Doug Price: For a doctor to make a purchase, a lot of times it may be the same cost as their lease or cheaper and then in 10 years they’ve got options to go, “Do I want to sell my practice and be a landlord? Do I want to sell it all?” And you might have a piece of property that could be worth more or the same as their book of business.
Speaker 2: Welcome to the Growing a Successful Orthopedic Practice podcast. Join us every episode to hear from fellow medical practice administrators, staff and physicians as we break down current issues affecting the industry and share real stories from guests on their way to growing a successful orthopedic practice. Let’s get started.
Keith Landry: Hello everyone and welcome to another edition of the Growing a Successful Orthopedic Practice podcast. Getting those orthopedic physicians and practice managers in gear to scale that business as quickly as possible, no matter what’s happening in the world today. And this episode is sponsored by OrthoLive.
Our guest today really has his finger on the pulse of a big trend over the last few years. Almost everywhere you go, you see the expansive medical offices popping up everywhere, urgent care centers. Just a huge part of the real estate world, medical practice is expanding all over the place and opening doors to serve their clients all over America and we are talking to Doug Price who’s an expert on this topic. He’s an agent at a company called Carr, Carr Healthcare Realty and Doug’s been working in the Central Florida area about four years now.
Doug, thanks for being here today. Going to be some great insights for our orthopedic physicians and their practice managers. Thanks for being here.
Doug Price: Yeah, Keith. Thank you for having me.
Keith Landry: Let me give folks just a little bit of background on why you’re an expert in this area. You specialize in representing medical organizations with their office space needs. That might be a new office, an expansion or relocation, maybe a practice acquisition or lease renewals and you represent the practice for the office lease and the purchase. We’re going to dig very deeply into these areas today. Doug, what would you say? What’s your first observation for our listeners about how explosive the medical realty is, I guess we refer to it as healthcare realty. How explosive is healthcare realty right now across the country?
Doug Price: Across the country it is continuing to grow. COVID has definitely played a little bit of a factor but doctors are starting to see your lease or your mortgage is your second highest expense. And so it’s something that you want to make sure you’ve got the right representation. Carr healthcare Realty, at Carr we are a tenant buyer representation only so we don’t list anything, we don’t sell anything, we never worked for landlords or sellers. We only work for the doctor and I oversee our medical division here in central Florida. So we are seeing a boost in it. Doctors are starting to see, as some may be exiting the hospital system. I just placed a start up family physician that they were with a large hospital for many years and now they’re on their own saying, “Hey, this is the time to go out on their own.”
You get some doctors that are a little hesitant. Today’s a big day, election day. Today’s a big day so doctors are kind of waiting. A lot of people are waiting to see, but it’s still a great investment. Second highest expense, for a doctor to make a purchase a lot of times it may be the same cost as their lease or cheaper. And then in 10 years they’ve got options to go, “Do I want to sell my practice and be a landlord? Do I want to sell at all?” And you might have a piece of property that could be worth more or the same as their book of business with their practice.
We are seeing it all across the country. We’ve got about a 160 agents across the country that focus just on healthcare. Again, I specialize in medical, I’ve got two guys that specialize in dental, things like that. We are very niched in that way, but interest rates are low so that helps for that explosion of just giving doctors options, giving them the tools to see they can do this and that they can have an asset for years to come because it really is about impacting their future. Right now we are seeing some good explosion across the country.
Keith Landry: Awesome. Doug, I gave a brief listing of some of the things you specialize in. Why don’t you just give us a sentence on each one so that we understand exactly what it is we’re talking about.
Doug Price: Yeah, you did a great job with it. There’s a startup looking to go out, most new leases, most startups are going to do a lease so some can do a purchase, but if you’re looking for a lease, we will help with identifying. Anybody can identify and just drive around and see a sign so we’re not just space finders. We put together a strategy to maximize that profitability through real estate. If you’re looking for lease, we’ll run that whole thing. Negotiations, there’s a lot that can be left on the table that you don’t want to leave on the table. Let’s say a doctor’s looking for a purchase. Maybe they’ve been leasing and they want to purchase something. We’ll help them with that as well. There’s a lot of due diligence, a lot of checkpoints that need to be walked through for a 60 day closing or you’re under contract for 60 days. Doctors are busy. We’re right there with them, making sure that everything is being checked off and it gets to the finish line.
