Medical Practice Valuation for Purchase or Buy-in (2)
Evaluating an appraiser
Even though business appraisal is not a licensed activity, there are a number of professional trade associations that recommend standards of compliance and ethics, or provide credentials. If you hire a professional appraiser, you should expect that person to belong to one or more of those associations. They include the Institute of Business Appraisers, American Society of Appraisers, the National Association of Certified Valuation Analysts, and the American Institute of Certified Public Accountants. If an appraiser represents membership of other associations as credentials, check out the credential requirements of the association. There are other associations that may be legitimate, but there are also “degree mills” offering appraisal certification merely for paying a fee, just as in other fields.
Being a “Certified” appraiser of a valid association does not insure competence in the specialty of medical practice valuation, nor does lack of Certification indicate incompetence. Check the credentials, experience, and references of the appraiser. “Knowing the business”, (in this case the medical business) is a key ingredient of competence for a specialty appraiser. You want your appraiser to know the difference between a General Practice and a General Surgeon.
Using medical practice benchmarks
A medical practice valuation requires comparison of the subject practice’s statistics to specialty benchmarks. It is inaccurate to lump all physician practices together as a common entity, as financial statistics differ radically by specialty. If you attempt to value a practice using generic or inappropriate benchmarks, finding the correct value will be a matter of luck rather than skill. Also, beware using outdated benchmark reports to save money on buying the current reports, another common error, as the accuracy of your valuation may suffer.
Demand use of a scientific method
Another standard that can be applied to an expert’s valuation opinion, especially for courtrooms, is that of the Daubert court case. The core issues of Daubert are twofold: 1) the information must be relevant (for example, the profitability of the practice related to its value) and more importantly 2) the valuation must be “grounded in the methods and procedures of science” or, as the Daubert opinion also puts it, “the inferences and assertions embodied in the testimony must be derived by the scientific method” and “supported by appropriate validation.” I once was able to have a bad appraisal by a crotchety old CPA thrown out as evidence in a divorce case because a blatant error in methodology in his valuation was defended by him with the statement “that’s how we’ve always done it around here”! Any lay person should be able to read and understand the valuation report and follow the scientific method of how the final value was achieved, and it should make sense!
Using a scientific approach to value a practice is an excellent way to lead a buyer and seller to a mutually agreeable price (or to respectful, knowledgeable disagreement) by carefully reviewing all the facts and assumptions. A valid assumption to disagree-upon for example is whether capitation will come to a particular market, and what its effect will be on profits.
Physicians typically respond well to scientific inquiry – just like having a good physical exam, vital signs, lab reports, and imaging on a patient is valued prior to rendering a confident medical diagnosis.
Reality check – finding a reasonable medical practice valuation
In the end, a valuation should be “reasonable”. A common test of reasonableness is that the purchase of a practice should pay for itself, above the income available from simple employment, within 5 years at most. Another is the “principle of substitution”. A buyer (investor) will not pay more for an asset -and get a lesser return- than that available from purchase of a substitute asset. In other words, a knowledgeable medical practice buyer won’t pay more for a practice than the cost of starting a substitute competing practice; nor will they pay money to buy a practice with income equal-to or less-than employment-without-purchase. They would just put the money into the stock market or T-bills instead, or start a practice across the street.
Exceptions to the rule start changing the valuation to other standards of value other than Fair Market Value, like Strategic Value; such as when a specific buyer brings synergy to the transaction. For example, a half-full practice might pay more than Fair Market Value for the other half-full practice next-door that is for sale, because it would make the purchaser’s practice full without extra fixed overhead. That’s strategic value to a specific buyer.
Buy, sell, or join – which is best value?
The “principle of substitution” applies to buy-ins too. You will often see practice buy-ins under the terms of working for an income less than the owners for the first 3-5 years, then the buy-in is for “just a percentage of the furnishings and equipment”. All things being equal, the fair market value of this buy-in versus practice purchase versus start-up are pretty similar. You can work for less money for 3-5 years, or buy a practice and pay it off with extra profit over 3-5 years, or start a practice and pay off the start up costs over 3-5 years.
