Private Equity Healthcare Bankruptcies are on the Rise

Key Points

• 2023 saw a wave of bankruptcies at private equity-owned companies.
  • At least 17 (21%) of the 80 healthcare companies that filed for bankruptcy in 2023 were owned by private equity firms.
• Another wave of PE-driven healthcare bankruptcies is expected in 2024 – almost all of the most distressed US healthcare companies are owned by private equity firms.
• Private equity’s excessive use of debt and aggressive financial strategies put healthcare companies at risk, and in turn threaten the stability of critical healthcare resources across the country.
• Case studies of bankruptcies by private equity-owned healthcare companies in 2023 include:
  • Envision Healthcare (KKR)
  • Center for Autism and Related Disorders (Blackstone)
  • YesCare/Tehum Care Services/Corizon (Flacks Group, Perigrove Capital)
  • Air Methods (American Securities)

Introduction

2023 was a record year for large healthcare bankruptcies, and healthcare companies owned by private equity firms accounted for some of the largest bankruptcies: KKR’s Envision Healthcare, American Securities’ Air Methods, and American Physician Partners, owned by Brown Brothers Harriman Capital Partners, all made major headlines.

The healthcare default and bankruptcy wave is projected to continue in 2024 as companies are increasingly facing credit rating downgrades and potential defaults – and most of the companies at the highest risk are owned by private equity firms.

The rise in bankruptcies raises questions about how the private equity business model creates risk for the healthcare system. Private equity’s heavy use of debt to fund its healthcare investments is becoming a major liability for its portfolio companies as interest rates have risen and remained elevated and labor costs for many healthcare companies have skyrocketed.[1]

Bankruptcies in healthcare are more than just legal or financial events – they can lead to closures, disruption or cessation of critical healthcare services, and layoffs. Such outcomes have ripple effects on the broader healthcare infrastructure, such as overburdening healthcare providers that need to fill the gaps left by closures. In addition, Medicare, Medicaid, and other government health programs make up a significant component of revenue for many healthcare companies, which means private equity-driven bankruptcies are not just threatening healthcare infrastructure, but in many cases publicly-funded healthcare infrastructure.

Private Equity and Venture Capital Behind Many Healthcare Bankruptcies 

There were an estimated 80 healthcare bankruptcies in 2023, and PESP found that at least 17 of those companies were backed by private equity firms. That amounts to approximately 21% of all healthcare bankruptcies last year. There were also at least 12 bankruptcies by companies with venture capital backing, accounting for another 15% of the year’s total healthcare bankruptcies.

The number of private equity healthcare bankruptcies has increased substantially in recent years. In 2019, there were 8 private equity healthcare bankruptcies, marking a 112.5% increase over the last 5 years.

This is consistent with other recent data on healthcare bankruptcies. According to Gibbins Advisors, there were 79 Chapter 11 bankruptcy filings at healthcare companies with more than $10 million in liabilities in 2023. This was the highest number of healthcare bankruptcies during the last five years. Bankruptcies of large healthcare companies (with liabilities over $100 million) also reached a five-year high, at 28 filings.[2]

Similarly, S&P tracked 81 bankruptcies in the healthcare sector in 2023,[3] including 34 bankruptcies of healthcare companies backed by either private equity or venture capital firms (“currently has a private equity or venture capital firm as its financial parent,” per S&P).[4] That figure combines both private equity and venture capital.[5]

Some private equity firms are repeat offenders when it comes to healthcare bankruptcies and unmanageable debt. For example, private equity firm KKR owned two major healthcare companies that filed for bankruptcy in 2023: physician staffing giant Envision Healthcare (profiled below) and oncology provider GenesisCare.[6] In addition, KKR owns three other companies that are distressed and carry heightened risk for default: Covenant Physician Partners, Global Medical Response, and One Call Corporation.[7]

In another example, H.I.G. Capital’s weight management company Jenny Craig filed for bankruptcy in 2023,[8] its mental health company Community Intervention Services filed for bankruptcy in 2021 after one of its subsidiaries paid a four-million-dollar settlement for alleged Medicaid fraud,[9] and its correctional healthcare company Wellpath Holdings currently has “very high credit risk.”[10]

Table: PE-Backed Healthcare Bankruptcies since 2019

Distressed exchanges
Some private equity firms have managed kick the bankruptcy can down the road through use of distressed exchanges. A distressed exchange is a transaction whereby a company offers creditors assets worth less than their original bonds or loans, enabling the company to avoid or at least defer a bankruptcy. In contrast to bankruptcy filings, these transactions occur out-of-court. However, some analysts still consider distressed exchanges to be defaults.[11]

Several large private equity-owned healthcare companies have recently executed distressed exchanges to stave off bankruptcy. Among them was US Renal Care, the nation’s third largest dialysis provider, which is owned by private equity investors including Bain Capital and Summit Partners. According to Moody’s Investors Service, under private equity ownership US Renal Care had “has had an aggressive financial policy, with very high financial leverage” and pursued an “aggressive expansion strategy which depleted its cash balances.”[12]

Other private equity-owned healthcare companies that have completed distressed exchanges include Elara Caring, a home health, personal care, and hospice care company owned by Blue Wolf Capital Partners and Kelso & Company,[13] and LifeScan Corporation, a medical supplies company owned by Platinum Equity.[14]

More PE-Driven Defaults and Bankruptcies Predicted for 2024

More healthcare defaults are projected for 2024, and private equity will likely be a key driver for many of them.