Maybe a doctor’s got two locations and they’re growing and they want a third or fourth so we’ll help with additional or relocations. What’s huge, as you mentioned is lease renewals. A lot of times a doctor, they don’t even know they can renegotiate their lease. Lease renewals are huge for having us come alongside. We’re not playing chicken, we’re not bluffing. We’re putting together a strategy. That’s your silver bullet. My lease is up every five years, seven years, 10 years, you want to make sure you’ve got somebody on your side that can help you move that needle. And then we do a lot of ground up projects. There’s a great piece of dirt, I’ve been looking for this size practice or this layout and I can’t find it, but I’ve got time, there’s a great piece of dirt here. We’ll help them walk through that for a ground up purchase and ground up purchases, there’s a lot that goes on. It’s a big project and you definitely want to have somebody on your side just kind of guiding you to make sure everything’s okay.
Keith Landry: Awesome. Now our orthopedic physicians and their practice managers have the lay of the land for the rest of this episode. That’s good stuff. Let’s look ahead to 2021. What are the big trends that you’re watching closely for healthcare realty? What are you really focused in?
Doug Price: Yeah. We’re looking at telehealth. We’re looking at what is telehealth going to be for 2021 in the future? I think on the short term, telehealth is huge. I’ve got a large group that they’re 80% right now all telehealth and we’re looking at large facilities and they’re kind of contemplating, why are we looking to purchase a 12,000 square foot building when 80%? We’re looking at what is that going to look like long term? I think until we understand COVID more, there will be a lot of telehealth, but at the end of the day, I think people need to be seen. A lot of patients want to be able to see. The doctors want to be able to have that relationship with their patients. We’re watching that. We’re seeing prices continue to rise. I do think at some point that might shift and we might see a little bit of a fallout of just what’s happened over the past year.
We’re looking at, hey, what is it going to look like over the next year for prices as a whole? And then I don’t focus as much on retail space, dentists maybe in retail or optometrists, some urgent cares could and we’re starting to see some medical doctors go into retail, but retail has been hit hard so we’re watching that. And for us, since we don’t work for landlords, this is a great time for us to come in and hit landlords hard because they’ve been hit hard and they have empty spaces. I think over the next year, that’s going to continue to grow where we’ll see more in spaces and we want to maximize that for our doctors.
Keith Landry: All right, let’s talk a little bit, not from medical care side, but the practice manager side for a minute. What should these practice managers be aware of if they’re planning to either lease a location or purchase a new location in 2021? Is it the price is the main issue?
Doug Price: Well there’s a lot of things. If they’re looking to lease, they want to know what their options are. And for us, I’ll go and I will pre-tour up to 30, 40 locations. I don’t want to waste, practice managers are busy. They’re really the ones running those offices that know what’s going on. From a lease renewal standpoint, a lot of times the doctors don’t know when their lease is up. It’s that practice manager that’s kind of keeping an eye on things. For them, step one is to know exactly when their lease is coming up. When I do speaking events, I always start with, “Who leases?” Hands go up. When does your lease expire? Or who knows? They all say, “I know.” When? And they go, “2022.” No, no, not what year, exactly when do you know? Because your landlord knows exactly. And he’s going to wait, he or she’s going to wait till the last minute until they slide that renewal that has no concessions, the rates going up and they go, “You’ve got no options.”
Step one, if you’re leasing and you’re looking to do something else is to know when your lease is up and then look at the options. We’ll pre-tour. We want to narrow that 40 down to the top 10 or so or top eight and then we pre-tour. He who has the most options, they usually win so we want to have those options. They want to know what the market is. What’s market value right now? What are normal concessions? What does it cost to build out a space? A lot of doctors and practice managers, they are shocked when they find that to build out, let’s say it’s a gray shell so it’s a dirt floor, it’s just a shell, a brand new center or a retail space or medical office space. And to build that out with not equipment, we’re talking just to get everything, cabinetry, the finishes, it’s about 140 to 150, a square foot. Sinks in the rooms. And that’s just the interior.
