Ambulant Intensive Care in Germany - An analysis from an M&A (mergers and acquisitions) perspective Authors: Günter Carl Hober and Martin E. Franz ...
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Ambulant Intensive Care in Germany An analysis from an M&A (mergers and acquisitions) perspective Authors: Günter Carl Hober and Martin E. Franz Oct. 2016
Contact Your contact persons for M&A For comments and additional information do not hesitate to contact the Conalliance M&A Healthcare Services Team. We are looking forward to your feedback and a mutual exchange. Günter Carl Hober Frank Herrmann Dipl.-Kfm. / MBA MBA Managing Partner und Associate Head of Healthcare M&A Europe Team Healthcare M&A Europe Tel.: +49 (89) 809 53 63-0 Tel.: +49 (89) 809 53 63-0 g.hober@conalliance.com f.herrmann@conalliance.com www.conalliance.com CONALLIANCE 2 M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
Important Notice No part of the report or service may be resold, circulated, lent or disclosed to non-customers without written permission of Conalliance. This information is based mainly on primary and secondary market research and own Conalliance analysis and therefore, is subject to fluctuation. Furthermore, no part may be reproduced, or transmitted in any form or by any means, electronic, photocopying, mechanical, recording or otherwise without the permission of the publisher, i.e. Conalliance. All statements of fact, opinion, or analysis expressed in this report are those of the respective analysts and M&A advisors of Conalliance. They do not necessarily reflect formal positions or views of Conalliance. The Information used and statements of fact made are not guarantees, warranties or representations as to their completeness or accuracy. Conalliance assumes no liability for any short term or long terms decision made by any clients based on analysis included in our reports (e.g. Commercial Due Diligence Reports, Market Reports, Target Screening Reports, etc.). CONALLIANCE Munich, October 2016 CONALLIANCE 3 M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
Please note also: Due to confidentiality reasons significant parts of this report have been blacked, edited and shortend. We kindly ask for your understanding. CONALLIANCE 4 M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
Part I
Market Model
CONALLIANCE 5 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYSummary „Market Structure & Patients“
1. The focus of this analysis is set on the ambulatory care and growth rates can be identified in Germany.
ambulatory intensive care market. 6. In Germany approximately 700 thousand people are being
2. The German ambulatory intensive care market is a cared for by ambulatory care services. Only of
specialized niche market embedded in a tight service these are ambulatory intensive care patients.
network, 7. The patient base in the German ambulatory care market is
• regulated by a social code and care legislation, as well expected to grow at an annual rate of % until 2030. The
as federal state specific legislation, largest growth rate is forecasted for the ambulatory service
• paid by health insurance and long term care insurance patient base.
• Serviced by medical and therapeutical service 8. The number of ambulatory care patients has grown in
providers and product suppliers. recent years at % annually. The number of ambulatory
3. The patient is normally referred into the system by intensive care patients has
stationary acute care. .
4. The number of total inhabitants in Germany decreases 9. Experts differ strongly in their view on effective growth
annually by 0.4% until 2060. The number of inhabitants rates for the future.
aged 65 to 80 and 80+, who are most likely to need care, 10.
grows during the same time period by 0.2% and 1.5%
respectively. Hence the group of people who are potential
patients grows. 11.
5. The total number of long-term care patients is
The majority of ambulatory 12.
care patients have a low Care Level (Care Level I represents
% in 2013). However, some regional difference between
CONALLIANCE 6 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYMarket Structure
7 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYMarket segmentation
The focus of this Industry German health care services market
analysis is set on the
General markets Nursing care Hospitals Practitioners Pharmacies
ambulatory care and
Market Ambulatory care Stationary care
ambulatory intensive
Sub segments Nursing care Intensive Residential Day/night Holiday care /
care market. care community care care assistance
Patient target group Children Adults Elderly people
Service provider company size Small Medium Large
Level of specialisation Intensive Care only Intensive Care & Nursing Care Nursing Care only
Indications COPD ALS Other
Main legislation SGB V SGV XI SGB V + XI
Admission MDK assessment and local MDK
Medical doctor and MDK
practitioner
German nursing care market is a growing subsegment of the level of specialization (i.e. are they exclusively providing nursing
German health care service industry. German nursing care care or intensive care or are they providing both). The ambulatory
represents 18 % of the total German health care spending. All non care services in focus are governed by the German code of social
hospital care services are encompassed in this market segment. law. (SGB V and SGB XI) Social code V regulates admission and
Stationary care services such as nursing care homes are not part of payments of German health insurance, social code XI regulates
the market assessed in this study. Ambulatory care services such as admission and payments of German long term care insurance.
intensive care and general ambulatory care as well as day care Admission to payments of health insurance is restricted by medical
services are the focus of the following analysis. Care providers can doctor prescription, access to long term care insurance payments
be segmented according to their main target group (children, is regulated by an MDK assessment (“Medizinischer Dienst der
adults, elderly), its company’s size (small, medium, large) and the Krankenkassen” – medical service of German health insurance).
CONALLIANCE 8 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYMarket participants of the ambulatory intensive care service
Health Long term Social
Payors
The German ambulatory insurance care insurance welfare
intensive care market is
Social
a specialized niche code V
market embedded in a
tight service network: § §
ambulatory intensive Social code V Social code XI
care is
• based on social code
and care legislation, Patientflow
as well as federal
state specific
legislation
• paid by health Patient Hospital
insurance and long This information is
term care insurance
• supported by medical
Rehab
clinic
Weaning no part of the
Relatives
and therapeutical
service providers, as
publically available
well as internet document
• medical and
pharmaceutical
suppliers
Medical
pharma
supply
The patient is referred
into the system by Care
stationary acute care. legislation
I, II, III
Source: own analysis, Conalliance7732
CONALLIANCE 9 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYPatients
10 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYThe total number of inhabitants decreases in Germany, the age group 65+ grows
The number of total Prognosis of German inhabitants (base case) by age group
(in 1000)
inhabitants in
CAGR
Germany decreases CAGR: -0,4%
2013 - 2060
annually by 0.4% until 80.766 81.435 79.230
4.364 5.915 75.964
2060. The number of 6.215 71.903
12.486 7.794 67.564
inhabitants aged 65 to 12.430 9.798
15.579 8.821 +1.5%
15.385
80 and 80+, who are 12.940
13.468 +0.2%
most likely to need
care, grows during the 49.232 48.775
43.595 -0.8%
40.213 37.736
same time period by 34.347
0.2% and 1.5%
respectively.
