benchmarking for medical practices - business valuation resources
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Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 0 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking for Medical Practices
Lori A. Foley, CMA, PHR, CMM
Tynan Olechny, MBA/MPH, AVA
© 2013 Business Valuation Resources, LLC
Page 1 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
What is Benchmarking?
• Process of measuring and comparing an
organization’s performance to national, and
regional, or industry averages
– Provides quantitative data to support informed
decision-making
• Internal vs. External
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 2 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Why Benchmark?
• Insight into:
– How business is operating compared to peers
• net income/overhead
– How individuals/entities are producing compared
to peers
• production, compensation
– How efficiently staff or processes are working
• A/R days, collection rates, A/R aging
Page 3 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Applications
• Routine daily management
• Situational analysis
• Self evaluation in contemplation of a sale
• External evaluation in contemplation of a purchase
• By appraiser to understand and normalize the business
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 4 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
What Can Be Benchmarked?
• Production
– Procedures - Patients - RVUs
– Cases - Medical records - wRVUs
– Visits - Hours worked
• Compensation/Benefits
– Compensation per wRVU
– Compensation to collections ratio
• Overhead
– Numerous expense categories
Page 5 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
What Can Be Benchmarked?
• Staffing Complement
• Efficiency Ratios
– Days in A/R
– Gross/Adjusted Collection %
• Collections
– Collections per wRVU
• Payor Mix
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 6 July 30, 2013
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© 2013 Business Valuation Resources, LLC
Benchmarking Resources
• Financial Surveys
– Medical Group Management Association, American
Medical Group Association, Sullivan Cotter & Associates,
Towers Watson, etc.
• E/M Bell Curve Data Book
• Specialty Medical Associations
– NERVES Socio-Economic Survey
• Entity itself (trending)
• Proprietary Internal Databases
Page 7 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Financial Surveys
• Medical Group Management Association • Physician Compensation & Production Survey
• Management Compensation Survey
• Cost Survey
• Individual Specialty Surveys (i.e. Anesthesia, etc)
– Most comprehensive; largest sample of physicians
– Generally represents small, single specialty medical groups
– Shifting split between private practice and Hospital/IDS-owned
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 8 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Financial Surveys
• American Medical Group Association • Compensation & Financial Survey
– Generally mid to large multi-specialty medical groups
– Not as many expense category benchmarks available
• Sullivan, Cotter & Associates • Physician Compensation & Productivity Survey
• Physician On-Call Pay Survey
– Generally represents larger organizations, including hospital based systems and academic groups
Page 9 July 30, 2013
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© 2013 Business Valuation Resources, LLC
Undertaking the Task
Critical to understand:
- The data you have
- What the benchmarks measure
- How they are defined and calculated
- What they [might] mean
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
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Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Obtaining the Data
• Clearly understand what information you are
seeking
• Cooperate with entity to get what you need
– Discuss systems, capabilities and data inputs
– Any gaps/overlaps due to system conversions
– Provide detailed requests for information
– Communication, communication, communication!
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© 2013 Business Valuation Resources, LLC
Working with the Data
• Understand what you received – is
normalization required?
– Any providers/services/locations added or
deleted?
– Significant changes to charge master/fee
schedule, reimbursement contracts, expenses?
– Double check report parameters and time periods
• Matching
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 12 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Working with the Data
• Understand what you received – is
annualization required?
– The more months included, the better
– Does the period reflect the norm?
– Are there alternatives to annualization?
• 12 months “moving”/TTM
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© 2013 Business Valuation Resources, LLC
Remember:
• Data comes from a variety of sources
– Not always comparable
• Collection of data is often contingent on how systems are set up
– Varying levels of sophistication
– Close but not quite “there”
• Definitions may differ according to situation
• Varying degrees of “electronic” data
• Always subject to interpretation
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
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Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Using the Benchmark Resource
• Read the narrative – make sure you know
what is being measured and how
– Often includes disclaimers as to how it should or
should not be used
– May narrate differences from previous years’
benchmarks
– Identifies and discusses trends in the data
• Be as specific as possible to each situation
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Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Using the Benchmark Resource
• Review the formula to perform the calculation
• Differentiate between Median and Mean
• High percentiles – it’s not always good to be at the top of the chart!
