Valuation of a Medical Practice

Reed Tinsley, CPA, CVA, CFP, CHBC

Need for a Valuation• Practice Sale

• To another physician• Acquisition by a hospital• Acquisition by other entity

• Retirement/Withdrawal• Buy/sell agreements• Buy out value based on FMV• Appraisal vs. formula methodology

Need for a Valuation

• Divorce• Refer to all related state law• Refer to all related state case law

• Merger• Distribution of initial equity

interests• Distribution of sales proceeds

Need for a Valuation

• New Owner Buy-In• If buy-in will be based on FMV• Formula approach?• Structuring the buy-in• Tax reporting issues

• Litigation

Key Point #1

The "strength" of the practice's income stream and what it produces for the owner(s) is what creates true value in a medical practice.

Key Point #2

The key to a successful valuation is deciding whether or not the practice's future income stream will mirror its present income stream.

Regulatory Issues Impacting the Valuation Process

Regulatory Issues

• Medicare Fraud and Abuse• Known as the "anti-kickback law"• Prohibits payments, offers, or

inducements of any remuneration for referrals

• Issue: If acquisition price exceeds FMV, transaction may be considered a remuneration for referrals• Generally applies to hospital

acquisition transactions

Regulatory Issues

• Stark II self referral law• Prohibits physicians from making

referrals for designated health services,

• If a financial relationship exists between the physician and the entity to which he or she is referring

• Stark definition of FMV

Defining Fair Market ValueStark II regulations states, as follows:“Fair market value means the value in arm’s length

transactions, consistent with the general market value. “General market value’’ means the price that an asset would bring as the result of bona fide bargaining between well-informed buyers and sellers who are not otherwise in a position to generate business for the other party, or the compensation that would be included in a service agreement as the result of bona fide bargaining between well-informed parties to the agreement who are not otherwise in a position to generate business for the other party, on the date of acquisition of the asset or at the time of the service agreement.

Defining Fair Market ValueStark II regulations states, as follows:Usually, the fair market price is the price at which bona

fide sales have been consummated for assets of like type, quality, and quantity in a particular market at the time of acquisition, or the compensation that has been included in bona fide service agreements with comparable terms at the time of the agreement, where the price or compensation has not been determined in any manner that takes into account the volume or value of anticipated or actual referrals.” (Federal Register, Vol. 69, No. 59, March 26, 2004, page 16128)

Valuation Note: This may restrict and prevent the use of certain market comps

Defining Commercial ReasonablenessStark I regulations states, as follows:• “With respect to determining what is “commercially reasonable,” any

reasonable method of valuation is acceptable, and the determination should be based upon the specific business in which the parties are involved, not business in general. In addition, we strongly suggest that the parties maintain good documentation supporting valuation.” (Federal Register, Vol. 66, No. 3, January 4, 2001, page 919)

Also, Stark II regulations state the following:• “An arrangement will be considered “commercially reasonable” in

the absence of referrals if the arrangement would make commercial sense if entered into by a reasonable entity of similar type and size and a reasonable physician (or family member or group practice) of similar scope and specialty, even if there were no potential DHS referrals.” (Federal Register, Vol. 69, No. 59, March 26, 2004, page 16093)

• Valuation Note: Just because a transaction may be “fair market value” does not necessarily make it “commercially reasonable”

Regulatory Issues

• Private Inurement• Applies to tax exempt hospitals - section

501 (c) (3)• Defined: No part of a hospital's net

earnings may inure to the benefit of any private individual

• Issue: Sales price in excess of FMV

KEY Factors

Impacting the Valuation of a Medical Practice

Key Factors

• Revenue and Cost • Revenues

• Increasing or declining?• Where did the revenues come from?

• Ongoing revenues?• If owner(s) stays• If owner(s) leaves

• One-time revenues?

