This two-volume work is co-authored by Mr. Cimasi, Chief Executive Officer and Mr. Zigrang, President, of Health Capital Consultants.  Health Capital Consultants in general, and Mr. Cimasi in particular, have provided the business valuation and the health care consulting communities with a prodigious amount of research, literature and guidance specific to the health care industry.  With The Adviser’s Guide to Health Care, Mr. Cimasi and Mr. Zigrang have added immeasurably to the body of knowledge.  

Each chapter begins with a listing of key terms which are explained in the text, as well as in a comprehensive glossary.  In addition, a table at the beginning of each chapter presents key concepts for that chapter, with a definition, a citation directing the reader to an original source, and the pages in the chapter where the key concepts are discussed.  These features make it a fairly easy task to navigate each chapter, as well as the entire book.  The two volumes also contain a thorough index and a detailed table of contents.

The text is, as advertised, intended for “consulting professionals who provide services to professional practices and related healthcare providers” (Volume I, page 5).  There is only one chapter devoted specifically to valuation topics.  A portion of this chapter covers territory that should be very familiar to experienced valuation professionals.  However, the chapter also contains a great deal of information on how valuations for companies in the health care field are unique and require some specialized knowledge.  For example: 

“In the past, professional practice valuation methodologies relied heavily upon the analysis of historical accounting and other data as predictive of performance and value.  Increasingly, however, circumstances surrounding the professional practice’s specific specialty and the market within which it operates may have the potential to make the historical information a less reliable indicator of the practice’s future financial performance.  The turbulent status of the healthcare industry during the past three decades has introduced intervening events and circumstances that may have a dramatic effect on the projections of future revenue, economic operating cost burdens.” (Volume II, page 141)

These statements illustrate the need for the consulting professional to have a good understanding of the industry.

This passage is also typical of the sober, matter-of-fact writing style of the two volumes.  

The focus of the Adviser’s Guide is on the professional practice component of the industry, and does not directly address other sectors such as inpatient (i.e., hospitals), outpatient and ambulatory centers, long term care and home health sectors.  

The first edition of the Adviser’s Guide was released in 2010, and much has happened in the healthcare industry since that time, including the implementation of the Affordable Care Act (“ACA”), the expansion of Medicaid to thirty states, a continuing shift from volume-based to value-based reimbursement models and the advent of emerging healthcare organizations, among others.  The first edition was drafted before the passage of the ACA in March of 2010, and this second edition discusses the Act in great depth.

The first volume is subtitled “The Four Pillars,” and this 444-page text consists of six chapters.  The first chapter traces the development of the practice of medicine from the beginning of human history and the evolution of the health care industry in the United States.

Chapters two through five of Volume I discuss in great depth The Four Pillars of the healthcare industry, a concept long used by Mr. Cimasi to explain and understand the industry.  These pillars, and the relevant chapters, address the regulatory environment, reimbursement policies, the competitive forces and the technological development of the health care industry.  The sixth and final chapter of Volume I discusses the confluence of forces that have developed over time to set the stage for the recent efforts at health care reform.

Volume II contains twelve chapters in 691 pages, each of which addresses, in detail, clear and thorough discussions of various aspects of the health care field to allow the consultant to fully understand the operations and challenges the industry faces every day.

For example, the chapter titled “Compensation and Income Distribution” addresses the various ways physicians may be compensated, including a modified point system (wherein the physician’s tasks and duties determine compensation), a factor-based system (standard job descriptions are developed based on expected production) or a combination of the two (an XYZ system).   Other chapters include in-depth discussions of emerging models that are changing the landscape of the health care industry, the roles of technicians and paraprofessionals, and the competition that comes from complementary and alternative medicine such as homeopathic and naturopathic practices.

The two volumes of The Adviser’s Guide to Health Care, Second Edition: An Era of Reform is a wide-reaching, comprehensive exploration of the dynamic and ever-changing health care industry, and will make an invaluable addition to the libraries of those professionals that provide valuation and other consulting services to health care practitioners.