Moody’s Investors Service rates companies based on their probability of default.  Out of 45 healthcare companies with a probability of default rating of B3 negative and lower, which is considered speculative, as of November 2023, all but three were owned by private equity firms – 93% of the most distressed healthcare companies in North America.[15]

Many of these companies have excessive leverage, often as a result of the aggressive growth strategies employed by their private equity owners. Moody’s notes that “The roll-up strategies implemented by PE firms in these subsectors have left companies with high debt loads, which have limited their ability to adapt to macroeconomic headwinds and changing industry dynamics.”[16]

There has already been at least one large PE-backed bankruptcy in 2024. Cano Health, a value-based primary health care provider for Medicare and Medicare Advantage enrollees, filed for bankruptcy in February 2024.[17] Its private equity minority investor and previous owner, InTandem Capital Partners, loaded it with $655 million in debt before the company went public. Cano had already laid off hundreds of workers in 2023, and its bankruptcy has the potential to impact more jobs and care for thousands of patients.[18]

Table: Most Distressed Healthcare Companies

Source: Moody’s Investor Service

What is Behind the High Rate of Distress?

The rise in healthcare bankruptcies, and bankruptcies by private equity-owned healthcare companies in particular, stems from a few factors.

Private equity firms routinely use much higher levels of debt than other companies. According to Bain & Company, debt levels on leveraged buyouts reached a 15-year high in 2022 of 7.1x earnings (EBITDA).[19] Meanwhile, average debt-to-EBITDA ratios for publicly traded healthcare companies are around 3x.[20]

All but three of the companies on the list of the most distressed healthcare companies have very high or excessive leverage, which Moody’s defines as having debt/EBITDA at above 7 times as very high or 8 or 9 times as excessive. Excessive leverage is often the result of leveraged buyouts and aggressive debt-funded growth strategies.[21]

In addition, private equity firms sometimes take on new debt to their portfolio companies in order to pay themselves and their investors dividends. These deals, known as dividend recapitalizations, often benefit private equity owners at the expense of the companies, their patients, their employees, and the communities they serve. For example, shortly before taking Cano Health public in 2021, InTandem Capital Partners added new debt to Cano’s balance sheet in part to finance a $100 million dividend to shareholders including the private equity firm.[22] Cano filed for bankruptcy this February[23] after laying off 21% of its workforce.[24]

For more on dividend recapitalizations, see our 2020 report: “Dividend Recapitalizations in Healthcare: How Private Equity Raids Critical Health Care Infrastructure for Short Term Profit”

Private equity’s reliance on high debt leaves companies more vulnerable to changing market conditions, including high interest rates and rising labor costs.

Interest rates have risen substantially in recent years; since March 2022, the Federal Reserve has raised its base rate eleven times, from 0.25% to 5.5% in July 2023.[25] Bond credit spreads have also widened which adds to the cost of borrowing for highly leveraged borrowers.[26] This can be particularly challenging for companies owned by private equity firms, whose characteristic reliance on high levels of debt means increased refinancing pressure amid rising rates and widening credit spreads.

In healthcare, this is compounded by a spike in labor costs, driven by staffing shortages that have led to increased utilization of expensive contract labor.[27]

The passage and implementation of the No Surprises Act, legislation aimed to rein in surprise medical billing, has also played a role. Three of the largest companies that filed for bankruptcy last year – Air Methods (American Securities), Envision Healthcare (KKR), and American Physician Partners (Brown Brothers Harriman Capital Partners) – cited negative impacts of the No Surprises Act as a factor in their financial distress.[28]

Bankruptcy Case Studies

Below are selected case studies of the private equity-owned healthcare bankruptcies in 2023.

