Mentis, founded in 2006 and headquartered in Houston, Texas, is a leading provider of inpatient and outpatient postacute neuro-rehabilitative care to persons with an acquired brain injury (“ABI”). The Company utilizes an interdisciplinary clinical model with customized modified care plans that focus on each patient’s specific behavioral, clinical and social deficiencies. The Company’s comprehensive services include a combination of neuropsychological services, 24-hour rehabilitative nursing, cognitive rehabilitation, physical therapy, speech and language therapy, occupational / vocational rehabilitation, recreational therapy, group therapy, and physical medicine and rehabilitation management. Mentis allows patients that have suffered an ABI to re-enter their homes, community and/or workforce in a shorter period of time with meaningfully enhanced outcomes and greater independence.

Top Down Investment Thesis

Acquired brain injury includes both traumatic brain injuries (“TBI”) (commonly caused by falls, auto accidents, workplace injuries, and assaults) as well as strokes, tumors or other conditions whereby the brain is damaged from a lack of oxygen. An estimated 2.4 million people in the U.S. sustain a TBI and another 795,000 sustain an acquired brain injury from non-traumatic causes each year. Currently more than 6.4 million individuals in the U.S. live with a lifelong disability as a result of TBI or stroke. Patients suffering from an ABI typically undergo a long and exhaustive care process that spans from the highest acuity setting down through lower levels of care and rehabilitation depending on the progress of each individual patient. The ultimate end-point for a patient, depending on their level of rehabilitation and independence, can span from a full recovery and independent living to a very limited recovery that requires life-long custodial care. This broad span of outcomes has very material cost ramifications as long-term custodial care can run millions of dollars depending on the age of the patient when they sustain their injury.

Excellere’s investment in Mentis is a result of the firm’s disciplined top down investment strategy, driven by several factors including i) an increased national awareness of brain injury, ii) the increased survival rate of those who have sustained a TBI due to medical advances, iii) higher incidences of stroke in a growing aging population, iv) cost pressures associated with increased healthcare spending shifting more patients to post-acute, lower cost settings, v) a strong and stable reimbursement outlook for neuro-rehabilitative care, vi) a niche market with a unique and complex patient and referral base making it very difficult for other rehabilitation facilities and new market participants to successfully treat ABI patients, and vii) Mentis’ outcomes-driven clinical model offers a clear value proposition to each constituency the Company serves (patients, families, referents and payers) by allowing patients to re-enter their homes, community and/or workforce in a shorter period of time with greater independence.

Buy and Build Strategy

Post-acute neuro-rehabilitation is an underserved and highly fragmented market consisting mainly of smaller local and regional providers. Throughout its growth, Mentis has demonstrated an ability to establish new de novo facilities using a systematic approach to new market evaluation, referral source education, licensing, payer contracting and local recruiting. This proven ability to open new facilities in a fragmented marketplace, combined with the opportunity to expand geographic coverage through new referral and payer relationships, expanded service offerings and enhanced technology, creates an attractive buy-and-build opportunity. Mentis is actively seeking strategic add-on acquisitions of post-acute neuro rehabilitative care providers that will enable the Company to broaden its geographic footprint and deepen its presence in the market.

To the extent you are interested in learning more about Mentis, please contact Ryan Glaws at or Matt Halverson at to discuss the neurorehabilitation services sector further.

Founded in 2001, TrialCard Incorporated (“TrialCard” or the “Company”) provides specialized services that solve the market access challenges faced by the pharmaceutical industry. The Company offers customized solutions for clients that assist with prescription adherence and abandonment, sales force support, patient case management, reimbursement and clinical support, market share lift, product rescue, and loss of exclusivity challenges. TrialCard’s pharmaceutical manufacturer clients optimize revenue through a brand’s life cycle, while patients and providers benefit from better clinical outcomes and lower overall cost of care. TrialCard’s broad suite of services is enabled by the Company’s database of pharmacy-level transactions, data analytics capabilities, award-winning customer experience center, and proprietary program management processes; all of which enhance program efficacy and return on investment for its customers.

