Investing in Freestanding ERs

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allendo

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There seems to be this mad rush lately to build freestanding ERs. Does anyone have any first hand experience with these from an investment perspective? I'm conisdering cutting back on my regular shifts and buying into one of these.

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I think it's a good thing to consider, and I've thought about it, if there were any around me. Find the thread on this.
 
I think it's an outstanding investment opportunity presently, especially in states that have legislation in place like Texas. The key to the business model is the ability to collect the facility fee in addition to the physician's fee. 80-85% of a patient's ER bill is usually the facility fee and only 15%-20% is related to the physician's fee. Thus, EmCare, Team Health, SDG's, etc., all make their profits based on 15%-20% of the patient visit. By being able to capture the entirety of the billing of the patient visit, the freestanding ER doc is able to make up to 5 times as much per patient as he would working in a SDG. Because of these economics, the breakeven point for the business can be as low as 4-5 patients per day. As most costs are fixed and related to labor, once you exceed the breakeven point, the profits increase dramatically.

It essence, a freestanding ER represents the privatization of emergency medicine and is very similar to the model in which the surgeons broke off from the hospital to form outpatient surgical centers. The often repeated mantra by administrators that the ER is the money loser of the hospital is false. By running much leaner than hospital ERs, freestanding ERs can greater capitalize on the facility fee. Additionally, by not participating in CMS, freestanding ERs can control their payer mix much better and are also free from federal health care legislation (CMS rules, EMTALA, Core Measures, etc).

I am involved in several freestanding ER projects presently. PM me if you would like any further information.
 
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Wait... Freestanding ER's don't have EMTALA mandates? They don't have to participate with CMS? How then are they not considered urgent care centers?
 
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If you don't take money from the federal government (ie. CMS reimbursement), you aren't subject to their sticks. You are however subject to state law. There is still a requirement for medical screening in Texas under state law, but it gives the provider greater latitude on the disposition of the patient after the screen.

Actually, CMS non-participation is a growing trend with hospitals as well. Several private, non-CMS participating hospitals exist and are expanding in non-CON (certificate of need) states. Many believe this is the beginning of a trend toward a two-tiered health care system which some also believe to be the ultimate (though unstated) goal of the ACA.
 
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Always fair to be cautious about something where the money is too easy to be true.

When/how will FSEDs get squeezed? Uncertain. But hard to imaging the system continuing to support something providing such a low level of value.
 
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Always fair to be cautious about something where the money is too easy to be true.

When/how will FSEDs get squeezed? Uncertain. But hard to imaging the system continuing to support something providing such a low level of value.
There's no way to know what they'll pay for, or what they won't in the future. (I heard that Medicare kept the facility fees for FSEDs relatively stable this year, though I'm not 100% sure). They'll pay unnecessarily ridiculous amounts of money for some things (inpatient procedures) yet cut reimbursement for others that are already more cost effective (same procedures done at different site of service like an outpatient physician office) to supposedly "save money." For example, the past few years they've been cutting reimbursement hardcore for many outpatient procedures, but increasing payments for the very same procures that already cost, in some instance 4-5 times more, to be done in a hospital or surgery center (called "site of service differential"). It's truly a scandal that few people are talking about. The system truly is insane, and it's hard to predict what crazy will do.

http://www.advisory.com/daily-briefing/2013/06/17/medpac-calls-for-site-neutral-payments
 
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When/how will FSEDs get squeezed? Uncertain. But hard to imaging the system continuing to support something providing such a low level of value.
Caths for NSTEMIs, stress tests in general, futile ICU care.
The ED is a small amount of the healthcare dollar, and if enough people do this, it will encourage the hospital to stop treating EPs like chattel. Plus, you'll stop minding the "work note" complaints when you get 100% of their facility fee, instead of none.
 