Envision Healthcare

On May 15, 2023, KKR-owned Envision Healthcare filed for Chapter 11 bankruptcy.[29] Envision is a physician staffing firm with approximately 70,000 employees across the US as of 2022.[30]

KKR first acquired Envision through a $9.9 billion leveraged buyout in 2018, [31] which Reuters reported was one of the largest buyouts since the 2008 global financial crisis.[32] KKR used approximately $7 billion in debt for the acquisition—about 70% of the overall deal.[33] This debt was not taken on by KKR, but rather loaded onto Envision.[34]

Envision’s bankruptcy was the culmination of credit downgrades and distressed debt exchanges beginning in 2020, in which KKR and Envision shielded their most valuable assets from some of their original creditors.[35]

Envision’s business model has historically relied on the inelastic demand of emergency medical care coupled with a strategy of out-of-network billing to charge much higher-than-average rates to patients via surprise bills.[36] This business model was deeply impacted by the passage of the No Surprises Act in December 2020, which banned most forms of surprise billing.[37]

In its May 2023 bankruptcy filing, Envision claimed that the “flawed” implementation of the No Surprises Act had contributed to its need to file for bankruptcy. The company placed blame on insurers, rather the Act itself, writing, “In fact, some payors (including Envision’s single largest payor) have used the No Surprises Act and its implementing regulations as an excuse to avoid payment to medical groups like Envision and affiliated entities.”[38] Pinning the blame on insurers, rather than the No Surprises Act, obscures the fact that Envision spent millions of dollars on a dark money campaign against surprise billing legislation.[39]

As Envision’s financial condition worsened before the bankruptcy filing, it announced layoffs of 167 New York employees in March 2023, 90 Florida employees in April,[40] and another 162 workers in Pennsylvania in May.[41]

Center for Autism and Related Disorders

Center for Autism and Related Disorders (CARD), which was owned by private equity giant Blackstone, filed for Chapter 11 bankruptcy in June 2023.[42]

CARD calls itself “the world’s largest and most experienced autism treatment provider…”[43] At the time of its bankruptcy, CARD reported having 130 centers across 13 states, with approximately 2,500 employees serving over 3,500 patients.[44]

Blackstone’s 2018 buyout of CARD for a reported $600 million was the largest ever buyout in the in the autism services industry.[45] Blackstone’s goal was to grow CARD to up to 4 times its 2018 size.[46] That plan did not come to fruition.

In the months and years leading up to the bankruptcy filing, CARD quietly closed down locations around the country. In the years following Blackstone’s acquisition, CARD closed 50 provider locations.[47] And just since January 2022, CARD has shuttered another 92 locations.[48]

CARD’s closures were hard felt by clients and their families. Many were given less than six weeks to find alternative providers, and wait lists at other providers were up to a year long.[49]

According to bankruptcy filings, CARD attributed its financial woes to a combination of headwinds triggered by the COVID-19 pandemic, wage inflation, a shortage of qualified clinicians, unprofitable payor contracts, and burdensome lease obligations and other corporate overhead costs. [50]

Through the bankruptcy process CARD agreed to sell itself back to its founder, Doreen Granpeesheh, for $25 million. Granpeesheh had retained a minority stake in the company following Blackstone’s acquisition and remained on the board until mid-2022.[51]

According to a Forbes investigation, Granpeesheh left CARD’s board “saying that she disagreed with issues ranging from cuts in training and certification programs, which started in 2020, to how revenue was being spent and bonuses for senior executives.”[52]

Granpeesheh’s concerns about changes at the company post-buyout echo concerns raised by former CARD employees. In a 2023 report by the Center for Economic and Policy Research (“Pocketing Money Meant for Kids: Private Equity in Autism Services”), interviews with former employees reveal that after acquiring CARD Blackstone began making substantial cuts to the company’s training requirements, including shifting away from in-person to online training and cutting the weeks of new hire orientation in half. CARD’s high standards began to deteriorate, and poor working conditions exacerbated staff turnover.[53] Patient-to-clinician ratios rose from 10-12 patients per staff member to up to 25.[54]

Blackstone’s exit and sale to Granpeesheh holds promise for CARD’s ability to recover, though the PE firm’s legacy will likely follow CARD in the coming years. CARD’s bankruptcy, alongside other recent closures by PE-owned autism providers,[55] paint a grim picture of private equity’s future in the autism services industry.

YesCare/Tehum Care Services/Corizon

YesCare (formerly know as Corizon Health) calls itself “the pioneer and foremost provider” of healthcare in U.S. prisons and jails.[56] It filed for bankruptcy in February 2023 through what is known as a “Texas two-step,” dividing itself into two different legal entities in a process through which it has sought to evade upwards of $50 million in liabilities.[57]

YesCare has been owned by private equity firms for at least 16 years. It was owned by private equity firm BPOC from 2007 to 2017.[58] In 2017, BlueMountain Capital Management became the company’s largest shareholder.[59] In June 2020 investment firm Flacks Group bought YesCare to become its sole owner.[60] As of August 2023, the company is owned by private equity investor Perigrove Capital.[61]

