A key part of our investment philosophy revolves around whether the cash flows generated by the businesses that we invest in are sustainable. While many factors play into our analysis, ESG considerations are a key component in determining the sustainability of cash flows and indeed, a business.

We recently looked into a new issue to fund the KKR-led buyout of Envision Healthcare, a provider of staffing and other services to the US healthcare industry. For the most part, Envision provides doctors when hospitals choose to outsource their emergency departments. We typically place a great deal of emphasis on the ‘G’ in ESG analysis, Governance. But in this case, the social aspects gave us cause for concern.

Healthcare is a social good. The US healthcare system can, at times, seem to challenge this basic assumption. The system has well-publicised issues with costs and a mind-bogglingly complexity that seems egregious to anyone who hails from a country with a healthcare system like the NHS. Be it rocketing drug prices, or paying for your ambulance journey to the hospital, or even $5,000 ‘discharge’ fees, at least you’re okay if you have health insurance, right?

Possibly not. Health insurers in the US often specify hospitals and services as ‘in-network’ and ‘out-of-network’. If they’re in-network, the insurers will pay a bigger portion of the bill. If not, patients might have to foot the whole bill themselves. So if you have to be rushed to the emergency department, you want to make sure you’re going to an in-network hospital. That way, you get to be “in-network”, treated by a doctor, released and all is well. But then the bill comes. Turns out, you’ve gone to an in-network hospital that outsources its emergency department to Envision Healthcare, and its doctor treats you, and all of a sudden…sorry, you’re out-of-network.

Indeed, the health insurer UnitedHealth is in a very public spat with Envision. UnitedHealth has even dedicated a portion of its website to calling-out Envision Healthcare’s billing practices. They estimate that the average charge for Envision’s doctors is three times higher than what Medicare would be for the same service. There’s also a working paper recently produced by Yale University. This paper suggests that Envision actively ups the number of out-of-network procedures when it takes over an emergency department and that its out-of-network charges are significantly higher than competitors’ out-of-network billing. The New York Times has also published a scathing piece on Envision’s practices that has sparked a US Senate investigation, as well as shareholder lawsuits.

Analysis of the company’s financials demonstrates the outsized profitability of charging individuals directly rather than via insurers. So-called ‘Self-pay’ constitutes just 13% of procedure volume, but contributes towards 46% of revenue. Moreover, the sheer size of these bills means they often aren’t paid in full (or at all), so Envision takes massive provisions for uncollectible charges.

Envision is moving more of its revenues to “in-network”. It argues that insurers are trying to avoid paying providers a reasonable rate and that they are trying to shift costs to the patient. But for us, this business model seems to take advantage of those who either don’t know to, or aren’t able to specify an in-network doctor, at an in-network hospital.

In our view, cash flows that seem to depend on opacity rather than transparency will be inherently less sustainable, and are not what we want in any portfolio.

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