Top Down Investment Thesis

According to the New England Healthcare Institute, medication non-adherence is estimated to drive $290 billion in avoidable spending to the U.S. healthcare industry annually through unnecessary hospitalizations and additional medical risks. Seven percent of prescriptions are abandoned at the point of sale and between 33% and 50% of patients do not take their medications as prescribed. TrialCard’s portfolio of services helps drive patient access and adherence for pharmaceutical manufacturers, while simultaneously adding value across the healthcare delivery chain (i.e., pharmacies, patients and healthcare providers). One significant factor in non-adherence is the out-of-pocket cost burden on patients, thus co-pay programs and product vouchers have proven to be powerful tools in driving adherence. Patients are 2.3x more likely to refill physician prescribed medication when using TrialCard programs. Additionally, these programs generate actionable consumer insights while driving superior patient outcomes, which benefit physicians, patients and payers. Another significant cause of non-adherence is the complexities of specialty drugs relating to payer support, clinical coordination and drug administration. To address this issue, TrialCard’s specialty therapy hub provides assistance for patients in navigating the complex reimbursement challenges associated with specialty drug therapies such as prior authorization, benefits investigation and appeals processes. Through improving patient outcomes and lowering overall cost of care, increasing adherence generates benefits for all constituents in the healthcare system.

Buy and Build Strategy

The patient access and pharmaceutical adherence services industry is highly fragmented with a limited number of competitors providing a complete customer solution. TrialCard is well positioned to continue the expansion of its capabilities, customer relationships and technologies across the entire patient journey. The Company is pursuing strategic acquisition opportunities in the outsourced pharmaceutical support services industry, including the following existing and complementary capabilities: (i) specialty therapy hub services, (ii) tele-detailing, (iii) patient support / education, (iv) disease management, and (v) consulting and enhanced analytics.

To the extent you are interested in learning more about TrialCard, please contact Brad Cornell at or Mike Vieth at .

PhyMED is a leading provider of outsourced anesthesia, interventional pain management and other complementary services to hospitals, medical facilities and ambulatory surgery centers. Formed in 1994 and based in Tennessee, PhyMED is a top ten provider of anesthesia services in the United States.

Top Down Investment Thesis

Excellere’s investment in PhyMED is a result of a four year search for an anesthesia platform based on the firm’s disciplined top down investment strategy, driven by several factors including i) the non-discretionary nature of anesthesia services that carry a high degree of medical necessity as sedation is required for most surgical procedures, ii) a clear and deep value proposition to patients, surgeons, medical facilities and payers, and iii) the highly-fragmented nature of the industry.

The key customers for an outsourced provider of anesthesia services are the healthcare facilities, and more specifically the surgeons that anesthesiologists work with. For the medical facilities, a contracted or outsourced anesthesiology partner provides dedicated anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs), while reducing the need for internal resources dedicated to recruiting, credentialing, scheduling, billing, collections and compliance. For the surgeon and facility, there is significant value gained through access to a consistent staff of anesthesia professionals available in order to maximize the efficiency and throughput of the operating room, which is one of the most profitable areas of a hospital.

The U.S. anesthesia services industry is estimated at over $23.0 billion and growing at 4% per year, in line with growth in total surgical procedures and case reimbursement rate trends. The number of U.S. surgical procedures is projected to grow 29% from 2010 to 2020.

Buy and Build Strategy

The anesthesia services sector is highly fragmented and comprised of over 1,000 providers nationally. This fragmentation, combined with the opportunity to significantly enhance the value provided to its customers’ experiences and outcomes through the use of technology-driven solutions, suggests an immense opportunity to execute a customer-centric, buy-and-build strategy. Specific areas of focus within the outsourced anesthesia services sector include other compliance-focused anesthesia providers and complementary service lines such as interventional pain management and critical care coverage.

To the extent you are interested in learning more about PhyMED, please contact Matt Hicks at or Justin Unertl at to discuss the anesthesia services industry further.

IPT is an oil and natural gas engineering services firm specializing in the integration of modern well completion, hydraulic fracture stimulation and reservoir engineering technologies. The Company is comprised of practicing petroleum engineers with extensive operator and service company experience throughout the United States and in select international markets. IPT is considered one of the foremost thought leaders in the hydraulic fracturing industry with over 20 years of experience working in most basins and major shale plays. IPT not only provides highly technical consulting services that significantly influence the economics of a well, but also represent an independent third-party expert at the well site that helps to ensure that all parties are performing their respective duties in a safe and efficient manner.

