the center for advanced medicine - mgma.com papers/2018... · coordinated care networks (ccn), and...

The Center for Advanced Medicine

Business Plan

Chad Collins, FACMPE

July 16, 2018

This paper is being submitted in partial fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives.

1 | P a g e

Table of Contents Page Project Summary…………….………………………………………………………….....4 Executive Summary.………………….……………………………………………………7

The Company Market Opportunity Capital Requirements Mission Statement Management Competitors The Company’s Competitive Advantages Financial Projections

Organizational Plan………………………….……………………………………………11 Summary Description of the Business

o Mission (projecting short- and long-term goals) o Business model (description of the company’s model and why it is unique to the

industry) o SWOT Analysis (strengths, weaknesses, opportunities and threats, both internal and

external) o Strategy (overview, short- and long-term objectives) o Strategic relationships o Kay stakeholders/key decision-makers

Services Administrative Plan

o Organizational chart o Approval plan o Responsibilities of the assigned teams

Operational Plan o Timeline and key milestones for success o Possible roadblocks o Strategies to address weaknesses/threats

Marketing Plan………………………………………..…………………………………..30 Overview and Goals Marketing analysis

o Target market and audience o Competition (Strengths and Weaknesses) o Market trends (Customer and Industry Trends) o Market research (research methods, database analysis, results summary)

Marketing Strategy o Description

Implementation of Marketing Strategy o Mode and methods for marketing

Financial Documents……………………………………………………………………..36 Summary of financial needs

o Applying for finance o How much capital you need o Resource costs associated/opportunity costs

Pro Forma Cash Flow Statement

2 | P a g e

Three-Year income projection Projected balance sheet Break-even analysis Profit & Loss Statement Balance Sheet Business Financial History

Innovative elements and expected business outcomes…………………….……………43 Positive impact on the health of our population and the organization Challenges and lessons learned Next steps to put project in action

3 | P a g e

PROJECT SUMMARY

4 | P a g e

Project Summary: As the landscape of healthcare continues to shift from a traditional fee-for-service (volume-based) model to a quality-focused (value-based) reimbursement model, organizations such as Patient Centered Medical Homes (PCMH), Accountable Care Organizations (ACO), Community Care or Coordinated Care Networks (CCN), and Full-Risk organizations recognize and are responding to this inevitable paradigm shift. Value-Based reimbursement models require organizations to improve on the delivery of patient care, focusing on quality metrics and improved outcomes. As a way to help organizations achieve these quality metrics, an area of focus would be to improve the care and coordination of services for patients by creating a system that is easily accessible, and has a seamless process for getting patients the additional care and services they may require. The proposed Business Plan is for the creation and construction of a new for profit multispecialty center called The Center for Advanced Medicine. The Center would be located in Central Florida, in one of the largest 55 plus retirement communities, currently consisting of 55,000 homes with a population of approximately 120,000, and growing. The facility itself will be a 285,000 square-foot, five story "bed less hospital" and multispecialty center, and will be an expansion of our large multispecialty practice. The Center for Advanced Medicine will be comprised of a number of employed specialists, as well as other specialties who will be clinical tenants within the Center operating as independent collaborative partners but within their own individual rented space in the Center and under their own individual tax ID numbers. The tenants within the Center have a vested interest in partnering with us as they approach and practice healthcare delivery in a similar fashion, which is driven by value and quality outcomes. Currently, we have 7 ambulatory primary care centers within the community and these primary care locations will be linked to our specialists through a single Electronic Medical Record, thus helping to create improved care coordination for our patients through primary care driven, patient centered care. The employed specialists within our practice will be the single largest tenant in the space, occupying approximately 25% of the space, and will coordinate the activities of the group of clinical tenants who will occupy the remaining 75%. With this Business Plan we have been able to secure letters of intent with all major clinical providers that will be represented in the project, including centers of excellence in Cancer (radiation and medical oncology); Imaging (MRI, CT, PET, etc.); Ophthalmology; Rehab, Pharmacy and an Ambulatory Surgery Center. Specialty physicians including cardiology, dermatology, urology, gynecology, gastroenterology, neurology, endocrinology, rheumatology, pulmonology, orthopedics, podiatry and general surgery will also be represented. Conveniences offered at the Advanced Center will include central registration for all scheduled services, retail pharmacy, lab, imaging, and an education and resource center to aid in the coordination of care for the patient. Other complementary amenities will include an adjacent 151-room hotel complete with a conference center, spa, and restaurant. For families who wish to arrive the night prior or do not want to travel home after surgery or other procedures, there will be a covered concourse connection from the surgery center into the hotel to allow for overnight stays. When operational, this project will service residents, employees, their guests, and the surrounding communities with anticipated visits exceeding 100,000 the first year (not including visits from other tenants in the building).

5 | P a g e

In coordination with collaborative key partners who have been hand selected to join us in this endeavor, this state of the art, innovative, outpatient healthcare facility will be best positioned to assume at-risk insurance contracts as it will promote and support high quality Patient Centered Care, enhanced and more effective care coordination, reduced utilization of services, reduced E/R visits, hospital admissions and re-admissions, lower medical costs, and support the evolution and migration of many healthcare services to an outpatient setting in a value-based reimbursement model of care. Currently, these services are being provided at high cost facilities located throughout the community, such as hospitals, and hospital outpatient settings with varying service levels and design setups resulting in fragmented care.

6 | P a g e

EXECUTIVE SUMMARY

7 | P a g e

Executive Summary

The Center for Advanced Medicine

As a result of the paradigm shift in healthcare moving from a volume-based to a value-based model of care, as well as responding to the rapid growth in the community, The Center for Advanced Medicine will be an expansion of the existing organization founded in 2012.