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Interesting. Its pretty much an physican owned "ER" hospital. Great business model if located in the right location since population base would be Non-CMS recipients. Two issues to consider:
1. what would you offer that would be differently from urgent care? Also, how much total reimbursement would one expect from the payor mix (insurance/self)
2. AHA will be your biggest burden, and they have money and lobbyist.
 
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2. AHA will be your biggest burden, and they have money and lobbyist.

Good point.

Remember, if you're carving out the profitable patients from fixed number of ED/UC visitors, someone else is losing that revenue stream.

But, for now, your main obstacle will be ... all the other folks already well on their way to cashing in on the FSED gold rush.
 
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Basically, a freestanding ER (FSER) is the same as hospital ER, but just not directly attached. One way to think of it is that it is the same as a typical hospital ER with a much longer hallway to the floor, OR, or cath lab. The hallway, though, does require transportation via an ambulance, which does take more time.

However, the overall door to disposition time is usually much less in a FSER. The patients experience little to no wait time and workups are performed much more efficiently. A complete chest pain work up (ekg, labs, cxr, d-dimer, 1st set of cardiac markers) can be completed in under 30 minutes. A full abdominal pain work up (labs, ua, meds, CT +/- US) can be performed in under an hour (with radiology reads in hand).

I have previously transferred a ruptured AAA to the OR in less than 40 min from arrival at our site. The patient got labs, a CT, and transport via EMS to the OR in much better time than he would of at the parent hospital. In reality, the patient would most likely have been still awaiting triage in the waiting room at the parent hospital as he presented with non-specific complaints (nausea, malaise, generalized weakness). I've also gotten STEMIs to the cath lab in less than 40 minutes (granted we are only 5 min. away from the parent hospital). Basically, a FSER can evaluate and stabilize any acute condition that a typical community hospital can. TPA can be administered for strokes, MIs can be diagnosed and transferred directly to the cath lab, and ovarian torsions can go directly to the OR.

Additionally, patients that know they need to be admitted to the parent hospital often preferentially come to a FSER after they have experienced the model. They realize that their workup will take much less time, the overall patient experience will be better, and that they will most likely get an inpatient bed quicker than they would at the parent hospital.
 
2. AHA will be your biggest burden, and they have money and lobbyist.

Actually, this has proven not to be the case. The hospitals that fully understand the model embrace it. They actually cater to FSERs for their admissions. They realize that FSERs are providing a pipeline of insured patients without costing them any resources. Hospitals get the benefits of the admissions without paying any of the overhead costs. Additionally, they are also able to expand their footprint into markets of their competitors. In actuality, hospitals make the majority of their profits off the inpatient admission, specialty services and procedures, and referral to outpatient services.

FSERs offer a 90% commercially insured patient base, much higher that what filters through their own ER. For this reason, some hospitals in the Houston area preferentially give beds to FSERs over their own ER (holding their own patients in the ER). They realize that they can capture revenue that they wouldn't normally get with a higher payer mix than their own ER.
 
Basically, a freestanding ER (FSER) is the same as hospital ER, but just not directly attached.

I would say the vast minority of FSEDs in the Houston area are affiliated with a parent hospital.

We get tons of surgical transfers from those facilities, and I would say their patient experiences are not nearly as streamlined as you say.

The parent hospital-FSED model is fine. These FSEDs with no affiliation are the questionable bit.
 
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I would say the vast minority of FSEDs in the Houston area are affiliated with a parent hospital.

We get tons of surgical transfers from those facilities, and I would say their patient experiences are not nearly as streamlined as you say.

The parent hospital-FSED model is fine. These FSEDs with no affiliation are the questionable bit.
The non-hospital associated FSEDs don't have to deal with a lot of the regulations and bylaws that effect other EDs. This includes a fair number of them being staffed by non-EM boarded physicians which is going to make a difference in quality of care. It's been extraordinarily difficult to transfer patients from our hospital-associated FSED the last couple of weeks due to ridiculous inpatient censuses at essentially every hospital in the city. Whether the NHAFSEDs are able to bypass this block through sweetheart deals with the hospitals is something I'm not sure about. I do know that we've had patients leave our main ED, be seen at a FSED, have a CT showing appy, and be transferred back to an inpatient bed in our hospital in less time then it was taking our admitted holds waiting on a med/surg bed to go up.
 
