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Healthcare Valuation, the Financial Appraisal of Enterprises, Assets, and Services


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Table of Contents

Foreword xi Preface xiii Acknowledgments xxiii About the Author xxv Disclaimer xxvii Volume 1 Introduction 1

Chapter 1: The Chronology of U.S. Healthcare Delivery: From Caduceus to Corporatization 5

Chapter 2: Reimbursement Environment 85

Chapter 3: Regulatory Environment 261

Chapter 4: Competition 465

Chapter 5: Technology 531

Chapter 6: Healthcare Reform 631

About the Companion Website 675

Index 677 Volume 2 Introduction 1

Chapter 7: Basic Valuation Tenets 5

Chapter 8: Valuation Approaches and Methods 39

Chapter 9: Costs and Sources of Capital 175

Chapter 10: Planning and Process for Healthcare Valuation Engagements 215

Chapter 11: Inpatient Enterprises 271

Chapter 12: The Valuation of Outpatient Enterprises 405

Chapter 13: The Valuation of Other Healthcare-Related Enterprises 605

Chapter 14: The Valuation of Tangible and Intangible Assets 709

Chapter 15: Healthcare Services 863

Chapter 16: The Threshold of Commercial Reasonableness 929

Epilogue 975 Appendix: Subject Property Interest 979 Bibliography 983 Glossary 1061 About the Companion Website 1085 Index 1087

About the Author

ROBERT JAMES CIMASI, MHA, ASA, FRICS, MCBA, AVA, CM&AA, is Chief Executive Officer of Health Capital Consultants, a nationally recognized healthcare financial and economic consulting firm. With over 25 years of experience in serving clients, his professional focus is on the financial and economic aspects of healthcare service sector entities including: valuation consulting; litigation support and expert testimony; business intermediary and capital formation services; certificate-of-need and other regulatory and policy planning consulting; and healthcare industry transactions including joint ventures, sales, mergers, acquisitions, and divestitures. He is a nationally recognized frequent speaker presenting research papers and case studies at national conferences and is often quoted by healthcare industry professional publications and the general media.