As of late 2021, the company had faced more than 1,000 lawsuits alleging substandard care.[62] Dozens of lawsuits filed against it were still proceeding through various state and federal courts shortly before it filed for bankruptcy in February 2023.[63] The bankruptcy paused legal action against the company in multiple states, including claims alleging medical malpractice, wrongful death, and deliberate indifference in violation of the Eight Amendment.[64]

YesCare was known as Corizon Health until May 2022,[65] when its owners took a series of steps to restructure the company and divide it into two entities.[66] One entity, named Tehum Care Services, was given a majority of the company’s liabilities[67] and service provider contracts,[68]  but left with only $1 million in cash from the Corizon bank account.[69] The other entity, YesCare, was given the rest of the company’s money,[70] its employees,[71] and its existing client contracts.[72]

This strategy, known as a “Texas two-step,” has attracted widespread scrutiny from civil rights organizations, lawmakers, and the US Department of Justice. In October, a group of nine senators wrote a letter to Corizon/YesCare/Tehum claiming that the bankruptcy is an attempt “to manipulate bankruptcy law with the aim of skirting accountability for the harms that incarcerated people have endured” under its care.[73] The US Trustee, which acts as Justice Department’s bankruptcy watchdog, also urged for the dismissal of the bankruptcy. [74]

As of March 2024, the bankruptcy case is ongoing.[75]

Air Methods

Air Methods, an air ambulance company owned by American Securities, filed for Chapter 11 bankruptcy in October 2023 with about $2.24 billion in debt.[76] Much of the company’s debt was tied to American Securities’ $2.5 million leveraged buyout of the company in 2017.[77]

Air Methods has around 4,900 employees[78] and operates a fleet of 365 aircraft across the US.[79] In the years leading up to its bankruptcy Air Methods began closing bases, including in Hawaii, Missouri,[80] Michigan,[81] Texas,[82] Kentucky,[83] South Carolina,[84] Oklahoma, Alabama,[85] and Georgia.[86]

In its bankruptcy filings Air Methods blamed the No Surprises Act for introducing “red tape” that hindered its ability to collect debts. This led to “unpredictable cash flows” which complicated the company’s ability to service its own corporate debt.[87]

It is unsurprising that that No Surprises Act had such an impact Air Methods’ financial stability considering how fundamental balance billing was to the air ambulance business model.

A 2021 white paper from the USC-Brookings Schaeffer Initiative for Health Policy found that private-equity-owned air ambulance companies were substantially less likely to be in-network (with 89% of their transports from 2014-2017 out-of-network) and, as a result, had a higher prevalence of surprise medical bills. The authors estimated that 55% of all helicopter transports delivered by private equity and publicly-traded carriers had the potential to result in a balance bill in 2017, compared with 29% of transports from hospital, nonprofit, and independently-owned providers.[88]

Surprise medical bills by private-equity-owned air ambulance companies were also significantly more expensive. Between 2014 and 2017 the size of surprise bills by private equity or publicly-traded companies providers grew more than 50%, reaching an average of $26,507 in 2017.[89]

[1] Butt, Rachel, and Carmen Arroyo. “Health-Care Debt Gets Harder Look as Distress Builds.” Bloomberg.Com, February 8, 2024. https://www.bloomberg.com/news/articles/2023-02-08/healthcare-debt-gets-harder-look-as-distress-builds-prices-drop.

[2] “Record Bankruptcy Filings in the Healthcare Sector in 2023,” Gibbins Advisors, January 25, 2024. https://gibbinsadvisors.com/record-bankruptcy-filings-in-the-healthcare-sector-in-2023/

[3] Ingrid Lexova and Umer Khan, “US bankruptcies hit 13-year peak in 2023; 50 new filings in December,” S&P Global Intelligence, January 9, 2024. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/us-bankruptcies-hit-13-year-peak-in-2023-50-new-filings-in-december-79967180

[4] Dylan Thomas and Annie Sabater, “US private equity portfolio company bankruptcies spiked to record high in 2023,” S&P Global Intelligence, January 11, 2024. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/us-private-equity-portfolio-company-bankruptcies-spiked-to-record-high-in-2023-80000182

[5] Small discrepancies in data between the various analysts tracking bankruptcies and private equity ownership may stem from how the healthcare industry is defined or the universe of bankruptcies they track.