We are a for profit organization, owned by physicians and non-physicians, that was founded in 2012, has more than 40,000 active patients and continues to grow rapidly. It is the largest multi-specialty practice group in the tri-county area with 40 primary care physicians and 20 specialty physicians, currently representing 12 different specialties. The organization works collaboratively with a variety of independent, single specialty groups in the tri-county area. It offers education, treatment, preventive services, and support for health-related community events. It’s all part of our vision to “Keep America Healthy.” The organization has developed eight Care Centers (seven primary care and one specialty care) which have revolutionized the delivery of care for this community. We also employ Hospitalists, and Nurse Care Navigators to help coordinate the services between Primary Care, with Specialty Care, the Hospital, the independent specialty groups in the community that we have collaborative relationships with, and community resources all to help achieve the best quality care and outcomes for our patient population. The tireless focus on quality and innovation has led the organization to achieve Level 3 Patient Centered Medical Home (PCMH) recognition and a 4.95-star HEDIS score, along with recognition of being ranked in the top 1% of health systems nationally for quality care and rated the #1 Physician Group in North and Central Florida Regions. The same forward-thinking clinical philosophy and high quality of care that is delivered at the Primary Care Centers will now be extended to the specialty care arena in the development of The Center for Advanced Medicine. What sets us apart from other healthcare centers?

Our Mission: We are committed to providing extraordinary, patient-centered health care to our patients, their families and our community, to ensure peace of mind through high quality, compassionate treatment, and to deliver care beyond their expectations. The Company is:

Patient-Centered: The organization focuses on the needs of the patient and involves the patient, and their families, in their health care decisions.

Community-Based: The great majority of health care services are rendered close to home.

Primary Care-Driven: Each patient has a relationship with a primary care physician and receives care delivered by a team led directly by that physician based in a Medical Home model.

Academically-Supported: Care rendered enjoys the benefit of modern science and ongoing learning through a formal relationship with a research university.

Innovative: Routinely implementing fresh ideas and methods – a process which has so consistently helped the organization achieve community acknowledgement and success.

Integrated: The primary elements of a comprehensive system are intelligently connected. Value-based: Both quality and cost remain the clear and unabashed focus of attention in

the delivery of care. In this respect, new and innovative technology is embraced to the extent that it supports the creation of greater value to the patients who are served.

8 | P a g e

We believe the above attributes set our organization apart and above other healthcare organizations in the area. Market Opportunities: Below is a list of some market opportunities for the organization to consider.

Fastest Growing Metropolitan Statistical Area in the Country for the past four years and still growing. Currently at 120,000 residents, the projected growth over the next four years will bring the number of residents to 150,000.

Underserved community, shortage of specialists in the Tri-County area. Partnering with like-minded providers/organization to offer expanded services and

products will enhance care coordination and continuity. The organization has a strong primary care presence in the community with a reputation

for quality, and patient satisfaction (top box scoring consistently above 98%). Word of mouth will help attract new business.

Capital Requirements: We are estimating that we will need to secure financing of $10,900,000 to assist with funding operations during year one, cover lease hold improvements, and acquisition of furniture, fixtures and equipment (fixed assets). It is projected that this loan will be paid in full by year 5. Management: The Center for Advanced Medicine will be managed by the following staff:

Executive Director: Master’s degree level Healthcare Administrator and Fellow of the American College of Medical Practice Executives, with seven to ten years healthcare management experience, possessing strong interpersonal, organizational, communication and leadership skills, along with proven critical thinking and problem-solving abilities, including resolution of complex problems requiring innovative solutions, as well as the ability to collaborate across various stakeholder groups to influence change. Will possess the ability to navigate in a growing, evolving, and sometimes ambiguous environment.

Medical Director: Licensed physician with experience managing physicians and programs within a multi-specialty organization.

Care Center Manager: Will hold a Bachelor’s level degree or commensurate of at least five to ten years of experience in healthcare management, Certification (CMPE) through the American College of Medical Practice Executives. Will be responsible for the day-to-day operations of the facility, including supervising the clinical and clerical supervisors.

Clinical Supervisor: RN level nurse with five to ten years of experience in healthcare management. Will be experienced managing a large group of clinical staff, including Medical Assistants, Nurses, Phlebotomists and X-Ray Technicians. Will be primarily responsible for managing the clinical day-to-day operations of the facility.

Clerical Supervisor: Will hold a Bachelor’s level degree or commensurate of at least five to ten years of experience in healthcare management. Will be experienced in managing a large group of clerical staff, including referrals, reception, medical records and telephone operators, and managing the clerical day-to-day operations of the facility.

9 | P a g e

Competitors: Below is a list of our competitor’s strengths and weaknesses Strengths-

Other multi-specialty practices in the Tri-County area. Similar services offered. Other practices have established longevity in the community. Practices may take a wider variety of insurances, specifically Medicare and

Other/Multiple Medicare Advantage Products. Weaknesses-

Similar large multispecialty practices in the Tri-County area are specialty driven, not primary care driven.

Unorganized; long wait times to be seen for new and existing patients Lack of quality metrics – nothing published to the community about their quality or

patient satisfaction. Physicians in these practices are disconnected from one another. Departments appear to

be compartmentalized and disconnected from primary care, with multiple EMRs and data bases.

Fragmented care and lack of care coordination can cause medical errors, unnecessary referrals for tests and procedures, delay in getting a correct diagnosis, which ultimately leads to higher medical costs for patients.

Our Company’s Competitive Advantages:

Although still somewhat new to this community, the organization has built strong footing through high quality, patient-centered primary care and specialty services.

The only recognized Level III Patient Centered Medical Home in the Tri-County area. Quality and patient satisfaction metrics published and are available to the public. Organization is state and nationally recognized for our exemplary quality of care. Strong community following equates to strong word of mouth referrals. Organized, seamless coordination of care and continuity. Use of Nurse Navigators

(Registered Nurses who are used to assist with transition of care out of the hospital and chronic care management) to coordinate care, staff hospitalists have a presence in the local hospitals to see and care for our patients when admitted, and primary and specialty care linked through a shared EMR.

Financial Projections: Financial projections provided in Financial Documents section, beginning on page 37.

10 | P a g e

ORGANIZATIONAL PLAN

11 | P a g e

Organizational Plan 1) Summary Description of the Business

a) Short and Long Term Goals: i) Short Term Goals:

(1) Designing and building the infrastructure of the Center for Advanced Healthcare in place.

(2) Recruiting the right number of physicians and staff hired to support the need of the community.

(3) Recruiting philosophically aligned collaborative partners to help support the vision and mission.