14.684 14.315 13.841 12.572 11.429 10.928 -0.6%
2013 2020 2030 2040 2050 2060
under 20 years 20 to 65 years 65 to 80 years 80+ years
In a base case prognosis German population is forecast to shrink 80 years of age is growing during this time at an annual rate of
from 2020 onwards from 81.4 mill. inhabitants to 67.5 mill. 1.5%.
inhabitants. Base case does only account for minor immigration and The likelihood to need intensive care increases strongly with age.
stable birth rates. According to first findings and expert interviews, 50% of all
During this period the age groups below 65 years are continuously intensive care patients are 70+ years of age.
shrinking in number. The age group 65-80 is growing between 2013
and 2060 with an annual growth rate of 0.2%. The age group above
CONALLIANCE Source: Bundesgesundheitsberichterstattung 11 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYA study of intensive care patients by age
A study by AOK North Distribution of intensive care patients by age
shows that more than
% of all ambulatory
intensive care patients
are
This data is no part of the publically
available internet document
2007 2008 2009 2010 2011 2012
0-19 years 20-49 years 50-69 years 70+ years
Source: own analysis Conalliance 2016, Drucksache 6/2054 Landtag MV, 2012
CONALLIANCE 12 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYThe number of long-term care patients is growing - ambulatory patients represent the majority
of long term care patients
Number of ambulatory care
The total number of Total number of long-term patients with long-term care
long-term care Total number of long-term care patients – split by type insurance support (by Care
care patients of care Level)
patients is
(in mill. patients) (in thousand patients) (in thousand patients)
%,
ambulatory patients
+XX% XX%
represent % of the
long term care nursing
market patients. % of This data is no part of
This data is no part of the publically
all ambulatory the publically In total, mill. available internet
patients are kids. available internet patients are document
document entitled to receive
The majority of ambulatory care
support
ambulatory care
patients have a low 1999 a 2013 a 2030 e 2013 a 2013 2015
Stationary
Care Level (Care Level I Adults Kids CL 0 CLII
Family
CL I CL III
represents % in Professional ambul. serv.
2013).
SOURCE A; xyz SOURCE B: xyz
The number of patients financed by long term care insurance has grown for by an ambulatory care service. In 2013 only children ( %)
annually between 1999 and 2013 by %. Until 2030 the increase of long were classified as care patients of the long term care insurance.
term care patients is forecasted to grow at an annual rate of % Almost two thirds of ambulatory care patients had a care level I
In 2013 almost % of all long term care patients were receiving classification ( %), almost % had a care level II and still % of
stationary care services. % or Million patients received ambulatory care patients had care level III.
ambulatory care support. % of all long term care patients were cared
CONALLIANCE 13 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYDevelopment of patients cared for by ambulatory care service 1999 - 2013
Patients of ambulatory services
The number of
SH 14.239
ambulatory care 14.752
8.965
16.492 MV
16.751 11.504
patients has grown
HB 4.545 13.817 Total # of patients cared for
between 1999 and 5.373 19.060 by ambulatory services
5.927
2013 steadily in all 6.476 HH 11.480
18.437
12.202 1999: 415.199
federal states. 12.747 20.682
NI 40.421
14.480 22.863 2013: 615.846
However, some 47.398 BE 27.769 CAGR: + 2,9%
regional difference can
55.764 ST
67.997
NW 93.916
14.198 BB 15.443
be identified. 17.011 18.689
94.187 Fastest growth:
19.602 22.662
106.832
23.031 29.391 Mecklenburg-
131.431
HE Vorpommern + 5,5% CAGR
29.506
TH SN 29.971
17.578 12.185 31.510
18.804
30.712 14.390 Slowest growth:
35.660 32.810
19.991 16.740 43.359 Schleswig-
44.605
RP 25.125 20.958 Holstein + 1,2% CAGR
SL
5.249
5.300 BW 56.658
5.865 42.408 BY 60.529
7.230 47.083 69.776
46.684 74.852
63.331
Source: XXXXXXXXXX , 2016 1999 2003 2007 2013
CONALLIANCE 14 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYPrivate operators care for of all ambulatory care patients
The ambulatory care Total number of ambulatory long-term care patients Total number of ambulatory long-term care
– split by type of service provider CHILDREN patients – split by age
market is mainly
serviced by private and (2013 figures) (2013 figures)
non-profit providers. TOTAL: TOTAL:
Two thirds of kids
cared for by
ambulatory care
services are up to five This data is no part of This data is no part of
the publically the publically
years of age. available internet available internet
document document
Public providers New Born 6-12 years
Non-profit companies Sucking babies 13-18 years
Private companies 1 - 5 years >18 years
The private German ambulatory operators care for % of all by provate operators is expected to be well above % of the total
ambulatory care patients. The non-for-profit providers care for market.
almost the same number of patiens, % of all patients. Public Of all ambulatory cared for children, sucking babies and the age
providers play a minor role with only % of the total patients group 1 to 5 year olds represent patients.
group. In the intensive care sector, the number of patients cared for
CONALLIANCE 15 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYAlmost 700 thousand ambulatory care patients, intensive care patients represent % of all
ambulatory care market patients
In Germany Ambulatory nursing care patients vs intensive Interviews concerning number of
approximately 700 care patients ambulatory intensive care patients
thousand people are
Interviews with clinical doctors in charge for
being cared for by
CAGR: % non hospital artificial ventilation suggest:
ambulatory care CAGR:
services. Only % • The number of new cases has grown
substantially over the last few years.
of these are
ambulatory intensive • Expert estimations about annual cases
This data is no part of differ strongly.
care patients. the publically
The number of available internet • Interviewees have stated new annual
document cases of between 1.000 and 10.000.
ambulatory care
patients grows. The
2013 20161)
number of ambulatory
Intensive care patients Other care Patients
intensive care patients
also grows.
