The Acquisition Playbook Breaks at the Talent Level

The traditional PE-backed healthcare platform playbook looks like this: acquire at speed, integrate rapidly, cut costs, centralize operations. It's worked brilliantly for hardware, software, manufacturing. In healthcare, particularly clinical platforms, it's breaking.

Here's why: healthcare platforms are acquiring good assets—usually a profitable clinic, a staffing model, a patient base—but they're buying them as operational entities, not talent platforms. And in healthcare, the operational entity is almost entirely talent.

You can consolidate vendor contracts. You can centralize accounting. You can merge IT infrastructure. What you cannot do without destroying value is consolidate clinical talent and organizational culture without losing people and, more importantly, losing the outcomes that made those businesses valuable in the first place.

A PE portfolio company we worked with acquired three ABA therapy clinics. Profitable clinics. Good outcomes. Good staff. The integration plan was solid: consolidate back-office, standardize processes, rationalize staffing. In 18 months, they'd lost 40% of their BCBAs and 60% of their front-line therapists. Outcomes degraded. Patient satisfaction dropped. The acquisition was eventually sold at a loss.

In healthcare, the operational entity is not the building or the process. It's the people. And people are the one thing you can't integrate without attention and intention.

Operating Partners Are Waking Up to Talent as a Value Lever

The smartest PE firms are now embedding talent specialists—either building recruiting competency in-house or partnering with firms that understand both PE and healthcare—as core operating team members. Not post-acquisition. Pre-acquisition.

They're asking different questions during diligence:

  • What's the attrition rate? (If it's below 10%, be suspicious. Healthcare attrition at sustainable clinics is usually 10-18%.)
  • What's driving retention? (Is it compensation? Culture? Patient outcomes? Something else?)
  • How dependent is clinical quality on key people? (Red flag if two therapists leaving tanks your outcomes.)
  • What's the market for talent in this geography? (Can you backfill clinical roles? At what cost?)
  • Who would leave in an acquisition? (Be honest about which people will leave if you change compensation, decision-making, autonomy.)

Operating partners who ask these questions are finding that talent acquisition and retention is a value creation lever, not a cost center. In fact, for many healthcare portfolio companies, it's often the most important lever.

The Winners Are Embedding Talent Acquisition as a Core Competency

Here's what the best PE-backed healthcare platforms are doing:

Before the acquisition: They're including talent specialists in diligence. They're stress-testing the talent model. They're asking "what happens if X number of people leave?" They're modeling the cost of talent loss on EBITDA.

Day one post-acquisition: They're not consolidating recruiting. They're bringing in embedded recruiting resources to start building a retention and acquisition strategy immediately. Not 90 days in. Day one.

Months 1-6: They're actively communicating with clinical staff about what's staying the same (compensation, clinical autonomy, patient assignments) and what's changing. They're addressing the uncertainty that causes people to start job hunting the moment they hear about an acquisition.

Months 6-12: They're using acquisition momentum to build talent pipelines. Now that they own multiple clinics, they can start thinking about career laddering. An RBT at clinic A can move to clinic B. A therapist can move into a supervisory role across the platform. This is when talent becomes a competitive moat.

Year 2+: They're not hiring for each clinic individually. They're hiring into a platform. They're building employer brand around growth, clinical excellence, and career opportunity. This attracts better talent than individual clinics can.

For one PE client we're working with, this approach has meant:

  • Attrition dropped from 28% (pre-acquisition blended rate across three acquired clinics) to 12% by year two.
  • They're able to fill open clinical positions in 8 weeks instead of 12-16 weeks. (In healthcare, that's enormous.)
  • Patient outcomes improved. (Because clinical continuity matters.)
  • They acquired a fourth clinic and integrated it much more smoothly because the talent playbook was already proven.

Why Contingency Recruiting Fails in Healthcare PE

Most PE firms default to contingency recruiting for portfolio company hiring. It's scalable, it's low-risk from a budgeting standpoint, and it works fine for hiring accountants and office managers.

In clinical healthcare, contingency recruiting is insufficient because:

1. Speed kills, but quality kills faster. A contingency recruiter has incentive to fill roles as fast as possible. In healthcare, a bad clinical hire damages patient outcomes, patient trust, and team morale. Speed and quality are in direct tension. Contingency structures create misalignment.