(4) Be open and ready for business on our target date. ii) Long Term Goals:

(1) Expanding our Service Catchment area to secondary markets. (2) Continue to onboard new physicians and staff to meet the growing needs of the

community. (3) To continue to partner with other physicians and practices who support this care-

delivery model. (4) To position the organization to take on additional at-risk insurance plans.

b) Business Model: The Center for Advanced Medicine will be unique in today’s healthcare

industry. Creating a 285,000 square foot outpatient multi-specialty center, complete with adjacent 5-star restaurant and a 150 room hotel will bring an enhanced level to the overall patient experience. The restaurant and hotel are planned and scheduled to open at the same time The Center for Advanced Medicine opens. Along with partnering with practices and physicians who are philosophically aligned with providing superior, high-quality care and treatment for our patients, The Center for Advanced Medicine will be able to offer a wide array of traditional, unique, and state of the art products and services. Currently, many of these services are being provided in the hospital or inpatient setting, which drives costs up for the patient but also may result in further testing or additional referrals that may not be appropriate nor be the best care for the patient. The services being offered at The Center for Advanced Medicine will be coordinated by our primary care physicians and will drive services to be done in this single outpatient setting. This will result in reduced utilization of services by eliminating testing and procedures that may be inappropriate and/or unnecessary for our patients. This will allow us to become a healthcare provider of choice and will give us a competitive edge not only in this community but in many of the secondary markets. It will be a destination point for many patients and their families seeking high-quality, patient-centered care and treatment.

c) SWOT Analysis: i) Strengths

As a result of a SWOT analysis that was conducted, below is a list of our strengths as an organization.

Cost

o Currently, our value-based, full-risk model offers higher quality which can relate to lower medical costs for patients and lowered costs for providers/practices. Reduced Admissions per 1000 will continue to drive this.

12 | P a g e

o Better coordinated care and continuity can reduce Emergency Room visits and hospital admissions and readmissions, which can result in lower costs. Currently, we are ranked #1 in Central Florida for lowest costs for ER utilization, hospital admissions, readmissions, and skilled nursing facilities.

o Overall greater accountability for healthcare costs. We are currently at full-risk, and managing this well.

Convenience – We currently experience the following: o Short to no wait times o 24/7 on call services o Same day acute care appointments in our primary care centers o Hospitalists on staff to see our patients when admitted to the hospital. o Center is accessible by golf cart, which is important for many residents

in the local community. Comfort

o Living rooms designed for comfort and a “home-like” feel; no waiting rooms

o Exam rooms are comfortable “visit rooms” o Greeters are present to welcome new and existing patients and get them

to the appropriate staff who can assist with their needs Confidence

o Highly trained and compassionate physicians and providers o State of the art facility o Forward science; most up-to-date medical research

Consequences o Focused on outcomes o Ranked top 1% of health systems Nationally for quality care o #1 physician group in North and Central Florida

Coordination o Single EMR for enhanced coordinated care o Team-based approach includes Physicians, Specialists, Hospitalists,

Nurse Navigators, and Practitioners o Same values shared across the entire Multi-Specialty Physician Group

Practice Community

o Relationships with partners Partnering with like-minded practices focused on the same goals;

better care for patients Building long-standing relationships with patients, engaging

them to raise the health of a community

o Purpose-driven. We impact and change lives. Re-shaping healthcare for the Community, and for the State of

Florida, o Care

Primary doctor at the center of relationship Holistic care plan (physical and mental) Focus on prevention

13 | P a g e

ii) Weaknesses

Although the organization is doing a lot of things right, there are some weaknesses that revolve around key positioning in the community, and aligning the work between multiple departments and key stakeholders. Below is a list of our weaknesses as an organization:

Recruitment o Weak talent pool for clinical, clerical and administrative staff. We’ve

“tapped the area” and need to expand our search efforts to find qualified candidates.

Operations o There is variability in how our primary care and specialty care centers

operate. Need more standardized policies and procedures in place in both settings.

EMR o Have outgrown our current EMR. Will need to replace to be able to

support our new growth. Fragmented marketing messages

o Brand inconsistency; lack of clear guidelines o Voice; lack of second person voice; too much focus on us o Key positioning; lack of unified messaging

Marketing collateral o Errors and out of date information (physician and provider information) o Not yet promoted on website o Need a 360 tour available on line (when construction is complete) o Create Brochure of information o Public Relations initiatives

Online Presence o Website functionality; not data driven o Online Reviews & Reputation; need to make public and automate

process o Search engine optimization; publish more keyword resources o Lack of news/PR o Lack of on-line scheduling capability for patients.

iii) Opportunities

Limited number of Medicare Advantage products. We will need to diversify and add more insurance plans.

Increasing amount of new movers to the community o Expand zip codes to increase reach o Boost existing campaign touches

Include digital touch Expansion of learning center resources

o Convert to digital content o Use as lead generation tool o Get on Community Events calendar o Add as Facebook Events

98% Satisfaction rate o More patient testimonials

14 | P a g e

iv) Threats Some negative perceptions in the community Negative media outlets with vendettas General lack of trust from referring primary care physician can divert referrals

to competing specialty physicians Competitive Landscape

o Potential for the local hospital to attempt to compete in the outpatient setting.

o Large number of single specialty practices encroaching on our market Scheduling new patients

o Improved access by competing practices.

d) Business Strategy: The idea of creating The Center for Advanced Medicine is to move towards a payment model under a value-based system. As mentioned previously in this plan, due to a paradigm shift in healthcare delivery, more and more healthcare organizations are moving from volume-based pay models to value-based pay models. What is needed to achieve this? i) Short term goals: 1-2 years

(1) Finding and partnering with philosophically aligned practices and providers in the community.

(2) Should there be a deficit of providers and practices to partner with, we will solicit physicians from practices outside of the community to join in this re-evolution of healthcare delivery. We can achieve this through various marketing techniques such as: (a) Mailing RFQs to physicians and practices outside of this community. (b) Visiting physicians and practices outside of the community to do face-

to-face educational sessions on who we are and what sets us apart from other organizations.

ii) Long term goals: 3-5 years

(1) Continue to find and recruit physicians to fulfill the healthcare needs of a growing population.