The FSED boom seems lucrative with states like Tx leading the pack in opportunities and pay. Any investment is a risk but in a state like Tx, nobody would blame you for investing...

Honestly, it's opportunities like these that made me apply for a TX license last year that's still in process. I have no idea if I'll use it but at least it will be there.
 
I love the physician owned FSED model. Physician and patient satisfaction is 100-fold greater in these facilities. I'm currently CMO at my company. As we expand, we are looking for more docs in Austin, TX and Colorado. We offer investment opportunity and profit sharing. PM if interested.
 
I love 3 things about the FSED concept:

1) You get the facility fee
2) You get control over the staffing levels and hiring/firing decisions for support staff
3) You get control over the EMR

That said, I don't like the fact that it skims the top payors out of the mix (especially if they've opted out of Medicare/Medicaid, but even if they're just doing it by building in the nice part of town; I dislike this about urgent cares too). I also don't like the fact that you don't have consultants to work with (correct me if I'm wrong) unless you pay them to be on call and that there is a delay of care in taking care of true emergencies- STEMI, traumas going to the OR etc.

As a business model, there is some real risk there. It wouldn't take much legislation to put you out of business.
 
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I love 3 things about the FSED concept:

1) You get the facility fee
2) You get control over the staffing levels and hiring/firing decisions for support staff
3) You get control over the EMR

That said, I don't like the fact that it skims the top payors out of the mix (especially if they've opted out of Medicare/Medicaid, but even if they're just doing it by building in the nice part of town; I dislike this about urgent cares too). I also don't like the fact that you don't have consultants to work with (correct me if I'm wrong) unless you pay them to be on call and that there is a delay of care in taking care of true emergencies- STEMI, traumas going to the OR etc.

As a business model, there is some real risk there. It wouldn't take much legislation to put you out of business.

I like the business model as well. Some states won't even let you get into the business. Alabama is one of the states where a free standing ED has to have a parent hospital and be owned by that hospital. No physician ownership here unfortunately. The pro forma on most of these is a thing of beauty though.
 
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I love 3 things about the FSED concept:

1) You get the facility fee
2) You get control over the staffing levels and hiring/firing decisions for support staff
3) You get control over the EMR

That said, I don't like the fact that it skims the top payors out of the mix (especially if they've opted out of Medicare/Medicaid, but even if they're just doing it by building in the nice part of town; I dislike this about urgent cares too). I also don't like the fact that you don't have consultants to work with (correct me if I'm wrong) unless you pay them to be on call and that there is a delay of care in taking care of true emergencies- STEMI, traumas going to the OR etc.

As a business model, there is some real risk there. It wouldn't take much legislation to put you out of business.
All businesses have risk, but I think any legislation designed to eliminate these would likely prevent new ones, and grandfather old ones in. Even if they were deep-sixed by legislation, it's likely that before shutting down you could sell your facility to whatever nearby hospital you were transferring business to, since they could then keep getting the business and now charge their own facility fees which are going to be significant. I'm not in a state where these are practical unfortunately.
 
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All businesses have risk, but I think any legislation designed to eliminate these would likely prevent new ones, and grandfather old ones in. Even if they were deep-sixed by legislation, it's likely that before shutting down you could sell your facility to whatever nearby hospital you were transferring business to, since they could then keep getting the business and now charge their own facility fees which are going to be significant. I'm not in a state where these are practical unfortunately.

how would they not be practical? I get not being legal, but not being practical?
 
how would they not be practical? I get not being legal, but not being practical?
I think they're not legal where I'm at, but honestly I haven't delved into the legalities or looked into it in depth enough to say that for sure. Physician-owned Urgent Cares seem to be the norm where I'm at, but you can't capture the facilities with those. I'm not interested enough to pay a healthcare attorney to answer that question for me.
 