2. Talent economics are different in healthcare. Good BCBAs have options. They're not passively job hunting. A contingency recruiter needs to fill the role. They don't need to sell the role. An embedded recruiter spends 40% of their time on recruitment marketing and talent cultivation because that's where the value is.

3. Portfolio effects are invisible to contingency recruiters. If one clinic is stealing talent from another clinic to fill a role, you've moved the problem, not solved it. Contingency recruiters don't care. Embedded recruiters can see this and optimize for the portfolio.

4. Onboarding and retention are invisible to contingency recruiters. They're paid at placement. What happens in month 4 when the new BCBA realizes the schedule is worse than expected and starts looking? Not their problem. Embedded recruiters care because their success metric is retention.

The Embedded Model Scales Hiring Capacity With Deal Flow

One of the smartest things PE firms are doing is building talent acquisition capacity that scales with deal flow, rather than headcount.

Traditional model: You have two recruiting coordinators. They can support 5-10 open requisitions. When you acquire a new platform company with 20 open roles, you panic. You hire more recruiters. Then the deal flow slows and you're overstaffed.

Embedded model: You have a core recruiting leadership team (1-2 people) embedded in the PE firm. When deal flow is light, they're building recruiting infrastructure, employer brand, talent pipelines. When you close an acquisition, you immediately bring in additional recruiting resources (temporary or contract-based) to handle the surge. Then they cycle out. Your fixed cost is low. Your variable cost scales with deal flow.

For a mid-market PE firm, this means:

  • Lower recruiting overhead than traditional embedded recruiting
  • Better quality hiring outcomes than pure contingency
  • Better data on talent economics across the portfolio
  • Ability to consolidate talent (move people across portfolio companies) without going through external recruiting

Healthcare Recruiting Is Harder Than Tech Recruiting

Let's be direct: healthcare recruiting is a different discipline than tech recruiting. The same playbook doesn't work.

Credentialing and licensure: A software engineer is portable. They take their skills anywhere. A BCBA is licensed to specific states. A physical therapist needs licensure and often needs to be licensed to the state where they're practicing, even for telehealth. This creates geographic constraints that tech recruiting doesn't face.

Mission-driven candidates: The best clinical talent in healthcare is often mission-driven in a way that tech talent isn't. They didn't go into ABA or nursing or respiratory therapy to get rich. They went into it to help people. Your recruiting story needs to speak to that. "We have great equity upside" doesn't move most healthcare professionals. "We're building the best clinical outcomes in the market" does.

Long hiring cycles: Tech hiring can move in 2-3 weeks. Healthcare hiring is often 2-3 months. Why? Because good clinical talent is employed elsewhere. They're not urgent about finding a new job. You need to build a relationship. You need to understand their constraints (does the new commute work for them? Are they tied to a specific patient population? Do they need a specific schedule?). Transactional recruiting doesn't work.

Lower salary expectations than tech: Healthcare professionals are not expecting venture-scale compensation. If you're using a traditional tech recruiting firm accustomed to compensating engineers, your compensation packages will be off. You'll either overpay for mid-level talent or underpay and lose people you really want.

Employment economics: In tech, hiring is about headcount. In healthcare, it's about FTE, utilization, billable hours, and margin. A BCBA costs you $80K salary but generates $150K revenue. The economics are different. Your recruiting strategy needs to account for that.

What This Means for Your Portfolio

If you're a PE firm investing in healthcare platforms (clinical or payor or tech-enabled health services), talent is not a post-acquisition integration problem. It's a value creation lever that should be included in diligence and baked into your 100-day plan.

The best outcomes we're seeing are when PE firms:

  • Embed talent specialists in operating partner teams before acquisition
  • Build talent economics into their model (understand the talent cost of scaling)
  • Recognize that healthcare recruiting requires different expertise than tech recruiting
  • Allocate recruiting budget as an investment in value creation, not a cost center
  • Measure recruiting success by first-year retention and outcomes impact, not speed to fill

The platform companies that are winning are the ones where talent strategy is inseparable from business strategy. Because in healthcare, talent is the business.