Experts differ strongly
All numbers about patients in the ambulatory intensive care market are registered, hence these numbers are based on various expert estimates.
in their view on not statistically registered. The data about relevant patients can only be The number of patients cared for by ambulatory care services has
obtained in expert interviews and by own calculation. All public statistics increased during recent years at an annual rate of %. During this time
effective growth rates. end at the level of ambulatory care patients, most statistics end in the the number of intensive ambulatory care patients – based on expert
year 2013. estimation – has grown at an comparable annual rate of %.
The total number of ambulatory intensive care patients is not officially
Source: own analysis Conalliance 2016, 2016, , 2016, expert interviews
1) Estimate based on figures „GKV Spitzenverband 2016“: % p.a. growth rate (2014-2015) of ambulatory care patients in long term care
CONALLIANCE 16 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYThe patient base of ambulatory care services is expected to grow at an annual rate of %
The patient base in the Growth prognosis for the care market by type of care provider 2013 to
german ambulatory 2030 (base case)
(mill. patients)
care market is
expected to grow at an
ambulatory service CAGR: XX%
annual rate of %
until 2030. The largest
growth rate is
forecasted for the family care CAGR: XX% This data is no part of
the publically
ambulatory service available internet
patient base. document
stationary CAGR: XX%
total CAGR: XX%
2013 2030
The German long term care market is expected to grow at an growth rates, stationary care grows on market average of %
annual rate of % until 2030. The highest annual growth is annually .
expected in the area of professional ambulatory care (ambulatory
care services) ( % annual growth rate). Family care has the lowest
Source:
CONALLIANCE 17 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYSuppliers
18 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYSummary Suppliers
1. The ambulatory care market is mainly serviced by private 6. Ambulatory care services offer on average the same
and non-profit providers. services of SGB V and SGB XI, % still offer additional
2. The German ambulatory care service market grows at an assistance to care services.
annual rate of %. Of the total number of (in 7. The number of residential communities for intensive care
2016) ambulatory care services, approximately are patients has seen a strong development during the last few
specialized intensive care services. Child care services are a years. Between January 2015 and July 2016, the number of
small niche market segment. Only % of the specialized total places available has doubled. However there are
intensive care services are child care services. strong regional differences. Strongest growth rates can be
3. The total number of ambulatory care services has grown in seen in Rheinland-Palatinate and Mecklenburg-
Germany between 1999 and 2013. However, the trend Vorpommern, minor reduction in places has happened in
differs strongly between federal states. In some federal Bremen and Hamburg.
states – such as - the total 8.
number of ambulatory care services has reduced, In
the total number is stable. In for instance,
the number of services has grown strongly. Exceptional
developments 1999-2013 with regard to the number of 9.
ambulatory care service providers:
• Fastest growth: % CAGR
• Strongest decline: % CAGR 10.
4. In 2013 the ambulatory care service market is dominated
by private providers, representing of all services.
5. There are strong differences in size between the different
provider types, on average the private providers are little 11.
more than half of the size (patient base) of non-for-profit
providers. One quarter of ambulatory care services cares
for or less patients. Mainly the larger care services have
gained size since 2007.
CONALLIANCE 19 M&A ADVISORS FOR THE HEALTHCARE INDUSTRY2% of all ambulatory care services are intensive care service providers, child care ambulatory
services account for 1,3% of total ambulatory care suppliers
The German
# of ambulatory nursing care Avg. # of patients per
ambulatory care # of ambulatory nursing care service providers for CHILD ambulatory nursing care
service market grows service providers CARE service provider
at an annual rate of
%. Of the total CAGR XX%
number of CAGR XX%
ambulatory care 2016: XXX
Child Care
services, approxi- service This data is no part of
mately are This data is no part of providers
the publically
the publically = XXX% of
available internet
specialized intensive available internet total
ambulatory document
care services. Child document
nursing care
care services are a providers
small niche market 2013 2016 2001 2013 2016 2013 2016
segment. Only % of Intensive care providers Child Care specialists Intensive care patients
the specialized Other care providers Adult & Child Care Other care Patients
intensive care services
The number of ambulatory care services has grown substantially at an depend on expert estimates. Experts estimate a total number of
are child care services. annual rate of % since 2013. Of the ambulatory care services ambulatory intensive care services. This represents % of the total
that were registered in 2013, approximately had at least ambulatory care service market. Of these services have
ambulatory intensive care patient. specialized on child care.
The total number of ambulatory intensive care services is not being
registered in official statistics, hence numbers about these services
Source: 2016, , 2016, expert interviews
1) Estimate: patients, intensive care providers
CONALLIANCE 20 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYNumber of ambulatory care services 1999-2013, strong regional differences
# of ambulatory service companies
The total number of
439
ambulatory care SH 354 398
382
402
406
services has grown in
HB 126
399
438 Total # of ambulatory
407
452
German between 1999 116
113 MV services
109
and 2013. However, 111 HH 343 310
314 374 1999: 10.820
the trend differs 334 431
NI 926 343 524
567
2013: 12.745
strongly between 342
998 BE CAGR: 1,2%
1.112
federal states. In some 1.189
ST
NW 1.231 481 BB 516
federal states – such 2.205 460 502 Exceptional developments
2.004 492 548
2.136 521 Fastest growth:
as Saarland, Schles- 2.309 534
598
Berlin +4,4% CAGR
641
2.377 HE
wig-Holstein - the total
860
TH SN 845
Highest decline:
number of ambulatory 411 371 892
376 787 362 972 Saarland - 2,2% CAGR
390 901 389 1.005
care services has
RP 446 1.002 411
417
1.052
451 1.066
reduced, In Hamburg
the total number is SL
153
stable. In Berlin for 131
BW 1.591
115 845 BY 1.583
instance, the number 116 984 1.778
112 1.010 1.829
of services has grown 1.110 1.845
1.140
strongly.