You do the math on 2,000 square feet or 3,000 square feet that’s a lot of money so they need to know that. We’re also working with landlords for tenant improvement allowances. We’re hitting them hard because we need help, our doctors need help with that. For a practice manager, for them to understand, what’s the cost of this? And we break that all down. We walk with them through that, but what’s the market like? What is there? A five year term is very different than a 10 year term in terms of how aggressive we can get on concessions. For them, step one is really starting to know when they have to exit and two, what’s big picture? Is this a short term? Is this a long term? Are they going to be here 10 years? Are they going to have to build it out? Are they looking to eventually purchase something? All of those things come into play, where we try to get a gauge as to what’s big picture of where this practice is going to be in five, seven, 10 years.
Keith Landry: Fantastic insights. And now a chance for you to really share some golden nuggets so people keep this podcast on their favorites list here. Let’s talk about picking a new location, whether you’re going to lease or buy. What are the factors that you have the expertise in that the doctor probably doesn’t? Things like traffic flow, foot traffic visibility. What are the things you’re looking most closely at when you help someone pick a location?
Doug Price: I’m looking a lot at competition radius. Wanting to see within a one mile, three mile, what’s their competition? A lot of doctors are going, Hey, I don’t mind competition. We will win our service on just providing a great service to our patients. Competition radius. Really what’s the field? Is this going to be a medical office building where there’s synergy of another practice right there that they can refer to? Is this going to be a standalone that a doctor’s looking to have a purchase that they own a building that’s got enough. Parking is huge. A lot of times doctors don’t fully think about parking where they may have a staff of 10, 15, 20 and that eats up spots right there. Parking’s huge. When I pre-tour, I want to know what that experience is. I want to know, hey, what’s it like to make a left hand turn out of here? What’s it like at 4:00 PM on a Thursday afternoon or Friday afternoon? Is it going to be crazy?
Also just that overall experience for the staff. If you’ve got a really old beat up car next to a really nice luxury car, what would you rather spend an eight hour car trip in? It’s going to be this one. From that staff that they’re going to be there eight to 10 hours a day. What is that overall experience for them? We’re looking at all of those things. We’re looking at, is it in an area where Medicaid insurance is. That if some doctors go, hey, I want to stay in this area or I want to stay in that area. But from a trend standpoint we’re looking at, where are people going? Where’s the puck always going? And so there are some areas around Central Florida that are hot areas. Those usually tend to have higher dollar from a lease or a purchase, but we’re looking at all of those things. And also if it’s an existing doctor, we don’t want to move them too far. If they are in this location, from a one to three mile radius we want to make sure patients will follow for them once they do move.
Keith Landry: Awesome insights there. Let’s look down the road a little bit. The factors you considered to see if this is still going to be a good location, seven to 10 years from now, because if the doctor purchases, now we’re talking potentially about some equity and some more options 10 years from now. How do you decide when you pick the location if it is likely to be still a good one, seven or eight years from now?
Doug Price: Yeah. Nobody can see into the future. If we did, man, we did not see this past year coming up. We are looking at, hey, what’s best for our doctor? And more times than not, if they can do a purchase and there’s some financial things that happen there, that if they’re in a position for the purchase, the purchase is usually a better option than the lease. It just is. I’ve got a doctor group right now in Lake Mary, we looked at lease options and purchase options. And when I did those spreadsheets for breaking it down, the purchase option actually was cheaper per month once you factor in with the tax deductions. And so that’s something that they just didn’t even think of to go man, in 10 years from now, again, I’ve got this asset. We’re looking at the areas that are up and coming areas.
We have historically seen appreciation. Real estate has continued to appreciate year over year. Now there have been 2008, there were some dips. The market has fully recovered from 2008. Now who knows what next year and two years from now as COVID has definitely created a dip as some doctors and other professionals have just had to walk away from their space or walk away from their lease. It’s serious stuff, but 10 years from now, there’s a good chance that the building they have is going to be worth more than it is now.
Now, if they’re purchasing a very old dilapidated building in a very bad part of town, 10 years from now, who knows? But for us, that’s usually not what we’re hitting on to try to guide our doctors. I don’t have a great answer for that. There’s no science to go, hey, in 10 years, what’s the market going to be? I can just look at hey, where we’re heading and what we’re seeing growth. Year over year, this area is seeing a X percent growth year over year and income is continuing to stay. Again, there might be some blips on the radar like COVID or 2008, but historically it’s usually going to continue to go forward progress.