They're not super practical in my neck of the woods (nor legal) since there are already 2 or 3 more EDs in this town than we need, set-up in the "high-rent" districts. One of the hospitals is wedging a hospital owned free-standing ED between two hospital based EDs that aren't anywhere near capacity as we speak. We're just all fighting over the same pie. If I were going to open a free-standing ED, it wouldn't be here.
 
I am considering an investment in a NNN Freestanding ER in Arizona called First Choice ER and affiliated with Adeptus Health a public co on NASDAQ. I believe they are affiliated with Dignity hospitals in AZ.

Has anyone invested in something like this and can lend me some info on your thoughts?
 
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First choice is expanding into az. they raised a bunch of cash. I didnt realize they were taking any investors at all (excpt via publicly traded stock).
 
Seems like it would kill your patient satisfaction and turn around times if you have to call 9 hospitals and transfer someone hundreds of miles away to another state to take care of their appy. Or do you have some arrangement whereby you can transfer even if the hospital is full? Wouldn't that result in potential EMTALA violations for the hospital if they are refusing other transfers?
The transferred patient might be upset because it took a long time. Nobody can fix that.
However, even if they took up 1 bed for hours, the other 6-7 are still rotating through. And if you're only seeing 25 patients per day, people can still go straight back, and be seen quickly. A hospital would build a 2 bed ED to see 25 pts per day, even if it didn't cost them any more not to. Hell, I see 45K in my shop, and it basically has 18 beds. No reason for it not to have 10 beds and 20 chairs, but the hospital can't see the economics behind it. FSEDs do.
 
Necrobump-ish.

How does one start up a freestanding ED? What physicians chiefly are staffing them? If they are privately owned, could a FM or IM trained physician invest their capital into their own start-up? Or for purposes of billing would this need to, by definition, be staffed by a board certified EM physician? I'm struggling to see how a freestanding ED is different from an Urgent Care center.

Personally I'd love to start up a freestanding ED in some place like Aspen or The Hamptons :)
 
The number of misconceptions on this thread still astounds me.

FSEDs don't have to be staffed by emergency physicians. They should, I agree with this. But hospital EDs aren't staffed by emergency physicians either. So the comparison is a wash. In fact, I would argue that there are 100x as many hospital EDs with FM/IM docs as there are FSEDs.

I would bet that there is already one or more in Aspen, as Colorado is one of the states that allows them. The Hamptons, not so much.

And the non hospital owned ones aren't "opting out" of CMS. CMS officially doesn't recognize them.

Consultants actually like to take call from FSEDs, because all the patients are insured. Just like transferring patients to hospitals. They know they're getting reimbursed. They know that the patients in their own ED are captive and likely won't leave, and the uninsured rate is higher. So they're always going to preferentially take the FSED transfers. I hate to have to tell people that money makes the world go 'round, but it does.

Lastly, independent FSEDs have as many regulations as hospital owned freestandings, and they have some other pain in the ass ones created by legislature. Stupid things like having car canopies that aren't related to patient care.

Yes, FSEDs aren't like ivory tower hospitals. But neither are rural hospitals. I agree that one day the legislature will probably cut the facility fee like they did without outpatient surgery centers. But even then, there's something to be said to be the boss, and pick the best lab system, the best EMR, the best nurses. And, if your volume goes up, instead of just telling everyone to suck it up, you hire more people. It's amazing how well things run without 70 layers of admin.

The corporate FSEDs will be the death of the system, just like they are killing EPs currently in hospitals.
 
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FSEDs are facing their biggest challenge yet: the turn in the court of public opinion.

I practice in Texas. I would have loved to invest 10 years ago in this concept, it was a no lose situation. Entering now is a highly risky proposition. (See:ADPT).

Regarding the Hamptons and other areas nationwide, certificates of need become the prohibitive hurdle.
 