(2) To improve catchment from secondary markets. (3) To be a provider of choice (4) Partnering with other sub-specialties in similar risk arrangements with other

payers, to include high-quality narrow network arrangements. (5) To be a sustainable full-risk organization offering high-quality patient-

centered care at lower costs, and achieving high patient satisfaction and better health outcomes for the communities we serve.

e) Strategic Relationships currently in place:

Ambulatory Surgery Center and Cath Lab Medical and Radiation Oncology Ophthalmology Pharmacy Laboratory Imaging Physical and Occupational Therapy External primary care physicians Home Care Agencies

15 | P a g e

Hospice Care Agencies Mental Health-Substance Abuse Facilities Rehabilitation Facilities Hotel operator Currently building relationships with Skilled Nursing and Assisted Living

Facilities (still a work in progress)

f) Key stakeholders/key decision-makers: A list of key stakeholders and decision-makers for this project are listed below.

Board of Directors Chief Executive Officer Chief Medical Officer Chief Financial Officer Executive Director for The Center for Advanced Medicine Physicians and providers Management team Employees Tenants within the center (partnering physicians/practices) Patients Community Payers

2) Products and Services:

Below is a comprehensive list of the products and services that will be offered at The Center for Advanced Medicine. We will be limited to the services listed below. Primary Care Services will be offered at our 7 primary care centers located throughout the local community. It is also worth noting that the Preferred Provider Tenants within the Center were hand selected because they have a similar philosophy in how they deliver medicine and work collaboratively with us to deliver high quality, patient centered, and cost-effective care. The Surgical Specialists will have an opportunity for ownership in the Ambulatory Surgery Center.

Services provided by our Multi-Specialty Practice o Orthopedics o Gastroenterology o Endocrinology o Audiology and Hearing aids (conduct screenings and sell hearing aids) o Rheumatology o Gynecology o General Surgery o Podiatry o Dermatology o Pulmonology o Pain Management o Nephrology o Virtual Visits

16 | P a g e

Services provided by Preferred Provider Tenants o Full service Lab o Health and Technology Center o Ambulatory Surgery Center/Cath Lab/GI Lab o Aesthetics Center o Ophthalmology o Procedure Suite o Rehabilitation (Physical, Speech, & Occupational Therapy) o Full service oncology (radiation and chemotherapy treatments) o Imaging – MRI, CT, PET, o Allergy/Immunology o ENT (Ear, Nose &Throat) o Oral - Maxillary o Adjacent Hotel

3) Administrative Plan

(Organization chart, approval plan, responsibilities of assigned teams)

a) Approval Plan and Responsibilities of Assigned Teams

Clerical Supervisor

Care Center Manager

Clinical Supervisor

CAM Management Organizational Chart

Medical Director

Executive Director

Chief Executive Officer

Chief Medical Officer

Board of Directors

17 | P a g e

i) Executive Director – The Executive Director, who reports directly to the CEO, will be responsible for leading all administrative aspects of the new Center for Advanced Medicine once operational and will be a key thought leader in its physical layout and optimization. The Executive director will oversee all operations of the Center and will work closely with other provider tenants to ensure the Center delivers on its promise of seamless, innovative, high quality, and patient-centered care. The Executive Director will have the Authority to:

(1) Integrate the Center for Advanced Medicine with existing and future specialty care services including supporting clinical services.

(2) Develop and implement service line plans for clinical services, workforce, finance, and business strategy including annual budgets.

(3) Implement contemporary clinical and operational practices to promote safe, timely, effective, efficient, and equitable patient-centered care.

(4) Approve equipment and supply orders up to $20,000

ii) Medical Director - The Medical Director, who reports directly to the CMO, is responsible for the continuous and progressive implementation/manifestation of the “clinical program” of the organization, through direct leadership and oversight of all medical professionals associated with the Center. The Medical Director advances the Mission of the organization primarily by enabling those medical professionals to function in their roles as effectively as possible. Collaborates with the Care Center Manager to make recommendations for annual budget and maximizes opportunities to meet and exceed budget guidelines.

iii) Care Center Manager: The Care Center Manager, who reports directly to the

Executive Director, is responsible for directing, supervising, and coordinating staff and activities at The Center for Advanced Healthcare to provide patient-centered, quality, seamless and cost-effective care. Operates within the context of an established budget. Collaborates with the Medical Director to make recommendations for annual budget and maximizes opportunities to meet and exceed budget guidelines. Approves payroll for all physicians, providers, and supervisors, and signs off on all medical and clerical supply orders not exceeding $5,000.

iv) Clinical Supervisor: The Clinical Supervisor, who reports directly to the Care

Center Manager, is responsible for oversight of all clinical operations related to nursing and medical support staff in line with clinical practice standards and patient-centered care, within the Center setting. Approves payroll for all clinical staff, staying within budget with respect to overtime. Tracks and maintains clinical supply inventory levels staying within budget, submitting orders to the Care Center Manager for approval. Clinical Supervisor has authority to approve purchases of up to $500.00.

v) Clerical Supervisor: The Clerical Supervisor, who reports directly to the Care

Center Manager, is responsible for general office management responsibilities, such as: planning, organizing and supervising of clerical support operations to support high quality, efficient, and patient-centered services. Approves payroll for all clerical staff, staying within budget with respect to overtime. Tracks and maintains clerical supply inventory levels staying within budget, submitting orders to the Care Center Manager for approval. Clerical Supervisor has authority to approve purchases of up to $500.00.

18 | P a g e

4) Operational Plan:

Below is a detailed Operational Plan, complete with timelines for success, and highlighted milestones to ensure we have a successful opening of the Center for Advanced Healthcare. While best laid plans can be made, there is any number of things that could prevent a smooth opening for the Center. For example, delayed approval of the building design and/or issuing of permits would hold up breaking ground and the start of construction. Issues with the final inspection of the Center could delay occupancy thus creating the inability to move in and get the Center ready for business. Any issues that could arise with the delivery of medical equipment, technology equipment, clinical and clerical supplies could also negatively impact the ability to open the Center on schedule. Weekly meetings will take place to review progress and troubleshoot obstacles. It will be crucial that all key players involved in this plan work diligently to ensure the tasks assigned to them, are completed timely and accurately to ensure we achieve the desired outcome of a successful opening of the Center for Advanced Medicine.

Operations Plan (Highlighted areas are Key Milestones)

Center for Advanced Medicine Construction and Occupancy

Anticipated Opening

1/2/2020

Deliverable Item Action Item Comment Anticipated Completion Date

Final Approval of Plans:

Final plans for The Center for Advanced Medicine to be approved by design team, contractor and stakeholders.