Source: Pflegereport 2016 1999 2003 2007 2011 2013
CONALLIANCE 21 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYPrivate operators dominate the ambulatory care service market with a large number of small
services
In 2013 the Ambulatory care services by provider Average # of ambulatory care
type patients per provider
ambulatory care
(2013 figures) (2013 figures)
service market is
TOTAL:
dominated by private
providers, representing
two thirds of all This data is no part
services. This data is no part of of the publically
There are strong the publically available internet document
available internet
differences in size document
between the different
provider types, on
average the private
private companies public providers
providers a little more private non-profit public
non-profit companies companies companies providers
than of the
number of non-for-
profit providers. The German ambulatory care services are mainly run by private care patients. (see above)
operators. In 2013 they have the largest number of care services On average the private ambulatory care services are smaller in size.
and represent % of all ambulatory care services. Non-for-profit On average they service patients, as opposed to patients
providers have % of all ambulatory care services. Only % of cared for by non-for-profit providers. Public operators have an
all services are run by public operators. average size of patients per care service.
However, private operators only care for % of all ambulatory
Source: XXXXXXXXXX , 2016
CONALLIANCE 22 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYThe ambulatory market is fragmented, the larger services have grown during recent years
Split of ambulatory care services by Services provided by ambulatory care
One quarter of number of patients cared for 2013 services 2007 vs 2013
ambulatory care Growth rate
since 2007
services cares for or
XX%
This data is no part of
less patients. Growth rate other ambulatory services
the publically
Mainly the larger care since 2007 available internet
XX% document
services have gained SGB XII assistance to care
This data is no part of
size since 2007. the publically
available internet
The ambulatory care Growth rate document SGB V
since 2007
services offer on XX%
average the same SGB XI
services of SGB V and This data is no part of the publically available
SGB XI, % still offer 0% 20% internet
40% 60% document
80% 100% 120%
additional assistance 01-10 16-20 26-35 51-70 101-150 2007 2013
to care services. 11-15 21-25 36-50 71-100 151+
Almost half of ambulatory care services ( %) care for have in number. This suggests first consolidation trends
patients in 2013. One third of care services ( %) care for or less All ambulatory care services offer SGB XI (long term care insurance)
patients. Only of care services reach a size of or more services in 2013. The number ambulatory health care services
patients cares for. offering health insurance financed services (SGB V) has grown
Since 2007 especially the larger ambulatory care service providers slightly since 2007. By 2013 % as opposed to % in 2007.
Source: Trendbericht Altenpflege 2015
CONALLIANCE 23 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYStrong increase in capacities of intensive care at residential communities compared to total number
of citizens
Intensive care capacity at residential communities Intensive care capacity at residential
The number of (# of places - split by state) communities (# of pl. per 100 k citizens)
residential
communities for Baden-Württemberg
intensive care patients Bayern
has seen a strong Berlin
development during
Brandenburg
the last few years.
Between January 2015 Bremen
and July 2016 the Hamburg
number of total places Hessen
available has
Mecklenburg Vorpommern
Niedersachsen
This data is no part of the publically
Nordrhein Westfahlen available internet document
However there Rheinland Pfalz
are strong regional Saarland
differences. Strongest
Sachsen
growth rates can be
seen in Sachsen-Anhalt
Schleswig-Holstein
, minor Thüringen
reduction in places
have happened in Total 2015: XXX 2015 2016 Ø 2015: Ø 2016:
Total 2016: XXX XXX XXX
Source: pflegemarkt.com
24
CONALLIANCE M&A ADVISORS FOR THE HEALTHCARE INDUSTRYHealth Expenditures
25 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYSummary Health Expenditures 1. Overall German health care expenditures have grown since 2010 at 3.1% annual growth rate. During the same time ambulatory care expenditures have also grown, at a similar rate of 3.2% annual growth rate. 9. 2. German long term care insurance expenditures have grown since 2000 at % annual growth rate. During the same time ambulatory care service expenditures (SGB XI) have also grown, at same rate of % annual growth rate 10. (Stronger annual growth than overall ambulatory care expenditures). 3. Total ambulatory care service expenditures (SGB XI and SGB V) amounted to Bill EUR in 2015. These are the total 11. expenditures for all ambulatory care services. 4. Experts estimate expenditures for ambulatory intensive care of bill EUR ( % of all ambulatory care expenditures) 12. 5. Yearly health expenditures per person grow at an annual rate of %. The highest health care expenditures per person relate to the age group 85+ years. 6. 13. 7. 14. 8. CONALLIANCE 26 M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
The overall German health care expenditures have been growing at a steady pace, total ambulatory
care expensitures have grown at % annual growth rate since 2010
Overall German health Health Expenditures 2010 - 2014
(in bill. €)
care expenditures have
grown since 2010 at CAGR: XX% This data is no part of
the publically
% annual growth available internet
rate. During the same document
time ambulatory care
Thereof
expenditures have also nursing
CAGR:
XX% services:
grown, at a similar
XXX
rate of % annual
growth rate.
2010 2011 2012 2013 2014
Invest Medical services Food / Accommodation Transportation
Preventional Measures Therapeutical / Care Services Goods Administration
German long term care insurance is guided by the core principle are medical costs. The overall care market represents one sixth
„ambulatory care before stationary care“. The German health ( %) of the total German health care spending’s.
ministry has declared this principle as the main guideline for the The ambulatory care market spending is growing at a simila growth
nursing care market development. In 1995, with introduction of rate than the overall health care market. However it has
the long term care insurance, this principle has continuously been continuously been growing between 2010 and 2014 at an annual
implemented in all laws concerning health care. rate of %.