– Example – 90th percentile in collections vs. 90th percentile in expenses
• Understand the metric definition – total compensation in one survey may not equal total compensation in another survey
• Consider the number of survey respondents
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 16 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Using the Benchmark Resource
• Data results from one benchmark metric do
not always correlate to data results from
another benchmark metric
– Example – Collections vs. Charges:
2013 MGMA Physician Compensation & Production Survey
Description Data Points 25th
Percentile Median Mean 75th
Percentile 90th
Percentile
Family Medicine - Total Collections
2,136 $ 325,241 $ 418,763 $ 433,343 $ 524,404 $ 637,880
Family Medicine - Gross Charges
2,378 $ 515,475 $ 656,422 $ 708,798 $ 841,652 $ 1,072,879
Page 17 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Understanding the Benchmark
• Result of the calculation seldom tells the
entire story – dig deeper!
– Surrounding circumstances and other factors
should be considered
• Creates a starting point for additional
questions, analysis and understanding
– Double check: Does the result of the calculation
make sense in light of the other information?
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 18 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Charges
– Better internal measure (e.g. year over year for
the same entity) than external
– Establishment of charges is subjective for the
entity
– Important to understand if calculating gross
collection rate (GCR) [payments/charges]
– Often benchmarked as a percent of the Medicare
fee schedule
Page 19 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Charges
• Example
– Practice A sets charges at 200% of the Medicare
allowable and has GCR of 62.5%
– Practice B sets fees at 400% of the Medicare
allowable and has GCR of 31.25%
– Benchmark is 66%
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 20 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Payments
• More objective measure than charges
• Remember - not all payment types may be
included in the benchmarks
– Read the benchmark to understand what to
include for comparison
– Understand the data to ensure that only
applicable amounts are included
Page 21 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Payments
• Payment considerations:
– Is A/R high?
– Are billing and collection processes routine and
operating as they should be?
– Are new providers credentialed so that claims
can be processed?
• An adjustment may be warranted to paint a
more complete picture for decision making
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 22 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Compensation
• Not all types of compensation are included in the
benchmarks
– Read the benchmark to understand what to include
for comparison
– Understand the data to ensure that only applicable
amounts are included
• Influenced by a variety of factors – ownership,
net income, contract, compensation formula,
sources of compensation
Page 23 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Compensation
• Compensation considerations:
– Does the provider have a contracted salary or ownership interest?
– Is compensation allocation tied to production?
– Is provider in a start-up or wind-down situation? Buying in?
– Does the physician receive compensation for call coverage, medical directorship, etc.?
– Is compensation being taken in the form of rent, personal expenses, etc.?
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 24 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Operating Overhead
• Can benchmark actual dollars or expense as a percent of net patient revenue – both may be relevant
– Again, beware of benchmark definitions!
• Personal and discretionary expenses are typically excluded
– Often requires a significant amount of normalization
• Non-recurring/extraordinary items are often excluded or normalized
Page 25 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Operating Overhead
• Operating overhead considerations:
– Keep in mind a function of both collections and
expenditures – “reasonable” expenses in terms of
$$ but low collections yield high percentages
– If you are analyzing part of a larger whole, are all
expenses fully captured?
• If not, how should they be accounted for?