Once plans are approved, permits to be secured for groundbreaking and the start of construction.

12/1/2017

Securing Permits: Contractor to secure permits to begin construction.

Once permits are secure, ground breaking ceremony to be scheduled

1/30/2018

Breaking Ground:

Property Management to work with Executive Director to Schedule Ground Breaking Ceremony

Ground Breaking Ceremony to be held. Key stakeholders to be invited.

3/1/2018

Approve Lease Agreement

Executive Director to work with Legal to review and finalize lease agreement.

To be approved by 1/1/2019

1/1/2019

Final Inspection:

Property Mgmt. will work with Contractor to schedule final inspection of the Center.

Schedule final inspection.

Target for final inspection walk

through 12/1/2019.

19 | P a g e

Take Occupancy of The Center for Advanced Medicine:

After final inspection has occurred and any and all items that need attention have been addressed, final walkthrough will be scheduled to take occupancy of the building.

All items that need to be addressed will be taken care prior to final walkthrough.

Final walkthrough to be scheduled

12/15/2019, obtain keys and take

occupancy.

Moving Day:

Care Center Manager, Clinical Supervisor, Clerical Supervisor and a host of clinical and clerical staff will begin unpacking medical and clerical supplies and getting all stations, and visits rooms set up.

Will take several days to get all areas properly set up.

Completed by 12/20/2019

Communications:

Website

Project team to work with marketing and IT to develop website design, content, patient portal and functionality of website, to include items such as pay‐per –click ads, search engine optimization, Facebook page, etc.

Marketing will set up photo shoots to capture Physicians, providers and staff. Will film brief interviews with physicians and providers, as well as interviewing and filing patients to capture testimonials.

6/1/2018

Rack cards

Rack cards will be ordered for all physicians who will be practicing at The Center for Advanced Medicine.

Will order 500 for each physician

6/1/2019

Business Card Business cards to be ordered for each physician.

1000 business cards for each provider will be ordered.

6/1/2019

New Patient Packets Obtain 300 Packets to be on‐site at the time of opening.

Packets will be available for patients to sign up on opening day.

10/1/2019

20 | P a g e

Ad in local news paper

Will connect with local newspaper to begin interviews with physicians.

Local newspaper will interview all physicians at The Center for Advanced Medicine.

10/1/2019

Press Release in local news paper

Press release for opening day to be printed.

Press release will be printed 2 months prior and then again one month prior.

First release ‐11/1/2019

Second release –2/1/2019

Train staff on communication and FAQs

Clerical staff to be trained on effective communication and FAQs

Will utilize Patient Service Representatives and Marketing to assist with training

11/1/2019

Templates for Specialists Templates to be set up for each physician and provider.

Templates will be built to allow for effective onboarding of new physicians as they build their patient panels.

10/1/2019

Post cards mailed to residents in the community to announce the opening of The Center for Advanced Medicine. Weekly spot lights in local Sunday paper to highlight opening.

Marketing will create post card for mailing and will work with local paper on content of spot light ads.

Letters to be approved by Executive Director

11/1/2019

Open House

Plan formal open house

within 30 days of

opening.

Plan for 2/2/2020

Planning starts

11/15/2019

Open house to be

scheduled for

2/2/2020

Equipment:

Multi‐Function Copier/Printer

Purchasing Dept. will set up account and order Copier/Printer units for the Center.

2 multi–function copier/printer units per floor.

Order to be placed 10/1/2019 Delivery

and installation scheduled for 12/16/2019

Scanners

Purchasing Dept. will work with IT Dept. and Billing Dept. to order and appropriate insurance scanners and card swipes for each check in and check out station.

Order to be placed 10/1/2019 Delivery

scheduled for 11/1/2019 Installation

scheduled for 12/16/2019

21 | P a g e

Computers / Computer Monitors/ Printers/Telephones

Purchasing Dept. will work with Care Center Manager and IT Dept. to order technology equipment.

Determine appropriate number of computers, monitors, printers and telephones for clinical and clerical areas.

Order to be placed 10/1/2019

Delivery scheduled for 11/1/2019

Installation scheduled for 12/16/2019

Building items

Brackets for exam rm. Monitors /Towel & Soap Dispensers / procedure light fixtures

Purchasing to work with IT and other vendors to get these items purchased and installed prior to opening.

10/1/2019

Medical Equipment

Care Center Manager and Clinical Supervisor to work with Purchasing to determine Medical Equipment needs.

Purchasing will work with Vendors to get medical equipment ordered and installed prior to opening. Anticipated delivery



Electronics ( Smartboards, TV's Monitors, etc.) / will need to schedule outside service to install all electronics

Purchasing to work with IT to get electronics ordered and installed

Will schedule outside service for install by 11/1/2019 for 12/1/2019 installation date.

Order to be completed 10/30/2019

Installation to be completed by

12/1/2019.

Supplies:

Clinical/Medical Supplies Start ‐ up order for clinical supplies will be created.

Care Center Manager and Clinical Supervisor will work with Purchasing Department and vendors to get the appropriate supplies ordered.



Vaccines/Medications Start – up order for vaccines/medications will be created.

Care Center Manager and Clinical Supervisor will work with Purchasing Department and vendors to get the appropriate Vaccines and Medications ordered.



22 | P a g e

Linens service

Purchasing to work with existing primary care linen service go get quote to add The Center for Advanced Medicine as a service location.

10/1/2019

Clerical Supplies Start ‐ up order for clerical supplies will be created.

Care Center Manager and Clerical Supervisor will work with Purchasing Department and vendors to get the appropriate supplies ordered.



Staffing:

Position Control

Position Control Sheet to be created for staffing at The Center for Advanced Medicine.

Care Center Manager will work with Human Resources.

3/1/2019

Recruitment

Recruiter to being recruiting for Physicians, Nurse Practitioners, and Physician Assistants

Will send mailers out to various physicians in the surrounding area and in specific regions in the Norther part of the country in hopes of enticing physicians to come to a warner climate to practice in our unique model of care. Ads will also be posted to specific websites, as well.

Ads to be placed 12/1/2018 (placing ads well in advance as it takes up to a year at times for a physician to start once recruited.)

Goal is to have 49 Specialists in place

by 1/2/2020.

