.7% growth on consolidated 2018 cost of services and cost of goods, increase as a result of the BHS Acquisition; and

 

   

a $328.9 million, or 15.2% growth on consolidated 2018 cost of services and cost of goods, increase as a result of growth in our other businesses. See additional discussion in “—Segment Results of Operations” below.

 

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