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FSEDs are facing their biggest challenge yet: the turn in the court of public opinion.

I practice in Texas. I would have loved to invest 10 years ago in this concept, it was a no lose situation. Entering now is a highly risky proposition. (See:ADPT).

Regarding the Hamptons and other areas nationwide, certificates of need become the prohibitive hurdle.

I have invested in two of our own FSEDs. We are seeing increasing growth due to our hybrid model where we don't over charge patients for their urgent care issues.

Adeptus and their First Choice / Texas Health emergency rooms have only themselves to blame for their current problems. They overcharge for simple issues, balance bill, and have had bad PR due to this and other quality issues. Most of their physicians are FM/IM.

If you provide a good service to patients, good quality care, prompt follow-up with a specialist and let them know how you will bill then you will see growth.

That's been our experience for the past two years and we are expanding slowly and meticulously.
 
I've looked at investing in a Freestanding several times and concluded it's not worth it. There is a big difference from being a founding member who owns a big share in one ED or company, and being an investor in an existing company.

The market is quite saturated, so most of the new ones opening are by already established companies looking for investors.

When you invest in a freestanding, you are giving money and time. Typically about $100K buy-in to purchase "shares". Each share is about 1% ownership of the company at that site. You also have to work one 24 hour shift per share that you buy. Most physicians purchase 6 shares which means they have to work six 24 hour shifts in a month. The initial startup pay is low, around $100/hour to work those shifts.

Working six shifts may not sound hard, but effectively it puts you out of commission for 12 days in the month. Those six shifts would give you around $15,000 in income for the month. If I worked at my regular job instead, I would work eight 12-hour shifts which at a conservative $300/hour would give me $28,000. Over 1 year that is loss of $156,000 in revenue for me. The average Freestanding takes up to 2 years to start generating profit. The means the total buy-in at that point is $412,000. Even if the ED starts making a profit of $3 million per year, the 6% share would only equate to $180,000. That means it would take a long time to make up the amount of money lost to the buy-in with significant risk attached.

I know several colleagues who have been essentially scammed by companies. They did their buy-in, and when the facilities started seeing enough patients to make money, they didn't get their share of the profit. The excuse the company gave was that they were "re-investing" the profits into expanding to other sites. Litigation is pending.
 
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I've looked at investing in a Freestanding several times and concluded it's not worth it. There is a big difference from being a founding member who owns a big share in one ED or company, and being an investor in an existing company.

The market is quite saturated, so most of the new ones opening are by already established companies looking for investors.

When you invest in a freestanding, you are giving money and time. Typically about $100K buy-in to purchase "shares". Each share is about 1% ownership of the company at that site. You also have to work one 24 hour shift per share that you buy. Most physicians purchase 6 shares which means they have to work six 24 hour shifts in a month. The initial startup pay is low, around $100/hour to work those shifts.

Working six shifts may not sound hard, but effectively it puts you out of commission for 12 days in the month. Those six shifts would give you around $15,000 in income for the month. If I worked at my regular job instead, I would work eight 12-hour shifts which at a conservative $300/hour would give me $28,000. Over 1 year that is loss of $156,000 in revenue for me. The average Freestanding takes up to 2 years to start generating profit. The means the total buy-in at that point is $412,000. Even if the ED starts making a profit of $3 million per year, the 6% share would only equate to $180,000. That means it would take a long time to make up the amount of money lost to the buy-in with significant risk attached.

I know several colleagues who have been essentially scammed by companies. They did their buy-in, and when the facilities started seeing enough patients to make money, they didn't get their share of the profit. The excuse the company gave was that they were "re-investing" the profits into expanding to other sites. Litigation is pending.

We are a democratic group running our FSEDs.

Our initial investments were much less than $100k for much more than 1% -- specifically, $20k for 2.8%. We've run for most of the first year without taking any money out of the company and allowing ourselves to pay down debts and become cash flow positive. This has helped us immensely even though we've lost out on income during this period of time -- we work anywhere from 1to 4 shifts based on number of shares. Because it is our business , we as a group we make any major decisions regarding profit allocation, paying down debt and paying ourselves for shifts worked. We have since increased our hourly to match our collections and profit margins based on group consensus.