Top Down Investment Thesis

Recent discoveries of oil and natural gas reserves, increasing global demand and the evolution of horizontal drilling and well completion technologies have spawned a substantial increase in exploration and production activity in the United States. According to the Annual Energy Outlook 2012 as published by the U.S. Energy Information Administration (“AEO12”), U.S. dependence on imported petroleum liquids is projected to decline by more than one million barrels per day by 2020 driven primarily by growth in domestic oil production. In addition, net petroleum imports as a share of total U.S. liquid fuels consumed is projected to drop from 49 percent in 2010 to 36 percent in 2035 as the United States continues to harvest its natural resources in pursuit of energy independence. Technological advances and the increasing commercial consumption of natural gas will also drive increased exploration and production activity. Since 2000, U.S. shale gas production has increased 17-fold, currently comprising approximately 30 percent of the total U.S. production, and is projected to comprise 49% of total U.S. production by 2035 (according to AEO12).

In order to unlock the potential of the oil and natural gas resources trapped in tight formations and shale plays, exploration and production companies have enlisted the services of hydraulic fracturing experts that employ advanced completion and stimulation techniques to optimize the output of their wells. The pressure pumping market, which includes hydraulic fracturing and other stimulation services provided to oil and gas exploration and production companies, is expected to grow from $16.7 billion in 2009 to $51.0 billion in 2012, driven in part by the effectiveness of these services to enhance well production.

Buy and Build Strategy

The oil and natural gas engineering services market is highly fragmented with a limited number of institutional service providers capable of managing national programs for customers. Furthermore, the majority of service providers offer only one solution to customers, rather than providing a fully integrated suite of capabilities that spans the lifecycle of an active well. This fragmentation, coupled with the limited service offerings of most industry participants, has created an opportunity to build an integrated solutions provider with a broad set of complementary capabilities to better serve customers. Specific areas of interest within the oil and natural gas engineering services industry include: (i) complementary high-end capabilities such as seismic processing or well design (ii) technology enabled solutions and software (iii) data collection, management and analytics, and (iv) regulatory compliance.

To the extent you are interested in learning more about IPT, please contact David Kessenich at or Brad Cornell at to further discuss the oil and natural gas services industry.

Personable Insurance (“Personable” or the “Company”) is an independent agent-driven, specialist non-standard auto insurance provider. Personable has partnerships with multiple insurance carriers and relationships with over 3,000 independent agents in California, Florida, Georgia and Texas. The Company plans to expand its capabilities further via the organic extension of its service offerings and acquisitions of additional non-standard auto assets and businesses in a number of key strategic states.

Top Down Investment Thesis

Excellere’s investment in Personable is a result of the firm’s disciplined top down investment strategy, and is driven by several factors including (i) the non-discretionary, critical nature of insurance products and services, ii) the highly-fragmented nature of the industry and iii) the opportunity to create a highly-compelling value proposition to carriers, distributors, service providers and insured companies and individuals (“insureds”).

The insurance products and services industry can be segmented into carriers, distributors (agencies and brokerages) and service providers. Carriers receive premiums for providing insurance coverage and typically assume the risks covered by the policy. Depending on a primary carrier’s risk preference, the actual risk may be offloaded to reinsurers who assume all or part of the risk associated with a particular policy. Agencies and brokerages serve as the distribution channel for carriers by selling policies to individuals and businesses, and in some instances rendering services such as underwriting, claims management and customer relations on behalf of their carrier partners. Finally, service providers supply both carriers and distributors with outsourced services and expertise in select areas in which a carrier or distributor may not maintain a core competency.

Gross premiums in the U.S. are expected to exceed $1.5 trillion in 2010/11, and with continued economic recovery, each segment of the insurance sector is poised for expansion at varying growth rates.