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Keith Landry: You gave us a great insight just a minute ago when you talked about doing the spreadsheets, comparing the lease versus the purchase for that particular practice. Give us a few more tidbits on that in general. When the practice manager is weighing this very important decision for the future of whether they’re going to lease or they’re going to buy, give us a couple more insider insights that are super valuable to them.
Doug Price: Yeah. Emotion is one thing, but it really comes down to the financials and the numbers. We can do tours and I’ve done tours where doctors really fall in love with this location and this is number one location and their second location is still great, but it’s not the number one. And then we look at the financials. Those financials, we’ve got spreadsheets that will break down purchase price. If it’s a purchase, purchase price. And again, we’re negotiating to try to get that as low as possible. Build out, the diamond is a built out space that’s plug and play, the doctor can move right into, but those aren’t always available. A lot of times it might be an office building that has a great layout, but there’s no exam rooms, they’re offices so that spreadsheet’s going to have times per square footage, a $135 or a $140 so that gets worked in there.
Any operating costs, if there’s a lease, there could be triple nets, which are common area or CAMs, common area maintenance costs that, the parking lot, there’s $5 a square foot for triple net. We’re factoring all of those in. For us, we want our doctor to see a real snapshot. Now, some are estimates on the purchase. Right now, bank rates anywhere I’m seeing three to 4% and some banks are getting even crazier it just depends on if it’s a 10 year, 15 year, 25 year, if it’s SBA, conventional. But we want to see, hey, at 4%, four and a half percent over 20 years with operating costs this is there a space that. One of those spots I just did, it was a 4,000 square foot building and 1,300 square feet was already leased out to somebody else. There’s some tenant income so I have that factored in per year because that’s going to offset some of those monthly costs.
The goal is to give them a real snapshot. The last thing I want is a doctor to go, “Man, I didn’t even know that in the state of Florida we’ve got a sales tax on real estate.” Yeah, that’s in there. It’s going to be a six or six and a half percent tax in there that the last thing I want them to think is it’s going to be 8,000 a month and then when it’s all said and done, it’s 11,000 a month. That’s not a win, that’s not a win for us. Those spreadsheets will break down everything and then they do have a tax deduction where based off of a 35 tax, we break all of that down where they can see pre-tax and then after tax, what those costs are going to be. Again, the goal is for them to have a snapshot real time to say, “Hey, this is what it’s going to look like.” Or whether that’s year one, year two, year three, year four, especially on a lease standpoint, we break all those numbers down.
Keith Landry: Fantastic.
Doug Price: We work with a lot of CPAs. We work with a lot of CPAs to make sure these numbers are accurate.
Keith Landry: Yeah. It’s not like falling in love with the residential property. It’s a math calculation.
Doug Price: This is a business. This is a business, absolutely.
Keith Landry: Awesome. All right. Now I want you to reach into your back pocket and pull out some of your secret strategies that you use when you negotiate a lease for one of your clients. I’m hoping none of the landlords will be listening, but how do you get the extra value for your doctors while you’re negotiating the lease?
Doug Price: Yeah. Look, we do have some secret tricks and tips. Again, this is all we do so synergy’s huge. If it’s a startup, a doctor may say, “Hey, I need help with credentialing. I may need help with this.” We know all of that because not that we do it, but we can point and be someone that can facilitate. Because we work solely in this, from a standpoint of leases, we’re trying to be logical. We will talk logically to a landlord that has maybe had a space empty for eight months, 12 months, 18 months and they really want to have somebody in their space. Now they would rather have a medical tenant because very rarely are medical doctors going bankrupt. Very rarely are they all of a sudden, it’s not like a restaurant where that restaurant was here yesterday and now the restaurant’s gone. Most medical doctors, unless they choose to exit, they’re going to have a long, healthy career.
We make sure the landlord understands that. Now, if it’s not built out, because the costs are high, it’s usually going to be a 10 year lease. I’ve had doctors say, “Hey, start up can I do a three year lease?” Well no, because when you’re paying X amount per square foot to build it out, you’re going to need that time to make that money back. And the last thing you want is after year five or three, the landlord to go, “They’re not going anywhere. They’ve put so much money into the space, I can now jack up their rate. I can really kind of mess with them because they’re not going to go anywhere, back to he who has the most options.” For us, we’re making sure our doctors understand, hey, this is what this is going to look like. But for the landlords, 10 year lease is very attractive.