@GeneralVeers is talking about corporations taking advantage of your time and money to bring their business to fruition, we don't. Our profits are distributed to us individually and not re-invested to expand to other locations. Individually we can invest in these new locations as we see fit.

As a result, we can re-coup our initial investment and loss of income much more rapidly than what @GeneralVeers has commented on. Plus, I get to control how the facility functions.

FYI, we fired out ultrasound technician company when they took too long with our ultrasounds and were technically inept with their imaging. It took one day to do so.
 
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Anybody work in a freestanding ER that are hospital owned specifically?

Any of these work on the "hybrid model" of reimbursement where urgent care issues are charged a lower rate versus emergent ones?
Is this Lower charge simply for the facility fee? Are the physician fees via the physician billing company still the same?
I wonder because our hospital is very close to wanting to open a freestanding ER and I'm curious.
 
Anybody work in a freestanding ER that are hospital owned specifically?

Any of these work on the "hybrid model" of reimbursement where urgent care issues are charged a lower rate versus emergent ones?
Is this Lower charge simply for the facility fee? Are the physician fees via the physician billing company still the same?
I wonder because our hospital is very close to wanting to open a freestanding ER and I'm curious.

Ours is a hybrid model and we do not charge a facility fee for the urgent care (only physician fees). Urgent care rates are much lower than emergency rates by at least a factor of 5-6. The same billing company does both for us. We are upfront with patients as to whether their complaint, symptoms and vitals constitute an ED visit vs UC and have them sign a document attesting to that designation. They are free to leave or stay for treatment. We do not turn anyone away if we believe they are having an emergent condition.
 
Just buy some Adeptus stock. I hear it's very affordable these days...
 
Anybody work in a freestanding ER that are hospital owned specifically?

Any of these work on the "hybrid model" of reimbursement where urgent care issues are charged a lower rate versus emergent ones?
Is this Lower charge simply for the facility fee? Are the physician fees via the physician billing company still the same?
I wonder because our hospital is very close to wanting to open a freestanding ER and I'm curious.
Does your hospital charge urgent care rates when those people show up in the ED?
No. I am as of yet unaware of an HOPD that has an urgent care. Hell, most FSEDs don't. They hybrid model is gaining traction though.
 
Anybody work in a freestanding ER that are hospital owned specifically?

Yes. It is the worst of both worlds. The hospital typically keeps all the facility pay, and the doctors collect the doctor fee. As a result pay is usually < $200/hour. Since the hospital runs the show, you are stuck dealing with administrator metrics like patient satisfaction. These patients DO expect to be satisfied, and will complain loudly if their expectations are not met. My advice is stay away from these.
 
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We are a democratic group running our FSEDs.
.

Kudos to you then for treating doctors fairly then. I see a lot of predatory, dishonest doctors trying to scam their colleagues in this business.

Even if you are keeping the money at the site, aren't you still looking at 3-4 years to recoup the loss of income by working at a lower rate?
 
It can be a great investment. You could also lose everything and then some. Any time you look at a deal like this you really need to get into the nitty-gritty. The devil is in the details.
 
Kudos to you then for treating doctors fairly then. I see a lot of predatory, dishonest doctors trying to scam their colleagues in this business.

Even if you are keeping the money at the site, aren't you still looking at 3-4 years to recoup the loss of income by working at a lower rate?

We should be able to recoup our loss of income and initial investment by our 3rd year. We should be able to recoup our initial investment this year (2nd) and be debt free next year.

Our loss of income in the beginning has afforded us the opportunity to become cash flow positive and pay down debt quickly. This is a positive in my book.
 
We should be able to recoup our loss of income and initial investment by our 3rd year. We should be able to recoup our initial investment this year (2nd) and be debt free next year.