German health care spending’s have developed since 2010 at an
annual rate of %. Main growth driver for increased spending’s
Source: 2016 , „ , 2016“ / „ 2015“
M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
CONALLIANCE 27Expenditures long term care insurance are part of German health care spendings, all health care
spendings have grown
Long-term Care Insurance Expenditures - split by cost types
German long term (annual spendings in bill. €)
care expenditures have
grown since 2000 at CAGR
CAGR: XX% 2000-2015
% annual growth
This data is no part of
rate. During the same the publically Stationary
time ambulatory care available internet Expenditure:
document
service expenditures XX%
(SGB XI) have also
grown, at same rate of Stationary Total Ambulatory:
total
% annual growth XX%
rate (Stronger annual Ambulatory
Ambulatory Services:
growth than overall
total
XX%
ambulatory care
expenditures). 2000 2014 2015
Stationary Care Ambulatory Services Appliances
Financial support ("Pflegegeld") Day/night/exceptional nursing care Other
German long term care insurance has payed in 2014 Bln Euros services has grown at an compound annual rate of %. The
for ambulatory care services. This represents with % of the total growth for spending’s in ambulatory care services is higher than the
spending of the long term care insurance. This is the third larges spending’s for stationary care services during the same time period.
area of spending’s of the long term care insurance. ( %)
Since 2000 German long term care spending’s for ambulatory care
Sources: , 2016“; „GKV Spitzenverband, 2016“
CONALLIANCE 28 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYExpenditures for intensive care patients (2% of total ambulatory care patients) account for 33 % of
total ambulatory care expenditures
Ambulatory Care Service Expenditures - split by
Ambulatory care
SGB V / XI
service expenditures
(annual spendings in bill. €)
(SGB XI and SGB V)
amounted to EUR
in 2015. These are the CAGR: XX%
total expenditures for
ambulatory care Ambulatory intensive care
services. services account for
Experts estimate
expenditures for
This data is no part of ~ bill. EUR
the publically t/o
ambulatory intensive available internet Ambulatory intensive
document care services
care of EUR ( %
of all expenditures).
2014 2015 2015
Ambulatory Services SGB XI
Ambulatory Services SGB V
German long term care insurance has payed in 2014 Euros services has grown at an compound annual rate of %. The
for ambulatory care services. This represents with % of the total growth for spending’s in ambulatory care services is than the
spending of the long term care insurance. This is the spending’s for stationary care services during the same time period.
area of spending’s of the long term care insurance. ( %).
Since 2000 German long term care spending’s for ambulatory care
Sources:„XXXXXXXXXX , 2016“; „GKV Spitzenverband, 2016“, Expert interviews
CONALLIANCE 29 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYHealth expenditures grow strongly with age
Yearly expenditures Yearly healthcare spending‘s by age group by
person 1) CAGR 2002 - 2008
per person grow at an
annual rate of %. XX% XX%
The highest health XX%
care expenditures per XX%
person relate to the XX%
age group 85+ years.
XX%
This data
is no part XX%
of the
publically
available
internet
document
2002 2004 2006 2008
< 15 years 30 - 44 years 65 - 84 years The official data for health care to 84“ and „85 +“) account for the
spending‘s by age group are highest health care spending‘s
15 - 29 years 45 - 64 years 85 + years dated, but give an indication for per person. Growth rates of
an cost trend and relative costs spending‘s per person were high
between the different age in the age group 65-84 years of
groups. age (second highest growth rate).
The two growing age groups („65
1) Now more recent data available by German statistics office
CONALLIANCE Source: 30 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYIndications
31 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYSummary Indications
1. The total number of clinics serving acute intensive care 6. To avoid bias, case study two (Linde company data) has not
patients is (CAGR: %) between 2010 and been included into the market model base data.
2014. However the total number of intensive care beds is
(CAGR: %) during the same time period.
Also the number of cases with artificial respiration during
intensive care has increased from 2010 to 2014 by %
annual growth.
2. The most relevant indications causing the need for
ambulatory intensive care are Amyotrophe Lateral Sclerosis
and COPD. Mostly chronical neurological and
pneumological diseases can lead to ambulatory intensive
care. These cases have grown in German hospitals at an
annual rate of % (until 2012) and % in recent years.
3. Cases of tracheostomy have increased over time. The
increased rates since 2008 are at around % annually.
4. COPD cases in German hospitals are expected to at an
annual rate of % until 2030. % of the registered
cases are classified severe cases. These cases have a high
likelihood to receive artificial ventilation (a main cause for
ambulatory intensive care need).
5. Research identified case studies about the disease
structure of residents (patients) of ambulatory intensive
care residential communities. Cases one and three are
regionally focussed case studies, Case two has been
initiated by Pneumological / lung diseases
are number one cause for ambulatory intensive care need.
CONALLIANCE 32 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYTrend towards specialised clinics and ambulatory intensive nursing service
The total number of Number of hospitals in Germany total / thereof intensive care
CAGR
(2013 figures) 2010-2014
clinics serving
intensive care patients XX%
XX%
is declining (CAGR:
%) between 2010 This data is no part of
the publically
and 2014. However
available internet
the total number of document
intensive care beds is XX%
XX%
increasing (CAGR:
%) during the same
XX%
time period. Also the
number of cases with
artificial respiration
2010 2011 2012 2013 2014
during intensive care
Total # of Hospitals
has increased from
Hospitals with intensive care
2010 to 2014 by % # of Intensive care beds in Hospitals
annual growth. Number of cases with artificial respiration during intensive care (in thousand cases per year)
Source: XXXXXXXXXX , 2016
CONALLIANCE 33 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYMost relevant clinical indications for ambulatory intensive care show significant increase
Hospital care cases
The most relevant
Main relevant diseases for ambulatory intensive care
indications causing the
need for ambulatory
XX%
intensive care are
Amyotrophe Lateral
Sclerosis, COPD. This data is no part of
the publically
Mostly chronical available internet
neurological and document
XX%
pneumological
diseases lead to
ambulatory intensive
care. These cases have
grown in German
hospitals at an annual
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
rate of
ALS Other Myopathies Obstructive lung diseases
in recent years.