With a blue chip, less than 1% default rates, we’re also hitting a lot on the bank loan is only going to be X amount. And so we’re putting that pressure on the landlords to say, “Hey, to build this space out, they need X amount of dollars in tenant improvement allowance or they’re not going to be able to open.” And again, tenant improvement allowance is an amount that the landlord is willing to contribute for this loan package or for this lease because ultimately they own the building so it’s going to add value to their building. And they understand that they want a doctor to be there many, many years. And so for us, a 10 year lease usually turns into a 15 year, a five year renewal or exiting doctor and we’re going to backfill that with doctor because it’s already built out. That landlord, we’re really just logically breaking down those numbers.
To landlords it’s all about numbers. It’s all about a business. A lot of times doctors have this misconception of my landlord’s a patient of mine, or I play golf with them, he’s not going to do me wrong. No, landlord’s job is to get as much from you as they can. They want lowest concessions, highest base rate. I want for my doctors, lowest base rate, highest concessions. There’s a battle there. Again, we never work, there’s a conflict of interest if I am working for that landlord, trying to stay on their good side because they have multiple listings. Nope. Don’t care about landlords, good respect there but it’s a battle that we want to fight for our doctors.
And then free rent. A lot of times the doctor may not know that they can get free rent. We want a doctor starting a new space, it’s going to take time. Reimbursements from insurance is going to take some time. We want to make sure that they’re getting some free rent on that front end, that we’re negotiating to have hey landlord, you want them to have a great start. You don’t want anybody starting behind the eight ball to where every month one they’re like, oh man, we haven’t gotten reimbursements from insurance. To be able to negotiate free rent, we’re hitting the concessions there to get as high as possible ,to get the base rate down. Those are things that I’ve had doctors say, “Hey, I bought a house before, I can negotiate this.” Nope, you can’t. A landlord does this day in and day out. This is their job just like I do this day in and day out. And one thing that I haven’t hit on yet, which is really the aha moment, is everything we do comes at no cost to our doctors.
They pay us nothing. They pay us nothing. I get paid just like in residential, there’s a set commission that is set aside that that landlord or that seller sees value in to pay a broker to bring somebody to that deal. Just because they’re paying me doesn’t mean I work for them. They would rather not pay me renewals. Landlords do not like us because we’re changing their dollar amount, their bottom line and helping our doctors. And so all of that happens where the doctor could have somebody like myself, walk with them through this entire process and it doesn’t cost them a thing. They could go 10 months down the road and say, “Man, my wife just got pregnant. Now’s not the time to open up a practice.” All right. I hope this was a great experience. I can’t wait to help you in the future. I’m not going to slide you a bill and say, “Man, I did hundreds of hours of work on this.”
No, our job is to serve the medical community. Now more than ever, they have just past year, I know it’s been tough on them. Our job is to serve them and to walk alongside of them to make sure man, that was a great experience. We’re referral based, there’s no side deals. I don’t get paid anywhere else. Our job is to make sure that they are taken care of. We’re putting all of those things. I know I said a lot better in that answer there, but we are posturing well. The moment you engage you’re negotiating. I’ll have doctors say, “I drove by and I saw a sign for sale or lease. I’m going to call that land.” No, do not call. The moment you call you’re negotiating. They’re going to find out, do you know the market? Do you have representation? Do you know what you’re doing? Have you done this before?
You’re busy. Give me the number. I’ll call. Let’s start that posture. For us, what are some of those tips and tricks? Posture from day one is key. We’re making sure the landlord understands or the seller understands that this is a great tenant or buyer that they want to have on this deal. Banks are even more than ever are hesitant to loan money. But for doctors, I still have some banks that they go, man for doctors will do a 100% financing. We’d love medical doctors and we love doctors. If they’re existing startups, there’s some things they got worked through, but they’re existing. We just posture all that. And then we logically walk that through with the landlord or that seller to make them understand why they want to have this deal happen with our clients.
Keith Landry: All right. Let’s talk a little bit about land deals now. What are things that the practice managers should know about doing a land deal and how that may be different from another commercial real estate transaction in general?