I teach practice management and other courses on faculty for a number of medical associations and residency programs. A common question asked is “should I buy a practice, join a practice or start a practice”. The answer from a financial standpoint is that it is all pretty much equal “at market rate”. There are overvalued and undervalued opportunities in “buy, start or join”. Paying too much to buy or join a practice is usually a terrible investment, and many practice offerings are overpriced.
The most important issue is that you will be spending most of your waking hours at work, and your family time and free time is precious. Go into practice in a location where, when you leave the office at the end of the day & lock the door & and turn around, you are where you want to be. With good practice management, the numbers will work out.
If we are valuing a practice for buy-in to a minority share, the issue of a discount for lack of control can be very important. The bigger and more democratic the group, the less important it becomes. It is critically important if the solo seller is offering a 49% ownership share for buy-in, since that share may be worth as little as zero, due to what is referred as “senior doctor rights”. Consider this case: the senior doctor won’t give up any income and gets all the new patients that walk in the door or respond to the yellow pages or come from existing referrers; the new doctor gets no salary & has to find his own patients somehow, plus pay 49% of all the expenses, the details of which are not disclosed, and may include the senior doctor’s car, health insurance, or home computer; and the senior doctor has 100% of the decision making authority including changing the new doctor’s hours, staff, income and expense formulas. 51% ownership = 100% control. Is 49% of this practice worth anything at all???
Start Your Own Practice
If you can’t find a practice for sale or a buy-in in your desired location at a fair price, you can start your own from scratch. It’s not that hard, and 100% financing is often available.
ABOUT THE AUTHOR
Author Keith Borglum has been a licensed healthcare practice broker, appraiser, and practice management consultant nationwide for over 20 years; a profession he continues to this day.
His practical & detailed knowledge of the every-day “business” of medical practice makes him a popular speaker on faculty for a number of medical associations nationwide.
Keith is co-author of two other medical practice business books, and contributor to hundreds of books and articles on practice management, profitability, and valuation.
Most notably, Keith’s credentials include:
– Licensed Business Broker since 1983
– Member of the Institute of Business Appraisers
– Member of the California Association of Business Brokers
– Member, American Medical Association’s Consultant Network, 1993-2005 (closure)
– Member, American College of Physicians’ Advisory Network & Experts Panel, 1995-closure
– Member, American Academy of Ophthalmology Executives Consultant Panel 2002-present
– Founding Member, American Academy of Family Physicians Consultant Network 1992-present
– Faculty, American Academy of Family Physicians’ Scientific Assembly Programs, 1998-present
– Faculty, AAAAI, Practice Management & Valuation Courses, 2004-present
– Faculty, American Academy of Dermatology; Residents’ Management Programs: 1998-present
– Faculty, American Academy of Dermatology; Practice Management Regional Courses: 2006
– Faculty, American Urology Association Western Section Annual Meeting 2006
– Member, Director & Faculty, National Association of Health Care Consultants 2000-2006
– Member, National Society of Certified Healthcare Business Consultants; Marketing/Membership Committee Chairman; current
– Contributor & Medical Industry Expert – The Business Reference Guide to Pricing a Business, 2004-2007, Business Brokerage Press; (the main annual reference book on business valuation for licensed business brokers)
– Affiliate, Medical Group Management Association, CalMGMA, NorCalMGMA 1987 – present
– Editorial Consultant to Medical Economics Magazine, 2004- present
– Co-founder, Director and Interim-President, MedicalSuppliesUSA.com
– Editor, Open Directory Project ; topic: Business Appraisal; (approving content for Google, AOL, etc)
Keith Borglum can be reached for valuation, consulting and lecturing services via his website at http://www.MedicalPracticeAppraisal.com where related articles are also available.
Reprinted courtesy of the author and Practice Support Resources Inc from the book: Medical Practice Valuation Appraisal Guidelines & Workbook http://www.practicesupport.com/Merchant5/merchant.mvc?Screen=PROD&Store_Code=PSR&Product_Code=293