[6] Mary Bugbee, “It should come as no surprise that KKR-owned Envision Healthcare has finally declared bankruptcy,” Private Equity Stakeholder Project, June 6, 2023. https://pestakeholder.org/news/it-should-come-as-no-surprise-that-kkr-owned-envision-healthcare-has-finally-declared-bankruptcy/ ; Becky Yerak, “KKR-Backed Cancer-Treatment Provider GenesisCare Files for Bankruptcy,” Wall Street Journal, June 1, 2023. https://www.wsj.com/articles/kkr-backed-cancer-treatment-provider-genesiscare-files-for-bankruptcy-953132cf

[7] Covenant Physician Partners ratings, Moody’s Investors Service, accessed March 2024. https://www.moodys.com/credit-ratings/Covenant-Physician-Partners-credit-rating-825736400/reports?category=Ratings_and_Assessments_Reports_rc|Issuer_Reports_rc&type=Rating_Action_rc|Announcement_of_Periodic_Review_rc,Credit_Opinion_ir_rc|Issuer_Reports_rc Global Medical Response, Inc. ratings, Moody’s Investors Service, accessed March 2024. https://www.moodys.com/research/Moodys-downgrades-Global-Medical-Responses-CFR-to-Caa2-outlook-remains-Rating-Action–PR_476993 ; Moody’s Investors Service, “One Call Corporation, accessed March 2024. https://www.moodys.com/credit-ratings/One-Call-Corporation-credit-rating-823643343/reports?category=Ratings_and_Assessments_Reports_rc|Issuer_Reports_rc&type=Rating_Action_rc|Announcement_rc|Announcement_of_Periodic_Review_rc,Credit_Opinion_ir_rc ; see also Moody’s explanation of ratings. “Corporate families rated Caa-PD are judged to be speculative of poor standing, subject to very high default risk, and may be in default on some but not all of their long-term debt obligations.”

[8] Shimite Obialo, “Here’s Why Jenny Craig Really Shut Down,” Forbes, June 13, 2023. https://www.forbes.com/sites/shimiteobialo/2023/06/13/heres-why-jenny-craig-really-shut-down/?sh=234ce24757a3

[9] Eileen O’Grady, “H.I.G. Capital’s Mental Health Company Files for Bankruptcy Amid Fraud Litigation,” Private Equity Stakeholder Project, January 19, 2021. https://pestakeholder.org/news/h-i-g-capitals-mental-health-company-files-for-bankruptcy-amid-fraud-litigation-2/

[10] Moody’s Investors Service gave Wellpath a Caa1 CFR, which is defined as “very high credit risk.” See: “Moody’s announces completion of a periodic review of ratings of Wellpath Holdings, Inc.,” Moody’s Investors Service, March 8, 2024. https://www.moodys.com/research/Moodys-announces-completion-of-a-periodic-review-of-ratings-of-Announcement-of-Periodic-Review–PR_486641

[11] Rating Symbols and Definitions, Moody’s Investors Service, January 2011. https://www.moodysanalytics.com/-/media/products/Moodys-Rating-Symbols-and-Definitions.pdf pg. 38.

[12] Moody’s Investors Service, “More defaults likely as roster of low-rated companies grows and interest expense rises,” November 30, 2023. Pg. 10.

[13] “Moody’s assigns B3 rating to BW NHHC Holdco’s incremental first-out superpriority term loan,” Moody’s Investorss Service, February 23, 2024. https://www.moodys.com/research/Moodys-assigns-B3-rating-to-BW-NHHC-Holdcos-incremental-first-out-Rating-Action–PR_486283

[14] “Moody’s affirms Lifescan’s CFR at Caa2; appends limited default (LD) to Lifescan’s Caa2-PD; outlook is stable,” Moody’s Investors Service, May 22, 2023. https://www.moodys.com/research/Moodys-affirms-Lifescans-CFR-at-Caa2-appends-limited-default-LD-Rating-Action–PR_476930

[15] Moody’s Investors Service, “More defaults likely as roster of low-rated companies grows and interest expense rises,” November 30, 2023.

Note that we chose to count Aveanna Healthcare as private equity owned, which Moody’s did not. Aveanna is publicly traded but considered a “controlled company,” where private equity firms Bain Capital and J.H. Whitney collectively own 68.3% of the company’s stock. See pg. 45 of Aveanna’s  SEC form 10-K.

[16] Moody’s Investors Service, “More defaults likely as roster of low-rated companies grows and interest expense rises,” November 30, 2023. Pg. 1, 7.

[17] “Cano Health files for bankruptcy, receives $150-mln financing commitment,” Reuters, February 5, 2024. https://www.reuters.com/markets/deals/cano-health-files-bankruptcy-receives-150-mln-financing-commitment-2024-02-05/

[18] See: Emily Olsen, “Cano Health reduced its workforce by 21% in Q3,” Healthcare Dive, November 10, 2023. https://www.healthcaredive.com/news/cano-health-q3-2023-job-cuts-earnings/699439/ ; “Cano Health wraps $655M term loan financing tight of talk; terms,” S&P Global Intelligence, December 15, 2020. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/cano-health-wraps-655m-term-loan-financing-tight-of-talk-terms-61760319 ; “Cano Health Closes Business Combination with Jaws Acquisition Corp. and Will Begin Trading on the New York Stock Exchange,” PR Newswire, June 3, 2021. https://www.prnewswire.com/news-releases/cano-health-closes-business-combination-with-jaws-acquisition-corp-and-will-begin-trading-on-the-new-york-stock-exchange-301305631.html

[19] Global Private Equity Report, Bain & Company, March 2024. https://www.bain.com/globalassets/noindex/2024/bain_report_global-private-equity-report-2024.pdf

[20] “Debt Fundamentals by Sector (US),” NYU Stern School of Business. Data used is as of January 2024. Accessed March 2024.  https://pages.stern.nyu.edu/~adamodar/New_Home_Page/datafile/dbtfund.html

[21] Moody’s Investors Service, “More defaults likely as roster of low-rated companies grows and interest expense rises,” November 30, 2023. Pg. 6-7.