Doug Price: Yeah. Land deals, you’ve got to have time. A land deal is going to be 18 months to 24 months of walking that entire process through. There’s a lot that needs to be done underneath the dirt before you can determine if you can build on top of that dirt. When you look at utilities, when you look at geo surveys, lots of different surveys that the banks are going to need. A phase one, a phase two, an ALTA survey. These are all checking the soils to make sure, was this a gas station at one point? Was this a laundromat? Was this something that, or next door that’s an oil or something has crept into? They want to make sure that underneath the dirt, there’s a lot going in. You also need to make sure utilities, everything is run, this going to be onsite water retention? Is this going to be off site water retention?
If I’ve got a one acre piece of land that I want to build a eight to 10,000 square foot building on, I need to know, can the parking allow for that? I need to know, can I fit that on that piece of land? Well, if I have to have water retention on that piece of land, then that’s going to come into play. Land deals are, if you’ve got the time and we work with a lot of great engineers that we want to make sure that the ground is great, it’s something that they can build on and there’s also a lot that you have to jump through with the county. Depending on what county it’s in there’s just a lot of codes. What type of landscaping buffer?
It may look like, hey, we need 25 feet of throe for landscaping and you’re going, I have to give up this much land because of landscaping? There are a lot of unknowns, but if you’ve got the time and you’ve got someone that can help you walk through it. We’re not project managers, but I do walk through that process. A good architect and a good GC can really take control of a land deal to where you don’t need a project manager to pay an extra percentage. I’ll be making sure the things are getting done and if you say, :I haven’t heard from so-and-so,” I’ll follow up on it. And again, you’re not paying me anything. Land deals, there’s a lot of moving parts, but if you have the time and you’re okay with a little bit of like, ooh, this could get crazy as we’re doing soil digs and things like that, the end result, you’re going to have a building that you built to where the layout was exactly what you needed, as opposed to trying to retrofit what you need into a space.
Keith Landry: Interesting. Doug, one of the biggest trends we’re seeing on the retail side of the American economy is the disruption of the old school retail shopping mall by eCommerce. Are we seeing a bunch of healthcare practices moving their locations into malls now? Is that a growing trend?
Doug Price: I haven’t seen enough that it’s a growing trend with independent physicians. For us, we’re after independent physicians. Hospital system to look at potentially going into a mall situation, yes, we are starting to see that. Now on the independent side, we have seen some groups come together. Hey orthopedics, hey well let’s work on orthopedics and partner them with another group that has great synergy to where they may now need 25,000 square feet or four groups. That’s where you can start to play with some of those things, but we’re seeing it maybe in some retail strips, but full on malls is still such large square footage. Not a lot’s going into malls. Malls are going to be colleges or assisted living or maybe some hospital stuff.
Keith Landry: Interesting. Okay. Those are great insights on that future trend. Doug, it’s been an awesome half hour, went by super quickly. You gave a bunch of stats and trends and insights. I feel like I learned a lot, so thanks.
Doug Price: I apologize for going fast and throwing up a lot of information.
Keith Landry: No. That’s what we’re here for. And I know that our physicians and practice managers are like, darn, that guy knows a lot. Doug Price, if folks want to get a hold of you, learn more about what you do and your services, how can they do that?
Doug Price: Yeah. My name’s Doug Price, Carr Healthcare Realty, carr.us. C-A-R-R, C-A-R-R.us is our website. My email is firstname.lastname@example.org. And we don’t compete so if you’re maybe outside of Central Florida or if you’re not a medical doctor and you need some help reach out to me, I’ll connect you with the right person. If you’ve got a lease coming up, we do free lease evaluation. We’ll look it over gladly to see if you’re in market, if it’s really a good spot or if it’s maybe time to go somewhere else. But carr.us is the main hub. We’ve got a lot of great articles. We do a lot of podcasts, a lot of great information. Again, your lease or mortgage is your second highest expense. You don’t have to go at it on your own. You’ve got somebody like myself and our company that would love to walk with you to make sure someone’s looking out for your best interests.
Keith Landry: All right, Doug. Thanks so much. We appreciate your insights. Thank you everybody for listening to this episode of Growing a Successful Orthopedic Practice podcast. We’ll do it again soon.
Doug Price: Thank you, Keith. Have a good day.
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