– If forecasting, consider fixed versus variable
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 26 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Operating Overhead
A C D E G
Entity Financial
Statements 12/31/10
Allocable
Expenses ($) (3)Allocation Basis (4)
Allocation
Rate (9)Common Size
Revenues
1 Professional Fees 2,000,000 (500,000) 1,500,000 Professional 0 1
2 Professional Fees - Direct 500,000 500,000 Percent Technical Revenue (1) 86.3% 431,657 (11) 100.00% 2
3 Total Income 2,000,000 431,657 3
4 Non-Physician Expenses 4
5 Accounting Fees 15,000 15,000 Percent Revenue 21.58% 3,237 0.75% 5
6 Automobile Expense 7,000 (1,000) 6,000 Percent Revenue 21.58% 1,295 0.30% 6
7 Automobile Expense - Direct 1,000 1,000 Direct 100.00% 1,000
V 8 Bank Service Charges 5,000 5,000 Percent Revenue 21.58% 1,079 0.25% 8
V 9 Collection Costs 1,500 1,500 Percent Revenue 21.58% 324 0.08% 9
Ancillary Service
Revenue & Expense Allocations
B F
Direct Adjustments ($)
(2)
Allocated Ancillary
Income Statement ($)
(10)
Page 27 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Production
• Important because it is a key driver of
revenue (along with reimbursement rates)
• In many of today’s affiliations, production is a
direct driver of provider compensation
• Measured in a myriad of ways
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 28 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Production
Measure Issues to Consider
Office Visits Number of patients seen in an ambulatory (office) setting
Encounters Can mean ambulatory visits or procedures
Procedures Can mean every CPT submitted or the number of times a certain case is performed
Cases Often comprised of multiple CPT codes or procedures; assistant surgeon cases may be reflected
RVUs/wRVUs
Impact of modifiers, multiple procedure discounts
Page 29 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Production
• Production considerations:
– If the entity has non-physician practitioners (NPPs), understand how they are tracked in the reports
• Billing provider vs. rendering provider
– Are the results reasonable - can one provider see ___ patients per day?
– Are there any planned changes with regards to production?
• Retirement/slow down, loss of patient base or key referral source, etc.
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 30 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Staffing
• Often one of the Practice’s highest line item
expenses
• Certain levels of staffing needed to achieve
certain economic results
• Both under and overstaffing may yield less
net income; consider during normalization
process
Page 31 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Staffing
• Staffing considerations:
– Must understand classifications and who is
included
• Some benchmarks exclude NPPs, others include
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 32 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Benchmarking Financial Indicators
• Reflect the results/efficiency of certain
processes, usually A/R related
– Days/months in accounts receivable
– % of A/R in each aging bucket
– Gross Collection Rate
– Adjusted Collection Rate
Page 33 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
A/R Benchmarking Considerations
• Accounts Receivable Indicators
– Understand the entity’s process for writing off bad
debt/uncollectible accounts
– Identify aging parameter – time of service, time of
filing, re-aging impact
– If entity changed billing systems during analyzed
period, make sure to account for related activity
in both
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 34 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
GCR Benchmarking Considerations
• Gross Collection Rate =
Payments
Charges
• If fee schedule is set very low, GCR can be very high and vice versa – does not necessarily reflect efficiency of collections
• Material changes in fee schedule affect comparison from one period to the next
Page 35 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
ACR Benchmarking Considerations
• Adjusted Collection Rate =
Payments
[Charges – Mandated Adjustments]
• Effective calculation relies on how
sophisticated entity is in tracking adjustments
by category
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 36 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
ACR Benchmarking Considerations
• Different benchmarks treat certain categories
differently
– Professional courtesy
• Can exceed 100% due to timing issues but
not for sustainable period of time
• Can be a measure of effectiveness of
collections
Page 37 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Applying Benchmarks
• Once appropriate benchmarks are identified,
valuation experts should use this information
to guide their analysis, looking for areas in
the practice that may deviate from the
applicable benchmark data
– Identify areas requiring adjustments
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 38 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Applying Benchmarks
• What questions should you ask to better
understand what’s going on in the practice,
using benchmark data as an indicator of the
norm?
– Does this benchmark make sense in light of other
information? What other factors could be causing
this result? How can or should practice
performance be adjusted to get to the norm?
Page 39 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Case Study 1: Physician Productivity
When comparing 2012 financials to those of
previous years, a valuation expert notices a
decrease in revenue. Valuation expert investigates
by looking at individual physician production.
-Physician A made $251,000 in 2012, and
generated 4,800 wRVUs.
-Physician B made $300,000 in 2012, and
generated 2,000 wRVUs.