Russ Glazer, AM, CBA, CVA, MBA
Partner
Gettry Marcus CPA
Woodbury, NY

 


 

The Adviser’s Guide to Health Care, Second Edition is a must-have resource for those involved with healthcare consulting and valuation.  This two-volume, 1,300-page treatise was written for advisors and consultants in the healthcare field, business valuers conducting health are valuations, and any practitioner with an interest in healthcare, healthcare reform, healthcare practices and how the healthcare industry impacts U.S. businesses.  

It has been my pleasure to know the authors of this text, Bob Cimasi and Todd Zigrang, for many years.  I have the utmost respect for their knowledge and expertise, which they have consistently shared with their colleagues.  Now, they have made an outstanding effort to share the benefit of their expertise and their firm’s prodigious research capacity with those involved in this field in this second edition text.  this two-volume set is unmatched in its thoroughness and in the quality of its research and scholarship.  It is a convenient, accessible one-stop point of service to those who want to enhance their knowledge of the healthcare industry.  

When I was at the IRS and coordinating a Job Aid on Reasonable Compensation,  I reached out to Bob Cimasi and HEALTH CAPITAL CONSULTANTS (HCC).  The Job Aid has been finalized and it was released to the public in April 2015.  Bob was extremely gracious in providing a detailed listing of sources used when evaluating reasonable compensation in the healthcare field, assisting the IRS with deciding which of these resources might be most helpful when evaluating reasonable compensation in providing an evaluation of each source.  As is typical for Bob Cimasi and his HCC team, his motivation was to help improve those working in his field of expertise.  His advice on reasonable compensation and especially related to hospitals, healthcare providers, related physician practices and other health related providers was invaluable.   This is yet another example of his dedication to this field and his interest in sharing his expertise with his professional colleagues.

Since joining the private sector over four years ago, I have had the opportunity to work with HCC, and have found in every instance that they operate with the highest level of integrity I would expect from the leader in this field.  With this as background, I looked forward to reviewing this text.

As the Foreword by David W. Grauer, Esq. explains, a lot has happened in healthcare and in our economy since the first edition of their book was published in 2010.   HCC has stayed on top of these issues and assembled the definitive text to bring readers up to date, which is a tribute to their dedication to the profession.  By providing a readily readable commentary, both advisers from beginners to experienced experts can benefit from being up to date in a very reasonable timeframe regarding their specific area of interest in healthcare.  With the detailed table of contents and index, a reader can easily and time efficiently find the information they are seeking.  

Volume I of the text, “An Era of Reform – The Four Pillars,” contains a description of the historical context of medicine and healthcare, followed by a detailed description of the Four Pillars of the healthcare industry, i.e., reimbursement, regulatory, competition and technology, as well as an elaboration of the current efforts related to healthcare reform.  As the book notes, “[t]hese four elements shape the professional practice and provider dynamic, while serving as a framework for analyzing the viability, efficiency, efficacy, and productivity of healthcare enterprises.” This exposition of the Four Pillars concept is the most current up to date commentary on this topic.

This concept of the Four Pillars is also referenced throughout Volume II, “Consulting Services.” Volume II presents 12 chapters that address such issues as: healthcare compensation; financial valuation; organizational structures; emerging models; physician practices; mid-level provider practices; technicians and paraprofessionals; allied professionals; alternative medicine practices; and, the new paradigm for professional practices.  

To assist the reader, the authors have included sidebars, tables and figures throughout this volume to provide additional clarification and understanding for the reader.  The availability of these useful tools allows the reader to gain additional and more thorough understanding of the subject matter. 

In particular, Volume II, Chapter 3, “Compensation and income Distribution,” and Volume II, Chapter 4, “Financial Valuation of Enterprises, Assets, and Services,” are standout texts that deserve special note.