Staff Recruitment

A number of clinical and clerical support staff will need to be recruited to support various positions within the center. Staff will come from a variety of different backgrounds, with varying levels of education, certification, experience and skills.

Human Resources will begin recruiting for staff 4 months prior to opening. Ads to be placed on The Center for Advanced Medicine’s website, as well as using other career websites and social

Ads will begin running on 9/1/2019

23 | P a g e

media, such as Monster, Facebook, Twitter, etc.…

Training Clerical Competencies

Care Center Manager and Clinical and Clerical Supervisors will be responsible for onboarding new Physicians, Providers and Staff.

Clinical and Clerical Supervisors will ensure that clinical and clerical competencies are in place for new staff to be trained. Uniforms and name badges will be ordered for physicians and staff prior to start date. IT will assist in training new staff and providers on the Electronic Medical Record system. All staff will attend orientation, which will include an overview of the organization, HIPAA training, OSHA training, and Compliance training.

Competencies to be in place by

9/1/2019. First orientation to

begin on 10/1/2019.

Clerical Team Training

Training on Electronic Medical Record

Orientation scheduled

Training Clinical Competencies

Clinical Team Training

Training on Electronic Medical Record

Orientation scheduled

Uniforms

OSHA training

HIPPA training

Name Badges

Credentialing

Credentialing Specialist and Physician Recruiter to ensure new Physicians are credentialed with the majority of the insurance plans The Center for Advanced Medicine accepts prior to the opening of the Center.

Close attention and monitoring timelines will be essential in the process to ensure providers are credentialed in a timely manner to ensure they will be able to see patients on opening day.

Target date 12/20/2019

Manuals:

OSHA OSHA Guard & OSHA training

Compliance Dept. will ensure that OSHA Manual is ordered and in place prior to the opening, and will set up OSHA training for all new staff.

10/1/2019

24 | P a g e

AHCA (Agency for Health Care Administration)

Care Center Manager and Clerical Supervisor will assemble the AHCA Manual. The Center for Advanced Medicine will be certified with the Agency for Health Care Administration.

Manual can be started and will need to consistently be updated as new Staff, Physicians and Providers are on‐boarded.

10/1/2019

Policy and Procedure Manual

Clinical and Clerical Supervisors, along with assistance from the Medical Director and Care Center Manager, will create the Policy and Procedures Manual for The Center for Advanced Medicine

Manual to be completed prior to the opening of the Center, and staff should be oriented to these policies and procedures.

11/1/12019

Employee handbook

Executive Director and Care Center Manager will work with Human Resources and Legal to develop an Employee Handbook.

Handbook will need to be completed well in advance of staff being hired, as they will need to be oriented to the handbook during orientation.

2/1/2019

Disaster Plan

Executive Director and Care Center Manager will work with Compliance Department to develop a Disaster Plan for The Center for Advanced Medicine.

Disaster plan should be in place prior to the opening of the Center.

11/15/2019

Licenses:

AHCA

Credentialing Specialist will apply for AHCA Certification for The Center for Advanced Medicine.

AHCA Survey will be scheduled to come and survey the site within 30 days of opening.

Apply for License by 6/1/2019, schedule site

review for 2/1/2020

CLIA

Credentialing Specialist will apply for CLIA License for the LAB to allow for Waive Testing on site.

License to be applied for and in place prior to the opening of the Center.

License should be in place by 11/1/2019

25 | P a g e

Medicare

Credentialing Specialist will contact Medicare and register new location.

Registration should be completed by

10/1/2019

X‐ray Staff Accountant will apply for the Radiology License.

License to be applied for and in place prior to the opening of the Center.

License should be in place by 11/1/2019

OSHA ‐ Biomedical manual Compliance Department will order the Biomedical Manual

Manual will be ordered and in place prior to the opening of the Center.

Manual should be in place by 11/1/2019

Bio‐Hazard Staff Accountant will apply for the Bio‐Hazard License.

County inspection will contact Clinical Supervisor to do initial inspection by 11/30/2019 and issue certificate.

11/30/2019

HCCE Permit

Credentialing Specialist to submit application for the Health Care Clinic Establishment permit

Permit to be issued no later than 7/1/2019

Application submission by

5/1/2019Permit issued by

7/1/2019

Billing:

Service Location needs to be added to the Electronic Medical Record system.

Billing Department will ensure The Center for Advanced Medicine is added to the EMR system.

Needs to be completed prior to the opening of the Center.

12/1/2019

Lab:

Set up accounts

Clinical Supervisor will work with account representatives at each outside lab to establish new accounts for the Center.

To be established prior to the opening of the Center.

12/1/2019

Other office set up:

Medical Equipment Inspector

Clinical Supervisor to set up biomedical equipment inspection ‐ after equipment is delivered and prior to AHCA inspection

Clinical Supervisor will contact Inspector to set date for 3rd week of September, 2019.

9/20/2019

Fire Extinguishers Included in the buildout and will be inspected prior to installation

9/20/2019

26 | P a g e

Keys Keys to be received after building has been inspected.

When keys are received. All Keys will be organized and kept on‐site in the Care Center Managers office

Keys to be handed over on 12/1/2019

Access codes

Care Center Manager will work with Property Management Company to get all appropriate access codes set up for employees.

List of employee and code requests will be sent to Property Management 30 days prior to opening.

12/1/2019

Time clock

Care Center Manager will work with Human Resources to ensure all staff has access to the time system.

Time clock will be installed 30 days prior to the opening of the Center. Clinical and Clerical Supervisors will ensure all staff is registered in the time clock.

12/1/2019

IT Switches and Data network

IT will install and confirm operation of all Data networks and switches.

Phones, computers, Internet to be operational prior to the opening of the Center.

12/1/2019

Office Safe Purchasing Department to purchase safe for the Center.

Safe will hold all petty cash and daily cash collected.

ordered by 10/1/2019

Petty Cash Staff Accountant will issue petty cash check to Care Center Manger.

Petty Cash amount for the Center will be $350.00

12/20/2019

Cash bags for Check in/Check out staff

Staff Accountant will issue check to Care Center Manager for funds for each cash bag.

Total of $800.00 for 8 cash bags.

12/20/2019

Wi‐Fi Free Wi‐Fi to be made available for our patients.

IT to set up WI‐FI capability.