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 40 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Case Study 1: Physician Productivity
National Compensation Survey Data, Neurology
Description Data Points 25th
Percentile Median Mean 75th
Percentile 90th
Percentile
2013 MGMA Physician Compensation and Production Survey 693 $ 221,076 $ 265,443 $ 298,599 $ 343,410 $ 470,966
2012 SullivanCotter Physician Compensation Productivity Survey 781 $ 201,991 $ 247,948 $ 253,185 $ 271,276 $ 347,365
2012 AMGA Medical Group Compensation and Financial Survey 1,062 $ 211,009 $ 249,250 $ 273,255 $ 301,540 $ 396,081
Average of Surveys, Rounded $ 211,359 $ 254,214 $ 275,013 $ 305,409 $ 404,804
wRVU Survey Data, Neurology
Description Data Points 25th
Percentile Median Mean 75th
Percentile 90th
Percentile
2013 MGMA Physician Compensation and Production Survey 587 3,818 5,158 5,589 6,810 9,155
2012 SullivanCotter Physician Compensation Productivity Survey 432 3,655 4,454 4,977 5,844 7,627
2012 AMGA Medical Group Compensation and Financial Survey 846 3,643 4,717 5,185 6,158 8,058
Average of Surveys, Rounded 3,705 4,776 5,250 6,271 8,280
Physician A Physician B
Physician B Physician A
Page 41 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Case Study 1: Physician Productivity
• Physician A is compensated at the median level, and seems to be producing accordingly.
• Physician B is compensated near the 75th percentile, and is producing far below the 25th percentile.
– Physician B’s compensation and production levels do not align.
– Physician B historically produced at the 90th percentile.
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 42 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Case Study 1: Physician Productivity
• Does this account for the decrease in revenue?
– It could. However, all possible factors that affect revenue should be explored.
• What next?
– The valuation expert should investigate Physician B’s compensation levels in previous years.
– Understand how compensation is calculated in the practice. Is a portion of revenue shared, e.g. Is there a direct correlation in the formula between production and compensation?
– The valuation expert should investigate other potential causes.
Page 43 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Case Study 1: Physician Productivity
• What other questions should the valuation expert
ask in this situation?
– Is the decrease in revenue a new trend, or has it been
ongoing? Is it expected to continue?
– Could the decrease in revenue be caused by factors other
than Physician B’s production?
• Are practice reimbursement rates normal? Are there problems
with collections? Has there been an increase in expenses? Have
there been any operational changes within the practice?
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 44 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Case Study 1: Physician Productivity
• What would any willing Buyer adjust to get
revenue back on track?
– Which of these findings require normalization in
the valuation?
Page 45 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Case Study 2: Operating Overhead
Valuation expert analyzes operating overhead
of a family medicine practice in comparison to
other similar practices. Currently, the practice
spends about 30% of its revenue on general
operating costs (excluding physician
compensation and benefits).
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 46 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Case Study 2: Operating Overhead
• The practice’s operating overhead
approximates the MGMA 25th percentile.
What does this mean?
General Operating Cost as a Percentage of Revenue, Family Medicine
Description Data Points 25th Percentile Median Mean 75th Percentile 90th Percentile
2012 MGMA Cost Survey 372 29.19% 41.04% 50.77% 62.12% 90.19%
Page 47 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Case Study 2: Operating Overhead
• What questions should the valuation expert
ask in this situation?
– Expenses may be low, but are they appropriate?
Is the practice understaffed or undersupplied?
– Are collections much higher than the norm,
resulting in lower expenses as a percentage of
revenue?
– Are all expenses accounted for?
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 48 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Keys to Remember
• Benchmarks do not tell the whole story, but
instead offer insight.
• Not all benchmarks are relevant, and not
everything is worthy of comparison.
• Keep it in perspective!
– A benchmark with an n = 356 is probably more
reliable than one with an n = 28.
Page 49 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Keys to Remember
• Finally, always step back and look at the
relationships of the analysis to see if they
make sense. If wRVUs and collections are
greater than the median and expenses are at
or below the median, why isn’t compensation
greater than the median? What is missing?
Benchmarking Medical Practice Performance
© 2013 Business Valuation Resources, LLC
Page 50 July 30, 2013
Prepared for BVR 2013 Online Symposium on Healthcare Valuation Part 7
© 2013 Business Valuation Resources, LLC
Thank You
Lori A Foley, CMA, PHR, CMM
404.266.9876
www.pyagatesmoore.com
Tynan Olechny, MBA, MPH, AVA
404.266.9876
www.pyagatesmoore.com