1. Valuation of a Medical Practice Reed Tinsley, CPA, CVA, CFP, CHBC

2. 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

3. 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

4. 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

5. 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.

6. 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.

7. Regulatory Issues Impacting the Valuation Process

8. 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

9. 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

10. Defining Fair Market Value Stark 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.

11. Defining Fair Market Value Stark 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

12. Defining Commercial Reasonableness Stark 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”

13. 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

14. KEY Factors Impacting the Valuation of a Medical Practice

15. 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?

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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.

26. 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?

27. Review Data Gathering Checklist

28. 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)

29. 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

30. Discount and Capitalization Rates

31. 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

32. 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

33. 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

34. 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

35. 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

36. Concept of Practice "Earnings" Practice revenuesxxx,xxx Less adjustmentsxxx,xxx Adjusted revenuesxxx,xxx Practice overheadxxx,xxx Less adjustmentsxxx,xxx Adjusted overheadxxx,xxx Adjusted net incomexxx,xxx Add: Owner compensationzzz,zzz Subtract: Replacement compensationzzz,zzz Equals: “Earnings”xxx,xxx

37. 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

38. Valuation Methods Income Approach Capitalization of earnings Discounted future cash flow (income approach) Asset Approach Workforce in Place? Market Approach Guideline Company Comparable Sales

39. 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

40. 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?

41. Questions Answers

42. Reed Tinsley, CPA, CVA, CFP, CHBC Houston, Texas 77070 Direct Line: 281-379-5988 Direct Fax: 281-605-5701 www.rtacpa.com Blog: http://rtacpa.blogs.com/ www.rtacpa.comhttp://rtacpa.blogs.com/