Key Factors• Revenue and Cost

• Revenues (continued)• Revenue adjustments: Teaching, subsidies,

Drug studies, medical directorship, special service revenues

• Impact of CPT coding• New doctors ramping up their productivity

Key Factors

• Revenue and Cost• Costs

• Comparable to similar practices• Adjust to reasonable cost structure if

necessary• Look for excess doctor-related costs that

are in reality disguised compensation• Make using normalization adjustments

Key Factors

• Costs to pay attention to:• Salary costs• Physician direct expenses (Travel,

CME)• Expiring leases• One-time costs• Adding costs as projected

revenues grows

Key Factors

• Medical Specialty• Impacts future reimbursement

patterns• Review recent and anticipated

changes to coding and charge payment

• Impacts• Adjustment for “reimbursement risk”• Impact on discounted future cash flow

method – future revenues

Key Factors

• Referral Sources• Applies to medical specialists• Issue: Will these referrals continue

into the future uninterrupted?• Obtain and analyze referring doctor

report• Analyze ages of the referring doctors• Identify recent changes to referral

patterns

• Impacts discount/capitalization rate or future revenue stream

Key Factors• Payer Mix

• Has direct impact on revenue stream• Impacts what the practice is paid for the

services it renders

• Identify recent changes to practice payer mix• Ex. Growth in managed care and Medicare

• Anticipate future changes in payer mix• Impacts reimbursement risk & revenue

projection

Key Factors• Service Mix

• Identify how the practice generates its revenues• Obtain and analyze CPT Frequency

Report

• Issue: Will these same services continue if there is a change in practice ownership?

• Impacts future income stream determination and related risks

Key Factors• Patient Demographics

• Identify demographics of practice patients• Issue: Will these demographics change in

the near future• Move to a different a payer class which pays

more or less• Ex. Patients moving into the Medicare program

• Impacts discount/capitalization rate• Might impact revenue growth projection

Key Factors

• Future Changes to Reimbursement • Has direct impact on income stream• Issue: Continued payer changes in

reimbursement rates• Medicare• Managed Care

• Impacts discount/capitalization rate• Impacts future earnings projection

Key Factors

• Practice Transition • Issue: Will the current owner(s) be

available to assist in the transition to the new owner?• If yes, can expect to maintain

revenues• If no, anticipate a drop in patient

volumes or referrals

• Generally want a transition period of 6 mo.

Key Factors

• Competition• Issue: Are there, or will there be,

competitors that will, or can, take patients away from the practice now and in the future?

• Is a practice “risky” if it doesn’t have competition?

Review Data Gathering Checklist

Business tax returns for year 2010 - 2012

1. Detailed tax depreciation schedule for year 2012

2. If available from tax preparer, future depreciation report

If you use Quickbooks, please prepare and email a "Portable" backup file

(Please provide QB version and any related login information)

For years 2010, 2011 and 2012, please list all non-operating, non-recurring expenses paid in each year

If you do not use Quickbooks:

1. Financial statements for years 2010 -2012 on the cash basis of accounting; most recent 20__ financial statements

2. Most recent 20__ YTD comparative financial statements on the cash basis of accounting

3. YTD general ledger for years 2011, 2012, and YTD 2013

4. Current aging of vendor accounts payable

5. If available, total payments to individual vendors for years 2011 and 2012

Charges, collections, and adjustments for 2010, 2011 2012 and YTD 2013

1. For the Practice

2. By Individual Provider, including extenders

Listing of gross charges and collections by specific payer for 2011, 2012 and YTD 2013

Current summary aging of accounts receivable

1. Total for the practice

2. By Individual payer class

Current summary of accounts receivable – credit balances only

Current Daily Patient Visits by Individual Provider (if applicable to specialty)

1. Office

2. Inpatient (hospital visits)

Listing of all current practice employees, their current annual salaries and their job duties

1. Also provide list of employees and their 2012 W-2 wages

2. If available, employee organizational chart

Current practice fee schedule

CPT frequency report of the year 2010, 2011, 2012, and YTD 2013

1. For the practice

2. by Individual Provider, including extenders

Summary of all lease agreements (lease term, lease amount, remaining term on lease)

Fixed asset inventory (Please list all assets in each room of the office)