Main relevant diseases responsible for cases of ambulatory care services CAGR 2005-2014
ALS %
Other Myopathies %
Obstructive lung diseases %
Source: Statistisches Bundesamt, Wiesbaden 2016
CONALLIANCE 34 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYEspecially COPD is a growing disease, it is #4 of the most wide spread diseases
Clinical cases by Indication
COPD cases in German
hospitals are expected COPD LUNG DISEASE
to grow at an annual
rate of % until
2030. % of the CAGR: XX%
registered cases are
classified severe cases.
These cases have a
high likelihood to
This data is no Serious state
receive artificial part of the Total # of COPD cases
publically
ventilation.
available
internet
document
2010 2030
Source: Statista.com, 2016; Lungeninformationsdienst, 2016
CONALLIANCE 35 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYVarious indications trigger the need for patients for intensive care - Examples
This chapter is no part of the publically available internet report
CONALLIANCE 36 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYUnderlying Assumptions
and First Results
of the ambulant intensive care market
value projection
37 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYSummary Assumptions underlying the calculation of market value projections
1. There are no official statistics about intensive ambulatory of stay in ambulatory intensive care on average (also based
care patients, services or expenditures. Therefore, the on expert interviews)
approach chosen uses manifold sources of information to 8. Accomodation structure is assumed to change over time,
either gain data points from which to further expand starting with Single accomodation share in 2013 as % of
analysis or to prove previous assumptions or results from patients, Residential communities (2013: %), and Child
other steps of the analysis. care (2013: %). It ends up with respectively
2. Research through various sources generated base in 2030.
parameters: base prices, growth rates, etc. 9. Furthermore, the calculation of the development of the
3. Market development was assessed in two scenarios, market is based on a set of various parameters:
conservative and realistic. The underlying assumptions were a. Single service patients receive 24hrs of care service per
taken from expert interviews as well as from research of day
various other expert sources. b. Patients in residential community accomodation
4. Key parameters are the annual increase in number of new receive 24 hrs of service, but share service personnel at
cases through aging of population and impact of medical a ratio of patients per service hour.
progress. Taking into consideration information from c. Pricing is assumed to start with 2016 values as follows:
experts, a cases per year and a % € per hour for single care, € for residential
annual rate of further growth of new cases were assumed in care (taking into account assumed care intensity
the first year, over time % ratio), € per hour for child care.
increase in 2030. d. % inflation per year (baseed on medical inflation rates
5. The increase rates assumed are the result of expert in recent years)
interviews (mainly medical doctors) revealing expert e. Regional factors – although to be considered in detailed
estimates on the number of new cases in 2013 at between evaluation – were not taken into account in the first
cases per year. round of market evaluation.
6. Age split of patients assumed with 0 – 19 years: %, 20 – 49 10. Consolidation of research results reveals an estimated
years: %, 50 – 69 years: %, and 70 + year: % were CAGR of the number of ambulant intensive care
taken from a combination of various sources available. patients (around patients – model realistic), leading
7. Panel mortality rate is assumed with % of total # of to a market volume CAGR of between % and % in the
patients per year, constant until 2030, equalling years period between 2012 and 2025 ( ).
CONALLIANCE 38 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYA manifold variety of sources has been consulted to build a reliable model of the ambulant intensive
care market
There are no official
statistics about • Official public data could be found for
intensive ambulatory
care patients, services Historical demografic development and demografic forecast
or expenditures. Patient and ambulatory care service details for patients and services financed by long
The aproach chosen term care insurance
uses manifold sources
of information to either • Other data base information and studies could be found on
gain data points, from
which to further expand Future development of number of patients of long term care
analysis or to prove Number of child care patients and services
previous assumptiona Type of medical indications and age split cared for by intensive ambulatory care
or results from other services
steps of the analysis.
• Expert interviews and specialist literature has been drawn on
Selected specialized information on ambulatory intensive care patients and services
Forecast of ambulatory intensive care patient cases
Official
statistical
data
Database Interview
CONALLIANCE 39 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYCalculation of patient cases / demand as hours of service required in Germany in ambulatory
intensive care
Research through QUANTITIES PRICING
various sources
Market Growth Factors Pricing factors
generated base Prices 2016 • Base Price per
Population Growth
parameters: base # of Patients 2013
• Aging Population (hourly rates) accomodation type
prices, growth rates, • Medical • Inflation rate
etc. improvement • Other
• Panel mortality of • ….
existing cases
Market Structure # of Patients Prices 2013 – 2030
• Development of 2013-2030 • Hourly rates
Accomodation Type • By year • By year
over time (2013-30) • By accomodation type • By accomodation type
Scope of hourly support
required
• Service hours per
case required - by
accomodation types # of Service hours total
• Development over market 2014-2030
time • By year
• By accomodation type
Total market 2014-2030
• By year
• By accomodation type
Sources of information Information compilation method: Result:
• Expert interviews • Bottom-up calculation • Dynamic model with options to build Scenarios
• Various Statistics • “Triangulation” with external expert
• Own calculation sources
M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
CONALLIANCE 40This chapter is no part of the publically available internet report CONALLIANCE 41 M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
Market model
OPTION “A”: 2012 - 2025
- split by age cohorte –
Various combinations of parameters
“market growth rate” and “share of residential communities”
55 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYThis chapter is no part of the publically available internet report CONALLIANCE 56 M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
Market model
OPTION “A”: 2012 – 2025
- split by accomodation type –
Various combinations of parameters
“market growth rate” and “share of residential communities”
65 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYThis chapter is no part of the publically available internet report CONALLIANCE 66 M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
Part II
Regulatory Assessment
77Summary Regulatory (1/2) 1. Social Codes books V and XI are the basic laws for care in this form of living in comparison to inpatient care. Germany 6. With this package of measures, residential (intensive) care 2. SGB V rules all the provisions for public health insurance, communities have been incentivized. This already led to a whereas SGB XI governs all the provisions for long term significant increase of residential (intensive) care care insurance. communities within recent years and we expect this trend 3. Social Codes books V and XI are modified and to continue – even at an increased level. complemented by a large number of laws and acts as e.g. 7. PSG II will change the current five care grades into three PSG I to III. PSG I is already in force, PSG II will come into future care levels. Patients in need of care have a force on January 1, 2017 (and most propably also PSG III). grandfathering, i.e. they will automatically pass from their PSG I to III mean a significant reform of the current law, and current care grade into the new care level without further thus reform pressure for the years to come can be examination. There will be up to 500.000 new beneficiaries evaluated to be rather small and restrained. As a (estimate by Federal Ministry of Health), 60.000 of them in consequence planning security can be assessed as fairly facilities for disabled people. Moreover all new nursing high. grades will grant higher monetary payments and 4. SGB XI – long term care insurance only finances a smaller ambulatory care patient contribution in kind, than the portion of all ambulatory intensive care services. The cost current cursing grades. for intensive care services is negotiated individually 8. According to experts, the next election result will not have between the health insurance of the patient and the a great impact on care politics. The program of the parties intensive care service provider for each and every case. For differs in this policy field only in details. intensive care patients, the negotiated hourly rate must be 9. paid jointly by the public health insurance, the long-term care insurance and sometimes also by the patient himself (own contribution/ co-payment). This procedure is evaluated by politicians to be suboptimal, but there no reform concept has been presented lately. 5. Benefits for residential (intensive) care communities were (next page) granted – also by PSG I to III – in order to support and favor CONALLIANCE 78 M&A ADVISORS FOR THE HEALTHCARE INDUSTRY
Summary Regulatory (2/2)
9. action for the (next) federal government. At the same time intensive care) mean a regulatory challenge for care service
it must be considered, that Germany is in a favorable providers, because of the different law in each federal
current economic situation. If this current situation state.