[22] “Cano Health wraps $655M term loan financing tight of talk; terms,” S&P Global Intelligence, December 15, 2020. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/cano-health-wraps-655m-term-loan-financing-tight-of-talk-terms-61760319

[23] “Cano Health files for bankruptcy, receives $150-mln financing commitment,” Reuters, February 5, 2024. https://www.reuters.com/markets/deals/cano-health-files-bankruptcy-receives-150-mln-financing-commitment-2024-02-05/

[24] Emily Olsen, “Cano Health reduced its workforce by 21% in Q3,” Healthcare Dive, November 10, 2023. https://www.healthcaredive.com/news/cano-health-q3-2023-job-cuts-earnings/699439/

[25] Jeff Cox, “Fed approves hike that takes interest rates to highest level in more than 22 years,” CNBC, July 26, 2023. https://www.cnbc.com/2023/07/26/fed-meeting-july-2023-.html

[26] Matt Tracy, “US corporate bond spreads widen as hopes dim for soft landing,” Reuters, October 4, 2023. https://www.reuters.com/markets/rates-bonds/us-corporate-bond-spreads-widen-hopes-dim-soft-landing-2023-10-04/

[27] “Massive Growth in Expenses and Rising Inflation Fuel Continued Financial Challenges for America’s Hospitals and Health Systems,” American Hospital Association, April 2022. https://www.aha.org/guidesreports/2023-04-20-2022-costs-caring

[28] Soma Biswas and Becky Yerak, “Surprise Medical Billing Law Heaps Pressure on Healthcare Providers,” Wall Sreet Journal, November 28, 2023. https://www.wsj.com/articles/surprise-medical-billing-law-heaps-pressure-on-healthcare-providers-f9583485

[29]Reuters. “KKR-Backed Envision Healthcare Files for Bankruptcy | Reuters.” May 15, 2023. https://www.reuters.com/markets/deals/kkr-backed-envision-healthcare-files-bankruptcy-2023-05-15/.

[30] Pitchbook profile for Envision Healthcare, accessed March 2024. https://my.pitchbook.com/profile/11808-82/company/profile

[31] Stinnet, Joel. “Envision Healthcare Completes $9.9 Billion Sale to KKR.” Nashville Business Journal. Accessed October 13, 2022. https://www.bizjournals.com/nashville/news/2018/10/11/completion-of-9-9b-deal-leaves-nashville-with-one.html.

[32] Brooke, David, and David Weinman. “Envision US$5.45bn TLB Sinks as US Healthcare Debate Rages.” Reuters, August 28, 2019. https://www.reuters.com/article/envision-us545bn-tlb-sinks-as-us-healthc-idCNL2N25O14W.

[33] Ronalds-Hannon, Eliza, and Davide Scigliuzzo. “The Debt Deal That Shows How Ugly Things Are Getting for Lenders.” Bloomberg.Com, October 5, 2022. https://www.bloomberg.com/news/articles/2022-10-05/kkr-s-envision-deal-shows-how-ugly-creditor-battles-are-getting.

[34] Ronalds-Hannon, Eliza, and Davide Scigliuzzo. “The Debt Deal That Shows How Ugly Things Are Getting for Lenders.” Bloomberg.Com, October 5, 2022. https://www.bloomberg.com/news/articles/2022-10-05/kkr-s-envision-deal-shows-how-ugly-creditor-battles-are-getting.

[35] Ronalds-Hannon, Eliza, and Davide Scigliuzzo. “The Debt Deal That Shows How Ugly Things Are Getting for Lenders.” Bloomberg.Com, October 5, 2022. https://www.bloomberg.com/news/articles/2022-10-05/kkr-s-envision-deal-shows-how-ugly-creditor-battles-are-getting.

[36] Cooper, Zack, Fiona Scott Morton, and Nathan Shekita. “Surprise! Out-of-Network Billing for Emergency Care in the United States.” Cambridge, MA: National Bureau of Economic Research, July 2017. https://doi.org/10.3386/w23623.

