Surgery center investors, like other business owners, must weigh the pros and cons of leasing or buying the space in which an ambulatory surgery center (ASC) resides. How does one decide which option is best? Investors who understand the financial impact ASC real estate ownership or leasing is likely to have on the short- and long-term development of their business project are better equipped to make sound decisions. Only then can investors thoughtfully examine other reasons for either leasing or owning their ASC space. Let’s explore the considerations of both options.
Leased ASC Space
Leasing space for an ASC from an unrelated third party is typically the most straightforward option. It avoids many of the additional steps required in the ASC real estate ownership model described below. Best practice allows the prospective owners to determine a geographic location that ensures the greatest potential for physician partner participation. The ownership partnership then locates a space that will meet its needs – no more, no less. The ASC partnership evaluates the lease rate of the space as well as the construction costs required to convert it to an operating ASC. Costs are then evaluated against the project pro forma to determine if the space best meets the identified needs and desired financial outcome.
Owned ASC Space
The second option is an ASC real estate ownership model in which the ASC LLC, or some portion of its members, own the space where the facility will be located. This model, while providing equity, presents a few challenges and considerations for the ASC investor group.
- Fair market value: Regardless of who owns the space, the terms of the lease must represent fair market value for like-space in the area to ensure the entity does not run afoul of federal Anti-Kickback laws. The health system partner cannot subsidize the ASC partnership with artificially low rent; nor can the ASC partnership pay an inflated rental rate in space owned by some, or all, of its physician investors or a potential referral source.
- Location, Location, Location: The old real estate adage holds true in our business as well. The location of the facility is the most important factor when considering ASC real estate ownership. I have seen some centers struggle, and others fail, because fifteen minutes is too far for the partners to drive. I have also worked with partnerships who are convinced a location twenty minutes away is the better option because the ASC real estate ownership deal makes more sense for those physicians. The bottom-line? The best location is the one that will be consistently utilized.
- The ASC is the primary business: A business owner once told me he would have been more successful if he had made fewer of his business decisions based on the fact that he owned the building. While real estate ownership may be attractive, if the ASC meets the expectations of a well-vetted pro forma, its returns should far outpace that of the real estate investment. Thus, the primary concern for the ASC LLC partnership should be the location and lease terms that make the most financial and operational sense for the ASC.
- Ownership structure: Many times, ASCs include the ASC real estate ownership in the ASC LLC partnership. In every one of these instances, problems arise down the road. Our advice, while not always accepted, is to have a separate LLC own the real estate. The real estate partnership can then lease space to the ASC LLC at fair market value. The real estate entity can be structured in a number of ways – owned by the ASC LLC partners, a subgroup of partners, an individual partner, or another similar arrangement. The benefit is this structure will allow the real estate to be dealt with separately from the ASC.
Owning versus leasing the real estate in which your business operates is never an easy decision. ASC owners must consider a variety of factors, including which option makes most financial sense and what will best serve its customers, physician partners, and patients. Carefully weighing all options will yield the best outcome when deciding if you should lease or buy space for your surgery center.
Robert Carrera, President/CEO