Our loss of income in the beginning has afforded us the opportunity to become cash flow positive and pay down debt quickly. This is a positive in my book.
Ours does 3 months of sweat, which is tough. But that saves hundreds of thousands of dollars until AR starts flowing. Pay down the debt aggressively, but pay docs what they are worth. Dividends paid after the sites have significant decrease in debt. Only BC/BE emergency docs can work at the sites.
 
The FSED boom seems lucrative with states like Tx leading the pack in opportunities and pay. Any investment is a risk but in a state like Tx, nobody would blame you for investing...

Honestly, it's opportunities like these that made me apply for a TX license last year that's still in process. I have no idea if I'll use it but at least it will be there.


hi, i'm late in the game and just stumbled onto this thread. can someone explain to me why TX is such a lucrative place to invest in a FSED? what legislations are in place that make it a good place to start a FSED? I was presented with an opportunity to invest in paris, TX and am seriously consdiering it. anyone in TX that can tell me what kind of patient population surrounds paris, tx that might help make this FSED succeed or fail?

Someone also previously mentioned that "Entering now is a highly risky proposition. (See:ADPT)." Can someone please elaborate?
 
hi, i'm late in the game and just stumbled onto this thread. can someone explain to me why TX is such a lucrative place to invest in a FSED? what legislations are in place that make it a good place to start a FSED? I was presented with an opportunity to invest in paris, TX and am seriously consdiering it. anyone in TX that can tell me what kind of patient population surrounds paris, tx that might help make this FSED succeed or fail?

Someone also previously mentioned that "Entering now is a highly risky proposition. (See:ADPT)." Can someone please elaborate?

Don't take this the wrong way, but from reading your post you should not be investing in FSEDs.

Texas has no requirement for certificate of Need which is why there are so many.

Adeptus (stock symbol ADPT) was the largest privately owned FSED chain, whose stock went from about $160 to $1 in the last year.

Generally speaking, the floor is falling out of the FSED market. Barring unique circumstance, it is a good way to lose money if you are entering the space right now.
 
Don't take this the wrong way, but from reading your post you should not be investing in FSEDs.

Texas has no requirement for certificate of Need which is why there are so many.

Adeptus (stock symbol ADPT) was the largest privately owned FSED chain, whose stock went from about $160 to $1 in the last year.

Generally speaking, the floor is falling out of the FSED market. Barring unique circumstance, it is a good way to lose money if you are entering the space right now.

Do you have any insight as to what is driving this change, and whether its consequence will be restricted to reducing ROI on investing in freestandings, or also actually negatively impact the demand for EPs by shuttering a large number of facilities?
 
It won't change. The number of jobs in Texas exceeded supply before FSEDs, and it definitely does now. Probably 20-25% of the docs working in Texas don't actually live here at this point, and commute in for work because of the rates. It's pretty ridiculous, but I get it.
If they closed all the FSEDs tomorrow, those people will probably stop commuting to Texas. But since they can't do that, it won't be an issue.
There will be a happy medium, and people will have to *gasp* not live in their big city and work at their FSED. They might have to build one in a smaller area.
There's people putting one up in Paris, TX right now. That's an interesting idea for sure.
But yes, if you're going to get into it, do some homework. Don't just expect to start mining bitcoins right out of the box.
 
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Why is the one in Paris, Texas interesting? Not from Texas so not familiar with that place. I have been seeing posts about it on the EM Docs FB page and am curious.
 
I looked at this pretty seriously a year and a half ago.

The sense I had was that I was late to the party and didn't invest.

Five, ten years ago would have been an entirely different story.
 
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Why is the one in Paris, Texas interesting? Not from Texas so not familiar with that place. I have been seeing posts about it on the EM Docs FB page and am curious.
It's in an odd place. And close to Oklahoma, where some of their state plans won't reimburse independent FSEDs due to the CMS rules.
I probably wouldn't invest in that one. But there are places that it could work.
 
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