[37] American Medical Association. “Implementation of the No Surprises Act.” Accessed October 26, 2022. https://www.ama-assn.org/delivering-care/patient-support-advocacy/implementation-no-surprises-act.

[38] Pg. 3; “Declaration of Paul Keglevic, Chief Restructuring Officer of Envision Healthcare Corporation, In Support of the Debtor’s’ Chapter 11 Petitions.” United States Bankruptcy Court for the Southern District of Texas Houston Division, May 15, 2023. https://www.courtlistener.com/docket/67385012/2/envision-healthcare-corporation/.

[39] Arnsdorf, Isaac. “Medical Staffing Companies Cut Doctors’ Pay While Spending Millions on Political Ads.” ProPublica, April 20, 2020. https://www.propublica.org/article/medical-staffing-companies-cut-doctors-pay-while-spending-millions-on-political-ads.

[40] Ickes, Amelia. “Envision Physician Services to Lay off 90 Florida Physicians, Healthcare Providers.” Becker’s Physician Leadership, April 3, 2023. https://www.beckersphysicianleadership.com/physician-workforce/envision-physician-services-to-lay-off-90-florida-physicians-healthcare-providers.html.

[41] Condon, Alan. “Envision Plans Layoffs in New York, Pennsylvania.” Becker’s Hospital Review, May 11, 2023. https://www.beckershospitalreview.com/finance/envision-plans-layoffs-in-new-york-pennsylvania.html.

[42] Soma Biswas, “Blackstone-Owned Autism Treatment Provider Files for Bankruptcy,” Wall Street Journal, June 12, 2023. https://www.wsj.com/articles/blackstone-owned-autism-treatment-provider-files-for-bankruptcy-fcaf010a.

[43] CARD LinkedIn profile. https://www.linkedin.com/company/the-center-for-autism-and-related-disorders-inc–card-/. Accessed July 11, 2023.

[44] “Disclosure Statement For The Joint Chapter 11 Plan Of Center For Autism And Related Disorders, LLC And Its Debtor Affiliates,” Chapter 11, Case No. 23-90709 (DRJ). Filed June 12, 2023.  https://cases.stretto.com/public/X244/12205/PLEADINGS/1220506122380000000028.pdf pg. 31.

[45] Sarah Pringle, “Blackstone Walks Away with the Win for Autism-Treatment Company CARD,” PE Hub, April 13, 2018. https://webcache.googleusercontent.com/search?q=cache:LH1mPoWV8_gJ:https://www.pehub.com/blackstone-walks-away-win-autism-treatment-company-card/&cd=10&hl=en&ct=clnk&gl=us.

[46] Rosemary Batt, Eileen Appelbaum, Quynh Nguyen, “Pocketing Money Meant for Kids: Private Equity in Autism Services,” Center for Economic and Policy Research, June 21, 2023. https://cepr.net/wp-content/uploads/2023/06/2023-06-Private-Equity-in-Autism-Services.pdf pg. 45.

[47] Phoebe Liu, “This Psychologist Got Rich Selling Her Chain Of Autism Treatment Centers. Now She’s Trying To Buy It Back.” Forbes, July 5, 2023. https://www.forbes.com/sites/phoebeliu/2023/07/04/doreen-granpeesheh-psychologist-got-rich-autism-treatment-centers/?sh=500dd2c72d1d

[48] “Disclosure Statement For The Joint Chapter 11 Plan Of Center For Autism And Related Disorders, LLC And Its Debtor Affiliates,” Chapter 11, Case No. 23-90709 (DRJ). Pg. 45.

[49] Batt, Appelbaum, and Nguyen, “Pocketing Money Meant for Kids: Private Equity in Autism Services.” Pg. 46.

[50] “Disclosure Statement For The Joint Chapter 11 Plan Of Center For Autism And Related Disorders, LLC And Its Debtor Affiliates,” Chapter 11, Case No. 23-90709 (DRJ). Pg.. 10.

[51] Soma Biswas, “Blackstone-Owned Autism Treatment Provider Files for Bankruptcy,” Wall Street Journal, June 12, 2023. https://www.wsj.com/articles/blackstone-owned-autism-treatment-provider-files-for-bankruptcy-fcaf010a.

[52] Phoebe Liu, “This Psychologist Got Rich Selling Her Chain Of Autism Treatment Centers. Now She’s Trying To Buy It Back.” Forbes, July 5, 2023. https://www.forbes.com/sites/phoebeliu/2023/07/04/doreen-granpeesheh-psychologist-got-rich-autism-treatment-centers/?sh=500dd2c72d1d

[53] Batt, Appelbaum, and Nguyen, “Pocketing Money Meant for Kids: Private Equity in Autism Services.” Pg. 45.

[54] Batt, Appelbaum, and Nguyen, “Pocketing Money Meant for Kids: Private Equity in Autism Services.” Pg. 47.