In chapter 3, “Compensation and Income Distribution,” as with the other chapters in the book, the reader is first treated to an excellent overview of the chapter, with a table of the key concepts, definition, a citation, and the page in which the source is discussed in the chapter, in tabular form.  Supplementing the table of contents and the index is a great idea to facilitate the reader’s ability to quickly access their needed information.  One of the subtopics presented in Chapter 3 relates in part to “facilitat[ing] more effective identification and communication of an organization’s values, dynamic, productivity objectives, and performance expectations.”  As a mediator and negotiator, I find this advice to be especially on point. 

Following this discussion, the technical areas addressing compensation, fraud and abuse regulations, provider compensation, and the compensation plan life cycle transition nicely to the ten steps of developing a compensation plan.  I am impressed with The detail in these ten steps, which is comprised of 106 footnotes over 17 pages, and is indicative of the comprehensive research and detailed analyses that are exhibited throughout this text.  The follow up commentary on governance and the role of consultants stresses the need for oversight and due diligence by the parties involved. Armed with this information on the common principles of a successful compensation plan, ensuring the plan is aligned with internal and external factors, and the spectrum of the physician plan framework is then discussed.  The four pillars concept from Volume I is not simply left in volume I. Rather, this concept continues to weave its way throughout the text, bringing home the utility of how the concept of these pillars impacts reasonable compensation and income distribution.

The end of Chapter 3 contains an added bonus of survey sources and the information of three professional associations, a handy resource followed by the appendices with The Compensation Plan Checklist and an example. 

This text presents all of the considerations necessary to address compensation and income.  I am not aware of any other text that presents such a comprehensive commentary on this topic.

chapter 4, “Financial Valuation of Enterprises, Assets and Services,” is similarly well organized in presenting information for consultants and valuation professionals on the Asset based approach; Capitalization of earnings approach; Cost approach; Discounted cash flow method; Excess earnings method; guideline public company method; income approach; market approach; and merger and Acquisition Method.

The fundamental concepts of valuation are presented as they relate to healthcare throughout the first third of Chapter 4.  After presenting these concepts, the next section introduces valuation approaches, methods and techniques within the regulatory framework, e.g., Revenue Ruling 59-60.  This section on valuation tenets is followed by discussions on: discounts and premiums; the classification and valuation of assets such as tangible personal property and intangible assets; conflicting definitions of intangible assets versus goodwill; classification of valuation of healthcare services; and, further thoughts on the standard of fair market value and the role of the valuation analyst. The chapter is succinctly concluded with a consideration of the reasonableness of the methodology and required supporting information. 

Table 4-6 in Chapter 4, “List of Selected Generally Accepted Surveys Utilized for Benchmarking Physician Executive, Management, and Administrative Services Compensation,” contains further indication of HCC’s tremendous research and analytic capacity, providing a comprehensive list of selected generally surveys utilized for benchmarking physician executive, management, and administrative compensation with a listing of the name and publisher of 32 sources of data.  This is indicative of the thorough research that went into this text.

The text is so well written that the reader can quickly gain invaluable insight in short order related to their specific questions or concerns.  

In his Foreword, David Grauer Esq. recommends that the novice read chapters 1 and 12 to gain insight into the field before diving into the text. I think this is sound advice.  The remaining chapters are an excellent resource and reference, and should be read by those wanting to know more regarding any or all of the topics covered in the chapters.  

I am very impressed at the comprehensive research and analysis that went into this treatise.  The exhaustive documentation and references by use of footnotes, complete bibliography, table of contents, and index facilitates the reader’s ability to utilize the book as a quick reference, or to dig deeper if so interested.  A significant asset to the healthcare consulting profession to have a ready resource to obtain more information based on reliability research, decades of experience, and dedicated attention to accuracy and detail by Bob Cimasi and Todd Zigrang.  In my opinion, this book is the most significant contribution to this field to date.

Michael A. Gregory, MBA, ASA, CVA
Chief Manager
Michael Gregory Consulting, LLC
Roseville, MN

 


 

The first of the eight factors to consider in the valuation of a business listed by the IRS in its Revenue Ruling 59-60 is stated as follows:

“The nature of the business and the history of the enterprise from its inception.”  