declines, there might be pressure on the public health 15.
systems quickly.
10.Because of the fact, that cost for intensive care services is
negotiated individually, the improvements in payments and
contributions (mentioned before) do not have any direct 16.
impact on the charges intensive care services may cash up,
because of the individually set hourly rates, which are not
directly affected by PSG. However the patient’s own
contribution/ co-payment could decrease. 17.
11. Future goals will become a professionalization of care in
terms of management, planning, guidance and control. The 18.
trend shows, that this professionalization should be
implemented by the federal states individually.
12. Residential care communities (also intensive care) seem to
be a future concept, because in general they decrease cost
for health and care insurances and at the same time
increase margins of care service providers (mostly by lower
supervision ratio).
13. However, new single agreements for ambulatory intensive
care 19.
intensive care
service providers through negotiation. 20.
14. At the same time, residential care communities (also
CONALLIANCE 79 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYOverview of relevant German law in ambulatory care (excerpt)
Social Codes books V and Social code / Sozialgesetzbuch (SGB)
XI are the basic and thus
most important laws for
Original Law
Sozial- Sozial-
care gesetzbuch gesetzbuch
(SGB V) (SGB XI)
This information is
1989 1995
no part of the
1989
publically available
Social codes
Social codes internet document
Translation
(Long term
(Public health
care
insurance)
insurance)
German ambulatory care market is governed by a the most important of all applicable laws for
larger number of interlinked regulations. During ambulatory care in Germany.
past almost 30 years the care relevant legislation The care of the patient is divided into SGB V and
has been continuously supplemented by additional SGB XI.
legislation.
SGB V summarizes all the provisions for public
The main law is the social code with health insurance. It regulates access and financing
„Sozialgesetzbuch“ (relevant SGB V and XI), being to medical services and service providers (next page)
CONALLIANCE 80 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYOverview of relevant German law in ambulatory care (excerpt)
Social Codes books V and ambulatory and stationary. The majority of Familie und zivilgesellschaftliche Aufgaben, BAFzA).
XI are modified and ambulatory intensive care services are reimbursed
by SGB V, health insurance. The PNG entered into force on October 30, 2012.
complemented by a large With the “Pflegeleistungs-Ergänzungsgesetz” from
number of laws and acts. SGB XI – long term care insurance only finances a 2002 it complements the care insurance and has
smaller portion of all ambulatory intensive care been extended through the PSG from 2015.
The cost for intensive are services. The cost for intensive are services is
negotiated individually between the health
services is negotiated insurance of the patient and the intensive care
individually between the service provider for each and every case. This
health insurance of the procedure is evaluated by politicians to be
patient and the intensive suboptimal, but there has not been presented any
reform concept lately.
care service provider for
each and every case. The „Pflegeweiterentwicklungsgesetz (PfWG)“ is a
so called „Artikelgesetz“, which influences and
changes several other laws, e.g. article 1 and 2 of
PfWG change the SGB XI, article 3, which comrises
the PflegeZG.
The PflegeZG allows employees to be released
from work duties for a limited time in order to care
for relatives in need of care, without suffering from
downsides or risks of jeopardising the employment
relationship. The FPfZG is a supplement to PfZG
and allows a limitation to 15 working hours/ week,
limited to two years. Half of the lost earnings are
covered by the government (Bundesamt für
CONALLIANCE 81 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYSGB V
Social Codes book V The Fifth Book of the Social Code (SGB V) example, wound care, dressing changes,
governs public health summarizes all the provisions for public health medication administration, medical assistance,
insurance. The SGB V entered into force on 1 blood sampling, ostomy care, also: meshed vital
insurance January 1989th. signs monitoring, invasive / non-invasive
ventilation).
The chapters are:
According to § 106 SGB V Insurance companies
1. General provisions and physicians' associations monitor the economic
2. Insured persons efficiency of medical care for outpatient services
3. Health insurance benefits and assess the indications, effectiveness and
4. Relationships of health insurance to care quality of services provided.
providers
5. Experts for the Assessment of Developments in In health insurance law, since 1994 the right of the
Healthcare patient in need of care for full inpatient hospital
6. Organisation of health insurance treatment is granted only, if the treatment goal
7. Associations of sickness can not be achieved through partial inpatient, pre-
8. Financing and post-inpatient or outpatient treatment
9. Medical service of the health insurance including domestic Nursing (§ 39 Abs. 2 SGB V; §
10. Insurance and performance, data protection, 43 Abs. 1 SGB XI, “ambulant vor stationär”). The
data transparency welfare law provides a number of benefits, to
11. Penalties and fines rules enable the patient to receive care in one's own
12. Reconciliation Regulations governing the household (§§ 63 Satz 1, 64 - 66, 70 SGB XII). This
reunification of Germany principle has been confirmed by politicians within
13. Additional transitional provisions the last couple of years, as e.g. recently by Federal
Minister of Health Hermann Gröhe in 2015.