[55]https://bhbusiness.com/2023/06/22/pe-backed-invo-healthcare-closes-autism-home-support-services-abandons-home-and-center-aba/

[56] Yescare. “Home.” Accessed June 22, 2023. https://www.yescarecorp.com.

[57] Tehum Care Services, Inc. “Voluntary Petition for Non-Individuals Filing for Bankruptcy,” p. 4. U.S. Bankruptcy Court, Southern District of Texas, February 13, 2023.

[58] Beecken Petty O’Keefe & Company. “Corizon Health | Portfolio | BPOC.” Accessed June 23, 2023. https://www.bpoc.com/portfolio/corizon-health.

[59] Geert De Lombaerde. “Corizon Lands $100M Investment.” Nashville Post, November 27, 2018. https://www.nashvillepost.com/corizon-lands-100m-investment/article_5705fbf4-4dc8-5947-9ee8-64147e7d1aeb.html.

[60] Matt Blois. “Investment Firm Acquires Corizon.” Nashville Post, June 30, 2020. https://www.nashvillepost.com/investment-firm-acquires-corizon/article_eeba5a0a-486c-5779-886c-2d50b1befc5a.html.

[61] Perigrove Capital. “Portfolio Companies.” Accessed August 14, 2023. https://www.perigrove.com/portfolio-companies/.

[62] Rachel Weiner. “Corizon Health Will Not Longer Operate in Arlington Jail.” Washington Post, October 25, 2021. https://www.washingtonpost.com/local/legal-issues/arlington-jail-corizon/2021/10/25/53ce61a0-35bd-11ec-91dc-551d44733e2d_story.html.

[63] Josh Moon. “Billion Dollar Prison Healthcare Contract Halted after Claims of ‘Undue Influence.’” Alabama Political Reporter, February 7, 2023. https://www.alreporter.com/2023/02/07/billion-dollar-prison-healthcare-contract-halted-after-claims-of-undue-influence/.

[64] Jimmy Jenkins. “Prison Health Care Provider Declares Bankruptcy, Leaving Arizona Malpractice Claims on Hold.” USA Today, February 17, 2023. https://www.usatoday.com/story/news/local/arizona/2023/02/17/former-arizona-prison-health-care-provider-declares-bankruptcy-lawsuits-on-hold/69915763007/.

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[66] Corizon Health, Inc. “Agreement and Plan of Divisional Merger,” p. 1. Texas Secretary of State, May 1, 2022.

[67] Corizon Health, Inc. “Agreement and Plan of Divisional Merger,” p. 131-145. Texas Secretary of State, May 1, 2022.

[68] Corizon Health, Inc. “Agreement and Plan of Divisional Merger,” p. 25-62. Texas Secretary of State, May 1, 2022.

[69] Corizon Health, Inc. “Agreement and Plan of Divisional Merger,” p. 10. Texas Secretary of State, May 1, 2022.

[70] Corizon Health, Inc. “Agreement and Plan of Divisional Merger,” p. 10. Texas Secretary of State, May 1, 2022.

[71] Corizon Health, Inc. “Agreement and Plan of Divisional Merger,” p. 3. Texas Secretary of State, May 1, 2022.

[72] Corizon Health, Inc. “Agreement and Plan of Divisional Merger,” p. 13. Texas Secretary of State, May 1, 2022.

[73] Senators Warren, Durbin, Hirono, Merkley, Blumenthal, Wyden, Sanders, Welch, and Booker. “Letter Re Corizon Texas Two-Step,” October 24, 2023. https://www.warren.senate.gov/imo/media/doc/2023.10.24%20Letter%20re%20Corizon%20Texas%20Two-Step.pdf.

[74] Dakin Campbell and Nicole Einbinder. “Justice Department calls for dismissal of the Corizon bankruptcy,” Business Insider. Fbruary 25, 2024.  https://finance.yahoo.com/news/justice-department-calls-dismissal-corizon-231837464.html

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[76]https://www.reuters.com/legal/medical-helicopter-company-air-methods-files-bankruptcy-2023-10-24/

[77] Bob Herman, “Air Methods bought out for $2.5 billion,” Axios, Marh 14, 2017. https://www.axios.com/2017/12/15/air-methods-bought-out-for-25-billion-1513300942 ; Mark Huber, “Air Ambulances Fly Through Economic Turbulence,” AIN, December 1, 2023. https://www.ainonline.com/aviation-news/business-aviation/2023-12-01/air-ambulances-fly-through-economic-turbulence

[78] Reshmi Basu, Luca Casiraghi and Ethan M Steinberg, “Air Methods Files Bankruptcy After Rates, Regulation Hit Profits,” Bloomberg News, October 24, 2023. https://www.bnnbloomberg.ca/air-methods-files-bankruptcy-after-rates-regulation-hit-profits-1.1988594

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