10/1/2019

27 | P a g e

Local Newspaper

Purchasing Dept. to set up account with local newspaper. Will work with Care Center Manager to determine how many papers will be delivered to cover various waiting areas of the Center.

Account to be set up and first scheduled delivery by 12/31/19

11/30/2019

Services:

Coffee machine service Purchasing Dept. to set up coffee service for the Center.

Will have in place by October.

10/15/2019

Shredding Purchasing Dept. to set up Confidential Shredding account.


10/15/2019

Nitrogen Purchasing Dept. to set up Liquid Nitrogen account.


10/15/2019

Bio‐hazard Staff Accountant to set up Bio‐hazard account.


10/15/2019

Linens Purchasing Dept. to set up Linen Service


10/15/2019

Cleaning

Purchasing Dept. to work with Property Management to set up cleaning service.


10/15/2019

TV/Cable Purchasing Dept. to work with IT Dept. to set up cable account.


10/15/2019

Landscaping and grounds

Staff Accountant to work with Property Management to set up Landscaping Account.


10/1/2019

Utilities: Water, Gas, Electric;

Staff Accountant to get all accounts for utilities.

All utility accounts to be transferred to be transferred over from Contractor prior to the opening of the Center.

Effective Date: /1/12020

28 | P a g e

Trash/Dumpster

Staff Accountant to set up account with Waste Management and order Dumpster.

Will submit application for Dumpster on 9/1/2019

10/1/2019

Oxygen Purchasing Dept. will set up account with Oxygen supplier.

Will order oxygen tanks for the Center.

Account set up by 10/1/2019, Tanks

delivered by 11/1/2019

Mail service Care Center Manager will contact USPS to inform of new address.

Mail to start being delivered by 1/2/2019.

Contact USPS by 12/1/2019 for

effective date mail delivery 1/2/2019

Pharmaceutical Suppliers:

Vaccines, Medications, and Drugs

Purchasing to establish account for The Center for Advanced Medicine.

Accounts to be established prior to initial supply order 10/1/2019

9/15/2019

Lab Supplies Purchasing to establish account for The Center for Advanced Medicine.


9/15/2019

Medical Equipment/Misc. Medical Supplies

Purchasing to establish account for The Center for Advanced Medicine.


9/15/2019

29 | P a g e

MARKETING PLAN

30 | P a g e

Marketing Plan 1) Overview

The following is an overview of the Strategic Marketing Plan for this project. The recommendations within this plan are based on numerous conversations held over the past several months with key stakeholders within the Organization, other stakeholders including partners, vendors, residents in the existing and surrounding communities, as well as a review of key marketing materials, data, technologies, and more. We also conducted a physician needs analysis using statistics from various organizations such as the American Medical Association (AMA), The General Medical Education National Advisory Committee (GMENAC), Mature HMO, and Kaiser Plans, as well as collecting data from Market Research on patient preferences.

The combination of all these inputs is critical to ensuring the success of the Center for Advanced Medicine and becoming America’s Healthiest Hometown.

Before a new marketing campaign can be launched a couple of items much first be addressed:

Our overall brand strategy and how we position our story and plan to resonate with key stakeholders in the existing and surrounding communities.

The overall patient experience from the top to the bottom of the sales and marketing lifecycle.

Therefore, the first half of this section addresses the above items, beginning with a brand overview and a SWOT Analysis from a marketing and sales perspective. This analysis helps us discover a new way of thinking about who we are and defining what we stand for, and how we engage prospective new partners to join us in this new and innovative care delivery model.

Once that foundation is established, the second portion dives into specific campaign plans, tactics and budgets to tell our story in a strategic attempt to acquire additional partnerships within the existing community as well as spreading to secondary markets.

31 | P a g e

Brand Overview

Below is a detailed outline of our Brand Overview, which includes our Vision, Mission, Qualities, Core Values and Product/Service recognition.

Vision:

What do we want to be?

We want to be the catalyst for helping our community become America’s Healthiest Hometown

Mission:

Why do we do what we do?

We are committed to providing extraordinary, patient-centered health care to our patients, their families and our community, to ensure peace of mind through high quality, compassionate treatment, and to deliver care beyond their expectations. Qualities:

How do we do what we do?

Patient-Centered – We engage patients in decision-making about their health.

Primary-Care Driven – Each patient has a relationship with a primary care physician and receives care delivered by a team led directly by that physician based in a Medical Home model. Coordinated Care – A comprehensive group of providers and specialists work together to provide coordinated care in a team environment.

Innovative - Routinely implementing fresh ideas and methods – a process which has so consistently helped the organization achieve community acknowledgement and success.

Integrated - The primary elements of a comprehensive system are intelligently connected.

Value-based - Both quality and cost remain the clear and unabashed focus of attention in the delivery of care. In this respect, new and innovative technology is embraced to the extent that it supports the creation of greater value to the patients who are served.

Core Values: What principles guide our decision-making?

Service – We exceed expectations. Stewardship – We are responsible for healthcare outcomes. Quality – We seek excellence in our care and care giving. Innovation – We create a better way.

32 | P a g e

Product/Service recognition: What is our service? Well, simply put, our service is patient-centered healthcare, which is driven by our Vision, Mission, Qualities and Core Values as noted above. We are creating a concierge-like full service, one-stop-shop to meet all of our patient’s healthcare needs and enhance the patient experience by complementing our services with 5-star accommodations and amenities. Imagine walking into a state of the art facility and being able to have all of your healthcare needs met. It will be a seamless experience, from the time the patient schedules their appointment(s), arriving and being greeted by a host/hostess to welcome and guide the patient to their check in point, being able to check in for all services at one central location, meeting with the physician for their appointment, test or procedure, to checking out and heading to the connected hotel to rest and recover in 5-star comfort if they choose. We are here to exceed the expectations of our patients!