Buy and Build Strategy

The insurance sector is highly fragmented and comprised of over 3,000 U.S. carriers, 35,000 distributors and 5,000 service providers. This fragmentation, combined with the opportunity to significantly enhance its customers’ experiences and outcomes through the use of technology-driven automated systems, has created an opportunity to execute a customer-centric, buy-and-build strategy. Specific areas of focus within the insurance sector include: Managing general agents (“MGAs”) in non-standard auto or other niche segments, rural and independent agencies, and service providers (specifically TPAs, loss control / underwriting support, subrogation, data providers and software providers).

To learn more about Personable or the insurance products and services industry, please contact Brad Cornell at or Justin Unertl at .

U.S. Water Services (“USWS” or the “Company”) is one of the largest independent, fully-integrated, industrial / commercial water treatment companies in the U.S., serving a wide range of industrial, commercial and institutional accounts. The Company’s chemicals division offers a comprehensive line of approximately 350 proprietary, branded and blended chemical products and support services. These chemicals improve production efficiency, reduce utility and maintenance costs, protect against contamination/corrosion, enhance compliance regulation and are non-discretionary purchases for customers providing highly predictable and recurring revenue for USWS. The Company’s equipment division offers a complete line of engineered water treatment capital equipment (filtration, softeners, delivery systems, etc.), parts and consumable supplies (filters, membranes, etc.).

Top Down Investment Thesis

The increasing cost of water due to scarcity, quality challenges and environmental policies has driven manufacturers and other water users to employ increasingly sophisticated techniques to treat their water supply for industrial processes and/or discharge. Small and mid-sized businesses often do not have the in-house knowledge to apply more advanced technologies or properly adhere to the evolving regulatory environment. Leading water treatment providers offer customers this expertise on an outsourced basis and can provide the diagnostic support to continuously evaluate the clients’ needs and offer proprietary chemical blends and engineered equipment to meet each customer’s unique requirements.

Buy and Build Strategy

Having completed the recapitalization with Excellere in January of 2011, USWS is actively seeking to acquire and/or partner with other water treatment companies in the United States. Companies serving the food and beverage, utility, microelectronic and other commercial industries would complement USWS current customer base.

To the extent you are interested in learning more about U.S. Water Services, please contact David Kessenich at or Patrick O’Keefe at .

AxelaCare, headquartered in Lenexa, Kansas, is a leading provider of home infusion therapy services, including Intravenous Immune Globulin (“IVIg”), Hemophilia and other traditional home infusion services, such as Intravenous Antibiotics and Total Parenteral Nutrition (“TPN”). The company, which was founded by a team of proven industry veterans, is experiencing rapid growth and currently operates three pharmacies serving patients in 25 states. AxelaCare’s full service approach includes hands-on clinical management of the patient intake process to ensure that patients are able to begin therapies in a timely and efficient manner. This combination of outstanding clinical and pharmacy services, along with AxelaCare’s culture of patient advocacy and support, significantly differentiates the company from other industry participants.

Top Down Investment Thesis

Excellere’s investment in AxelaCare is a result of the firm’s disciplined top down investment strategy. In 2008, Excellere targeted the specialty pharmacy sector (including home infusion) as an attractive buy-and-build opportunity and spent the subsequent two years carefully seeking a partnership with an industry leading management team who shared a vision to build a truly differentiated company.

AxelaCare competes within the specialty infusion sector of the specialty pharmacy industry. Specialty infusion services primarily involve the intravenous (i.e., directly into veins or muscles, or under the skin) administration of medications to treat a wide range of acute and chronic health conditions. Physicians, hospital discharge planners and case managers generally refer patients to specialty infusion providers to continue their therapies at home or in other non-acute settings.

The market for specialty infusion is approximately $10 billion and growing at approximately 8% to 12% annually. This significant organic growth is driven by numerous factors including: (i) favorable demographic trends, (ii) a growing pipeline of new pharmaceuticals and therapies that are appropriate for infusion, (iii) patient preference for home care (especially in cases of chronic diseases), (iv) lower costs as compared to treating chronic illnesses in a hospital setting, and (v) technological advancements that have made delivering complex therapies in the home safer and more prevalent. Approximately 70% of the drugs now under development in the biotech pipeline will require some degree of specialized, hands-on administration via injection or infusion.