Most recent business property tax appraisal invoice

Summary of all current notes payable (original principal, interest rate, term of note, final payment date)

List of top 8 managed care payers and current reimbursement rate received from each(Also include reimbursement for the practice's top 20 CPT codes)

Provide narrative of reimbursement trends for the practice over the last 3 years

Copy of any prior valuation reports

Work RVUs by provider for year 2010, 2011, 2012 and YTD 2013 (if report available from billing software)

Summary description of the practice (when started, services offered, etc)

Provide breakdown of age distribution of the patient base (ex. Ages 30-40: 35%)

List all expected capital expenditures in the next 5 years (ex. Computers, equipment, leasehold improv)

Expected revenue growth in the next 5 years 1. Explain why you think revenue targets can be reached

2. Describe all internal and external factors that may impact your revenue stream in the next 5 years

Referring Doctor Report for years 2010, 2011, 2012 and YTD 2013 (if practice relies on physician referrals for patient base)

Copy of partnership or shareholder agreement

Copy of any agreements with hospital

Discount and Capitalization Rates

Capitalization Rate

• To "capitalize" means to convert the income stream into an indication of value by dividing or multiplying the selected definition of the stream by some factor, called a capitalization rate

• Is derived from the discount rate

Discount Rate• A discount rate represents the total

expected rate of return (stated as a percentage) that a buyer (or investor) would demand on the purchase price of an ownership interest in an asset (such as U.S. Treasury bills) given the level of risk inherent in that ownership interest

• Discount rate is used to derive present value factors which are used to discount a future benefit stream to a present value

Discount Rate• Often calculated as the sum of (a) the

"safe rate," (b) equity risk premium, (c) risk premium for size, and (d) a premium for the amount of risk involved in the investment

• Safe rate is intended to represent the annual rate of return currently available from investments offering maximum security (and thus the lowest risk), and the highest degree of liquidity

Discount Rate• The equity risk premium is the extra return earned

by an average equity investor in excess of long-term Treasury securities

• There is obviously more risk associated with a smaller business than a major S&P 500 company; thus, everything else being equal, investors in a smaller business will demand a higher rate of return; this is the risk premium for size

• The risk premium should take into account the (a) the risk that the predicated amount of future income from the investment will not actually be realized, and (b) risk of future loss, through unforeseen circumstances, of part of all of the principal amount invested

Target the Following Practice Risks• Competition risk

• Number of competitors is growing• Reimbursement risk

• Evidence of changes to current reimbursement rates and related future trends

• Market risk• Evidence of changes to payer classes

• Ability to recruit physicians to practice

Concept of Practice "Earnings"

Practice revenues xxx,xxx

Less adjustments xxx,xxx

Adjusted revenues xxx,xxx

Practice overhead xxx,xxx

Less adjustments xxx,xxx

Adjusted overhead xxx,xxx

Adjusted net income xxx,xxx

Add: Owner compensation zzz,zzz

Subtract: Replacement compensationzzz,zzz

Equals: “Earnings” xxx,xxx

Earnings Surveys For Replacement Compensation

• MGMA Physician Compensation Survey• MGMA Cost and Productivity Report• American Medical Group Practice

Association• Modern Healthcare's Physician

Compensation Report• Issue: Post-acquisition compensation –

how to handle

Valuation Methods• Income Approach

• Capitalization of earnings• Discounted future cash flow

(income approach)• Asset Approach

• Workforce in Place?• Market Approach

• Guideline Company• Comparable Sales

Methodology Issues

• Discounted Cash Flow• How to model future years

• Detail out revenues and expenses with adjustments

• Summary approach• Growth rate to use

• Anticipating capital expenditures

Methodology Issues

• Discounted Cash Flow (continued)• How to calculate working capital

needs• Terminal year growth rate?• How is real estate handled?

• Market Approach• Is there really one for medical

practices?

Questions

Answers

Reed Tinsley, CPA, CVA, CFP, CHBCHouston, Texas  77070Direct Line: 281-379-5988Direct Fax: 281-605-5701www.rtacpa.comBlog: http://rtacpa.blogs.com/