You know that you are reading a book written by a valuation professional when the first section of The Adviser’s Guide to Health Care begins by explaining exactly where our healthcare system began, starting with a description of astrology and moving from there into detailed descriptions of each following step until he getting to where we are now.  Mr. Cimasi and Mr. Zigrang obviously understand the nature and history of the whole healthcare industry from its inception, and after reading Chapter 1, I now have a much better understanding than I did.

However, these books are not written with only the valuation professional in mind.  True, Chapter 4 in the second volume discusses steps involved in the valuation of a practice, the methods and analyses that should be included in an appraisal as well as a section on the valuation of intangible assets held in a medical practice, but that is only one of the 18 total chapters included in this set.

The organization of the two volumes has been well thought out.  Volume one contains introductory information and detailed descriptions of the four pillars of the healthcare industry: Reimbursement Environment, Regulatory Environment, Impact of Competitive Forces, and Technology Development.  The last chapter of the first book discusses the Patient Protection and Affordable Care Act as well as the Health Care and Education Reconciliation Act of 2010 and how this legislation will impact the health care industry going forward, looking at not only the professional practice providers, but also individuals, small to mid-sized employers, larger employers, and even insurers.  

Some other sections in volume one that I found to be very helpful are as follows in no particular order: “Reasonable Compensation” Defined by the IRS, Certificate of Need (CON) and the description and explanation of the Stark Law.  The authors have done an excellent job of explaining these and many other issues that impact health care providers.

The books are broken up throughout with useful charts and graphs illustrating points discussed in a more visual way, as well as an occasional useful example or a phrase or anecdote that brings additional life to the pages.  Each chapter begins with a chart showing what the key concepts mentioned are, along with their definitions and on what page the topic is first mentioned.

Volume two is almost twice as long as volume one.  The authors did not skimp on the sharing of their knowledge of the various consulting services that are in demand in the health care industry.  The first half of the book is focused on describing some of those consulting services that are in demand such as assistance in developing compensation plans, the valuation of healthcare practices and the emerging models of practice operation, to name a few.  

The second half of volume two is taken up with facts and explanations of what the various types of practices and healthcare providers are that currently exist.  For example, as I was going through the list I found one I had never heard of before: Otolaryngology.  It is described beginning on page 378 and after reading it, I know now that otolaryngologists are head and neck specialists and it is the oldest medical specialty in the United States.  There are also descriptions in Chapter 9 of the various other professional occupations that exist in order to either assist doctors or to provide certain services in their own right such as nurses, therapists, technologists, technicians, sonographers, dosimetrists and others.  The chapter provides a basic job description, a discussion of how the industry is trending around each one and where the demand for each is coming from.  

Both books included in the set, The Adviser’s Guide to Health Care, are full of very useful information that I expect to be referencing time and time again.  The healthcare industry has changed a lot since the year 4 BC and especially in the past few years.  How physicians get paid and how a medical practice can maintain its profitability are questions whose answers may be different depending on what is going on at any given point in time.  Doctors provide very beneficial services, but each practice is also a business and if we as consultants can help our medical professionals stay focused on their specialties, instead of on figuring out how to stay solvent, than the rest of society will benefit as well.  I believe that The Adviser’s Guide to Health Care will be a significant asset in any consultant’s library.

Shawn M. Hyde, CBA, CVA, CMEA, is the Business Valuation Manager at Yeo & Yeo CPAs, a Top 100 Certified Public Accounting and business consulting firm with offices throughout Michigan. He has over 15 years of valuation and appraisal experience in numerous industries. He is a Certified Business Appraiser, Certified Valuation Analyst and a Certified Machinery & Equipment Appraiser. He has written and taught courses for the Institute of Business Appraisers (IBA) and for the National Association of Certified Valuators and Analysts. He has served on the IBA’s Education Board, and the IBA’s Board of Governors, and is a past Editor in Chief of the IBA’s professional journal, Business Appraisal Practice.

Shawn M. Hyde, CBA, CVA
Yeo & Yeo
Saginaw, MI