?Not all valuations are created equal. The valuation of healthcare businesses requires consideration of nuances created by industry practice and by regulations. Healthcare Valuation: The Financial Appraisal of Enterprises, Assets, and Services by Bob Cimasi provides a valuable framework for any business valuer endeavoring to value healthcare-related business interests.? ?Bob Morrison, ASA BV/IA, American Society of Appraisers Business Valuation Discipline Chair ?All appraisers dealing with healthcare subjects should have this necessary handbook. Healthcare valuation has emerged into a specialized field, requiring background, discernment and work experience in order to be effective. Healthcare businesses are constantly changing ? the insight provided by Mr. Cimasi?s wealth of experience is indispensable.? ?Robert Schlegel, ASA, MCBA [Past International President of the American Society of Appraisers] ?Bob Cimasi?s Healthcare Valuation ? The Financial Appraisal of Enterprises, Assets, and Services, is a timely and essential resource for any professional who is retained to provide valuation services relating to the healthcare industry. The book is extremely comprehensive, written by one of the most distinguished and recognized U.S. experts on the subject. In this user-friendly authority, the author shares with readers his in-depth knowledge of the industry as well as his many years of hands-on valuation experience, in a detailed, intelligible, and cogent manner. While geared to American appraisers, the book can also serve as an important compendium for use by my colleagues in Canada as well, whether for domestic or cross-border assignments. Bob Cimasi?s book is a highly valuable addition to the appraisal profession?s body of knowledge and is a definite must-read.? ?Richard M. Wise, FASA, MCBA, FCBV, FRICS, CVA, FCA, CPA, CA [Former President, Canadian Institute of Chartered Business Valuators] ?Brilliant! Bob Cimasi?s Healthcare Valuation is the definitive treatise for the complexities of valuation in the healthcare industry. This book successfully achieves its goal as both a resource and a reference, comprehensively explaining valuation theory and value drivers unique to healthcare entities in the context of healthcare reform and how we got here. It is a superb and insightful guide for healthcare finance and management professionals, as well as their professional advisors ? not only appraisers, but also accountants, attorneys, bankers, and M&A advisors ? and academia.? ?Chris M. Mellen, President ? Delphi Valuation Advisors, Inc. and co-author of Valuation for M&A: Building Value in Private Companies. ?Shannon Pratt?s forward clearly articulates the outstanding quality of this text. Bob is an expert in the field. This text provides excellent background and with his firm grasp of the subject matter, Bob presents in depth commentary on all facets related to healthcare valuation including inpatient, outpatient, outpatient ambulatory, other related enterprises and healthcare services. In short this is a one stop service for anyone doing healthcare valuations.? ?Michael Gregory, ASA, AVA, PE [Former IRS Territory Manager responsible for valuation specialists covering fourteen states] ?Bob Cimasi?s new text is a critical resource for any financial analyst delving into the world of healthcare; without an understanding of the core regulatory and procedural elements governing healthcare operations and finance, the analyst risks generating a conclusion which could be unsupportable. This book should be on the desk of everyone working in the area of healthcare financial analysis.? ?James B Lurie, ASA, CBA, CVA, BVAL, Managing Member Emeritus, CapVal-American Business Appraisers, LLC ?Cimasi's Healthcare Valuation is a rare and unique asset to the community. From the Preface, which contains a fascinating historical perspective of the valuation profession to the concluding chapter on Basic Valuation Tenets, which looks at the profession from a rare economic perspective, Healthcare Valuation is the perfect book for these imperfect times.? ?Howard Lewis, Executive Director, Institute of Business Appraisers [Former National Program Manager of the IRS Engineering and Valuation Program] ?It is no secret that modern healthcare in the United States, and its valuation, is extraordinarily complex. As an added difficulty, the four pillars of the healthcare industry described by Bob Cimasi (regulation, reimbursement, competition, and technology) are in such a state of flux that the shifting landscape can overwhelm even the most seasoned healthcare professionals, executives, and advisors. That is why Mr. Cimasi?s heavily researched work, Healthcare Valuation, is so invaluable. It serves as a trustworthy and definitive resource for myriad questions ranging from the tenets of valuation to the true drivers of value. I predict it will soon become required reading for anyone involved in the field.? ?Robert L. Wilson, Jr., Healthcare Group Practice Area Leader, Smith Moore Leatherwood LLP ?Cimasi delivers again! Bob has provided an unyielding dedication to the profession of valuation and the healthcare industries over the past thirty years. He and his team have been dedicated to providing resources and sage guidance to practitioners and he does not disappoint with this latest endeavor. Healthcare Valuation: The Financial Appraisal of Enterprises, Assets, and Services is a valuable guide for healthcare providers and advisors alike. ?Lari B. Masten, MSA, CPA, ABV, CFF, CVA, ABAR, Masten Valuation, LLC [Past chair & Current Maember of NACVA Executive Advisors Board] ?Bob Cimasi?s latest book, Healthcare Valuation, provides a robust discussion regarding the capital markets and cost of capital as these topics relate to the healthcare transactional marketplace in an era of reform. Cimasi delves into those considerations that drive the healthcare capital markets, and the resulting impact on healthcare enterprises, providers, payors, and consumers as they navigate evolving models of care by investing in newly emerging healthcare organizations.? ?John Paglia, Ph.D., CFA,CPA [Associate Professor of Finance, Director of Pepperdine Private Capital Markets Project ? Pepperdine University] ?Bob Cimasi?s new book, Healthcare Valuation: The Financial Appraisal of Enterprises, Assets, and Services, will be must-reading for valuation professionals --- generalists like me and specialists in healthcare valuations --- who need to get up to speed in dealing with the intricacies of ?Obamacare.? The book is an up-to-the-minute analysis of the vast changes in this complicated and controversial new law, and it is written in a concise style that covers the waterfront of issues created by the changes.? ?Dick Thorsen, CPA/ABV, ABAR, CVA, CMEA [Past Member, Board of Directors & Vice President of the American Institute of CPAs] "This book should be the keystone tool in a business appraiser's research library who conduct business appraisals in the ever changing healthcare industry. The book is packed with references and support for identifying and quantifying risk factors that impact the valuation of healthcare related businesses." ?Jeffrey D. Jones, ASA, CBA, CBI [President, Certified Appraisers]

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