ELFA Equipment Management Conference Edward G. Detwiler, ASA

Transcription

1 ELFA Equipment Management Conference 2014 Healthcare Equipment Financing & Implications of the Affordable Care Act Edward G. Detwiler, ASA MEMBER Accredited Senior Appraiser, American Society of Appraisers Machinery & Technical Specialties Discipline Board Member, HealthCare Special Interest Group Panel of Commercial Arbitrators, American Arbitration Association Associate, American Bar Association

2 Confusion Start with Gradual Market De-Regulation Add Increasing Health Insurance Premiums Add Denial of Claims (limits & pre-existing) Add Business Failures (benefits lost) Add Financial Melt-Down (unemployment) Add Market Collapse (loss of investments) End with Healthcare Reform From The Hillary Factor (1993) to ObamaCare

3 Wild Stories Some are Actually True (or at least partly) People are losing health insurance coverage! Insurance is more expensive than before! Young adults don t get sick and don t need insurance! Tens of millions of people will be added to the system!

4 Posted in Medical Device Business Source: CMS, with calculations by MD+DI

5 Transition from Volume-Based to Value-Based Care Cleveland Clinic CEO Toby Cosgrove, MD, said the transition to value-based care is being slowed by "criticism, misunderstanding and a reluctance to do things differently," according to a Harvard Business Review blog post. Dr. Cosgrove said all health systems must embrace the challenge to improve quality while lowering costs, and "whether providers like it or not, healthcare is evolving from a proficiency-based art to a data-driven science." This includes moving from freelance physicians to hospitalemployed physicians and from one-size-fits-all community hospitals to vast hospital networks organized around centers of excellence.

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8 Economic Obsolescence is considered external to the product, as in the case of changing values based on regulations. Consider multiple effects of Market changes Reduced demand for new equipment due to concerns about reimbursements will extend equipment life and used equipment will maintain higher values (FMV & OLV).

9 Stark II OBRA 93 Fraud & Abuse, Self-Referral Safe Harbor Leasing Contracts allowed many imaging centers to avoid problems Leasing became a solution and a problem Enron and other disasters have led to new proposed accounting standards the end of the operating lease?

10 CT Systems Once predicted to have an estimated useful life of 5-7 years Now some sources, including GE, report the average life of a CT in the US to be nine years! We have been forecasting for many years, and just a few years ago had to revise our forecast of market values to 7 years from 5. (not just CT, but most diagnostic imaging systems) This means that equipment is holding its value better than before and has implications that leases will be written for longer periods and will be more likely to be extended or bought out at higher values.

11 Residual Value Calculated by Lessor, as some value between: Fair Market Value and Orderly Liquidation Value Considering risk factors: Stick Rate for each particular lessee and its appetite for new technology. Economic factors at play recession or recovery Expansion, consolidation Re-imbursements, procedure efficacy

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13 Proton Therapy Systems Once cost $130,000, and investors lined up to build. New introduction at less than half that cost means loss of half the value. This is Marketing 101! Approximate pricing (total capital cost): IBA ProCure SC360 Mevion Medical S250 ProTom International Radiance 330 $130 million $25-35 million $50 million

14 Test of Reasonableness In estimating value, always: Use more than one approach the market approach may seem best, but conditions can cause fluctuations try a cost approach formula that may raise doubt. Look for oddities in the transaction are both parties using good judgment and good business principles? Strategic acquisitions that work in the financial community don t pass the test in the highly regulated healthcare marketplace. Consider Income Approach to see if the equipment acquisition is justified.

15 Market Consolidation While not great in the short run for manufacturers and finance companies, consolidation does show cost reductions through better use of resources. Example: Two cardiologists, each offering nuclear stress testing, are acquired by hospital. Sharing such services saves on equipment cost, maintenance, technicians, space and other cost factors. Neither practice is hurt, because both are able to send patients to same system and the duplicate assets can be re-allocated or sold off. Other obvious benefits include sharing of staff and other underutilized assets, as well as call and vacation coverage.

16 Regulatory Impact on Equipment Values From a presentation I made in 1993, entitled The Hillary Factor Anti-Kickback and Self-Referral legislation referred to as Stark II put a large number of imaging and therapy centers at risk or out of business The number of imaging procedures were cut in half, as was the cost per procedure. Market was flooded with excess equipment, new equipment sales were nearly zero So, it s not so bad after all, is it?