Patients in need of (intensive) care, who are cared According to our analysis, there is no intention to
by an ambulant care service, can according to SGB change this principle for the future.
V receive contributions for treatment care (for
CONALLIANCE 82 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYSGB XI
Social Codes book VXI The Eleventh Book of the Social Code (SGB XI) The remuneration of outpatient care services and
governs public care contains the rules for the social care insurance in household assistance is based on uniform
Germany. principles (§ 89 SGB XI). A differentiation in the
insurance remuneration according to different payers is not
According to SGV XI patients in need of (intensive) allowed. For these compensation agreements the
care, who are cared by an ambulant care service, umbrella organizations of care funds have given a
can receive contributions for home care, as basic recommendation shortly after introduction of
care and household assistance (basic care: as help care.
washing, eating, dressing and undressing).
If the patient has appointed an authorized care
Only those care service providers with a supply service, it has to specify the content and extent of
contract with the care funds may render their the services, including agreed compensation with
services at the expense of the long term care the care in detail in a contract (§ 120 SGB XI).
insurance (§ 72 SGB XI).
The care insurance pays for the consumption
To ensure efficient and effective nursing care, the certain care aids, such as disposable gloves or
“Landesverbände” (national associations) of the mouthguard. If the patient needs additional care
nursing care insurance have to enter into so called aids, such as a walker, a bath lift or carephone the
“Landesrahmenverträge” (master agreements for doctor can prescribe it. The insurance company
each state) together with the association of bears the cost.
outpatient and stationary nursing facilities and
with the participation of the MDK (medical service According to § 43 Abs. 1 SGB XI home care has to
of the health insurance), the Association of the be vantage amongst inpatient care: The goal of the
local social welfare institutions and the association care insurance is primarily to support home care,
of private health insurance ( § 75 SGB XI). This is so that patients can remain in their home
directly binding on the care funds and eligible care environment as long as possible. Home and short-
services. time care take precedence over inpatient care.
CONALLIANCE 83 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYSGB XI: Benefits for residential (intensive) care communities
Adjustments of Social Patients with care level, who are living in a By these measures, residential (intensive) care
Codes book XI favor and residential care community, have the same rights communities are given advantages to the
to care services as people who are cared for at stakeholders: On the one hand, the dependency
support care home (eg. as care allowance, care benefits in kind, between the patient and the care provider is
communities, which leads care aids, short-term care, etc.). reduced, patients can save money and live in an
to a win-win-situation for environment together with people, who are
patients, intensive care In addition, each group member (precondition affected by the same obstructions and handicaps.
care level > “0 with limited everyday skills“) will On the other hand, care providers could currently
providers and (public receive per month € 205 Euro (from January 1, increase their margins because of operational
care) insurance 2017 214 Euro) according to § 38a SGB XI savings (i.e. better relation between labor cost and
(requirements for these additional services, please work input because of an advantageous care
see § 38a SGB XI). ratio). And at the same time, public care insurance
benefits from lower hourly rates (also because of
Additionally each patient in a residential the advantageous care ratio).
(intensive) care community receives a onetime
payment amounting to 4.000 Euro With this package of measures, residential
(“Wohnumfeldverbessernde Maßnahmen“). This (intensive) care communities have been
grant is limited to a maximum of 4 persons per incentivized. This already led to a significant
residential (intensive) care community, i.e. a total increase of residential (intensive) care
of 16.000 Euros. communities within recent years and we expect
this trend to continue – even at an increased level
Usually there are more cost advantages to a (please find more detailed information on this
residential care community: Costs for domestic aid topic in the „market chapter“ ).
can be shared and typically rental costs and
incidental expenses are lower in a residential
community, than for a one- or two-bedroom
apartment.
CONALLIANCEOverview of Landesrahmenverträge according to § 75 Abs. 1 SGB XI
full-time institutional part-time institutional
State law modifies and Federal state ambulatory care Short-term care
care care
compliments federal law. Rahmenvertrag für das Land Baden-
Baden-Württemberg Württemberg - 09.07.2002
Thus regulation is
different in (almost) all Bayern Rahmenvertrag für das Land Bayern
Rahmenvertrag für das Land Berlin -
states within Germany. Berlin 01.10.2011
Rahmenvertrag für das Land Brandenburg -
Brandenburg 01.05.1997
Rahmenvertrag für das Land Bremen -
Bremen 01.08.1997
Rahmenvertrag für die Freie und
Hamburg Hansestadt Hamburg - 17.11.2009
Hessen
Rahmenvertrag für das Land Hessen -
01.05.2009 This information is
Mecklenburg- Rahmenvertrag für das Land Mecklenburg-
Vorpommern Vorpommern - 01.07.2009
no part of the
publically available
Rahmenvertrag für das Land Niedersachsen
Niedersachsen - 01.01.2001
Nordrhein-Westfalen
Rahmenvertrag für das Land Nordrhein-
Westfalen - 01.10.1999 internet document
Rahmenvertrag für das Land Rheinland-
Rheinland-Pfalz Pfalz - 01.01.2007
Saarland Rahmenvertrag in Saarland - 01.01.2011
Rahmenvertrag im Freistaat Sachsen -
Sachsen 01.06.2012
Rahmenvertrag in Sachsen-Anhalt -
Sachsen-Anhalt 01.08.2004
Rahmenvertrag für das Land Schleswig-
Schleswig-Holstein Holstein - 01.07.1996
Thüringen Rahmenvertrag Thüringen - 21.10.1998
CONALLIANCE 85 M&A ADVISORS FOR THE HEALTHCARE INDUSTRYYou can also read