Buy and Build Strategy

The specialty infusion sector is highly fragmented, with an estimated 700 to 1,000 home infusion providers in the United States. This fragmentation, combined with the industry’s strong organic growth, creates an attractive buy-and-build opportunity. AxelaCare is actively seeking strategic add-on acquisitions of home infusion providers that will enable the Company to broaden its geographic footprint and deepen its presence in the attractive home infusion market.

To the extent you are interested in learning more about AxelaCare, please contact Ryan Glaws and or Justin Unertl at .

MTS Medication Technologies (“MTS”) is a leading international provider of pharmaceutical adherence packaging solutions focused on the long term care, retail and nutraceutical markets. MTS designs, develops and manufactures proprietary pharmaceutical adherence packaging along with a complete line of highly specialized automated equipment to assist institutional pharmacies and long term care facilities with pharmaceutical dispensing, inventory management, and storage. MTS serves more than 8,000 customers in the United States, Canada, Europe, Australia, and the Middle East.

Top Down Investment Thesis

Pharmaceutical adherence packaging (i) increases patient compliance for their drug regimens; (ii) enables pharmacies to dispense drugs more efficiently/reliably and store/handle drugs properly; (iii) makes compliance easier for patients, who often must consume multiple drugs, multiple times per day to comply with their doctor’s prescribed regimen; (iv) provides physicians, through greater patient adherence, with the comfort that their prescriptions are being followed properly; and (v) reduces healthcare costs through fewer emergency room visits/deaths/hospital admissions related to non-adherence. Estimates indicate 28% of emergency room visits are related to the misuse of drugs; 70% of which are preventable and 24% of which result in hospital admissions. In addition, U.S. healthcare costs related to treating patients due to medication non-adherence is estimated to be $60-$100 billion annually (Healthcare Compliance Packaging Council).

Buy and Build Strategy

Partnering with Excellere to pursue a buy-and-build strategy, MTS is currently looking for acquisition opportunities that would enable the company to add more products and services to its existing customers, as well as increase its reach through new customers and distribution channels both domestically and internationally.

For more information regarding MTS please contact Matt Hicks at or Ryan Glaws at .

Advanced Pain Management (“APM”) is a Milwaukee-based, leading provider of interventional pain management services throughout Wisconsin. APM has the expertise to diagnose and treat a broad range of pain conditions, including pelvic, spine, neck, hip, cancer, diabetes, and obesity-related pain.

Top Down Investment Thesis

Chronic pain is estimated to cost the U.S. economy $90 to $100 billion per year. Costs continue growing due to increasing obesity, the aging population, and overall poor lifestyles. Interventional pain management (“IPM”) is a multidisciplinary approach for managing and eliminating pain and became more visible when it was granted a medical sub-specialty from the Centers for Medicare and Medicaid Services in 2003.

Interventional pain management develops customized plans, and uses minimally invasive outpatient procedures, such as nerve blocks, epidurals, and implants to help patients manage or eliminate pain. IPM is an attractive alternative to higher-risk heavy drug regimens that simply mask the pain or costly surgeries that require lengthy recovery and questionable long term outcomes. As a result, IPM offers an excellent value proposition to the patients, referring physicians, and payors

To learn more about Advanced Pain Management, please call David Kessenich at or Matt Hicks at .

ASI is a trusted advisor to the Federal Government, providing consulting services, productivity tools and training to over 56 clients within the Department of Defense, Homeland Security and Civilian agencies.

Top Down Investment Thesis

The dollar volume of Federal government purchases has grown by 63% over the past six years to approximately $425 billion (~8.5% growth). Meanwhile, the aging demographics of the federal workforce, high turnover among government employees and budgetary pressures have created greater demand for a trusted advisor to assist the Government in improving acquisition, program management and broader IT processes and outcomes.

Buy and Build Strategy

ASI is pursuing acquisition opportunities that will allow it to accelerate its geographic expansion into key markets (Huntsville, AL; San Diego, CA; etc.) as well as add additional differentiated service offerings for its clients within two general categories:Smaller,

  • Niche Service Providers – Government consulting and training companies that enhance and broaden ASI’s current service offering.
  • Divestitures – There is an excellent opportunity to acquire the divisions of larger, diversified companies that are compelled to divest their acquisition support business units to eliminate conflicts of interest.

To learn more about ASI, please contact Patrick O’Keefe at .