2) Market Analysis a) Target Market and Audience: The primary target market for this venture is the

community where the Center for Advanced Medicine will be positioned, which is a 55 plus community encompassing over 45 square miles. Our target audience will primarily be retirees, however, there is a working class community here as well and that client demographic of 18 and older will also have the benefit of being able to access services at the Center. We will expand our reach to a secondary market in the surrounding tri-county area

b) Competition: Primary competitors in the areas we will target will be similar specialties located in these communities. Geographically, some will be closer to patients which may drive patients in that direction simply for convenience purposes. Our challenge will be to creatively and tactfully market The Center for Advanced Medicine in a way that will entice patients to want to experience what we have to offer. We will need to highlight and spotlight the attributes of the Center in such a way that patients will make it a destination point to experience the care and services we are offering.

c) Market Trends: There has been significant growth in the existing community over the past several years. From 2015-2017 the population grew 17%, from 100,000 to 117,000 residents. By 2020 the expected population in this community will reach 128,000 residents. With growth this significant there is a continued need for additional healthcare services, and physicians and staff to provide these services. The challenge is being able to grow fast enough to meet the demands and needs of the community.

d) Physician Demand: In researching physician demand by specialty from a variety of

organizations, such as the American Medical Association (AMA), the Graduate Medical Education National Advisory Committee (GMENAC), the Health Maintenance Organization (Mature HMO), and Kaiser Permanente Plans, trends show a growing shortage of physicians across multiple specialties with an estimated deficit of just over 111 physicians in 2015 and an estimated deficit of just over 160 physicians in 2020. These projections are calculated based on:

A 5 year population growth from 2015 to 2020 of 5.02% annually Physician Demand is per 100,000 population

33 | P a g e

The estimated Surplus/Deficit of providers should be considered an average for a typical US population and not always representative of this community’s population. Based on this data it is clear that demand continues to be on the rise, while supply continues to slip.

3) Marketing Strategy: Budget % allocations on-and off-line with expected return on investment of less than one year.

Assets and associated costs needed for Marketing Campaign ITEM ESTIMATE Post Card Design $1,800 Post Card Mail and Postage (8 months) $16,000 Testimonial Videos – 3 $10,000 Digital Ad Designs $800 Digital Ad Spend (4 Months) $7,000 Print Ad Design (4 Months) $7,500 Radio Spot Production $1,500 Radio Ads (4 Months) $10,000 Open House Event

Entertainment (3 hours) $1,500 Catering $5,000 Advertising (Local Paper) $2,500 Giveaways $10,000

ANNUAL TOTAL $73,600

4) Implementation of Marketing Strategy: Mode and methods for marketing A variety of marketing tools and strategies will be used introduce the Center for Advanced Medicine to our target market group.

Specialty Physicians will spend time in Primary Care: Our Specialty Physicians will be spending 10% of their time in the Primary Care Centers, collaborating and educating our Primary Care Physicians on the various specialties and services that will be available at The Center for Advanced Medicine.

Monthly CME Webinars: Our Specialty Physicians will present a monthly CME webinar, broadcast to all our Primary Care Centers, each month. This is another way to help connect our Specialists with our Primary Care Physicians, and they can earn CME credits in the process.

We will have regular meetings with Managed Care Organizations. Post Cards: Will be mailed out each month, several months in advance of the opening of

the Center, and will highlight something specific about the Center, i.e., the services and specialties offered at the center, the hotel/spa/restaurant that will be connected the Center, photos of the physicians that will be practicing at the Center, how to access our Website to view learn more about who we are, and much more.

Testimonials: We will have patient testimonials uploaded to the website so potential new patients hear about the experiences they have had receiving their care from the current specialists in our Organization.

34 | P a g e

Digital Ads: We will have streaming digital ads streaming on television sets within the primary care centers of the Organization, highlighting the opening of the Center for Advanced Medicine, and the services and amenities that will be offered.

Print Ads: We will have weekly featured articles in the local newspaper that will run several months prior to the opening of the Center for Advanced Medicine. The Articles will contain interviews with our specialists as well as new physicians and practices that will be partnering with the Center for Advanced Medicine.

Radio Ads: We will have frequent radio ads running on the local radio station in the community. This station is played all day throughout the town centers in the community. So, it won’t only reach the people in the community but will reach people coming in from outside of the community as well.

Open House/Grand Opening: We will host an Open House that will allow patients and members of the community to come in and tour the facility. We will have staff available to sign up new patients, and there will be live entertainment and refreshments for our guests.

5) Evaluating, monitoring results of marketing plan, effectiveness metrics For the various marketing methods that will be used to promote the new Center for Advanced Medicine, it will be important to track the effectiveness of these tool and the effects they have on the business. We anticipate seeing an initial surge in inquiries and new patient sign-ups once the ads begin running. Below are the goals we will set and track:

Goal 1: We would like to see phone volume for new patient inquiries increase by 15% once ads begin through print, radio, digital, postcards and patient testimonials.

Goal 2: We would like to see new patient sign – ups, as a result of above mentioned ads and the Open House, increase by 10-15%

Goal 3: We would like to see walk-in traffic increase, as a result of the ads, and would like to sign up at least 5% of those walk-ins to be new patients.

We will also track the methods by which new patients heard about the opening of the Center (newspaper, radio, digital, etc.…)

35 | P a g e

FINANCIAL DOCUMENTS

36 | P a g e

Financial Documents 1) Summary of Financial Needs:

We are estimating that we will need to secure financing of $10,900,000 to assist us with covering capital expenses such as capital to fund operations, capital to fund first year deficit, capital to fund lease hold improvements, and capital for fixed assets. The capital for fixed assets covers the exam rooms and offices located within the 64,000 square feet of space. The cost for the buildout of the remaining space will be spread out and covered by the tenant partners.

2) Pro forma Cash Flow Statement: Below is a projected 3-year Cash Flow Statement for the Center for Advanced Medicine.

2020 2021 2022

Cash Flow From Operations Net Income (2,725,004)$ 958,097$ 3,856,127$

Adjustment for Depreciation Expense 692,747 720,301 761,503

(Increase)/Decrease in Accounts Receivable (2,258,872) (656,768) (603,568)

(increase)/Decrease in Other Receivables

Increase / (Decrease) in Accounts Payable 132,638 11,261 12,327

Increase / (Decrease) in Accrued Payroll 477,391 534,094 600,124

Total Cash Flow from Operations (3,681,100) 1,566,985 4,626,513

Cash Flow From Investing Purchase of Equipment (2,609,230) (192,878) (288,414)

Tenant Improvements (6,400,000)

Total Cash Flow from Investing (9,009,230) (192,878) (288,414)

Cash Flow From FinancingProceeds from Loan $10,900,000 ‐ ‐

Proceeds from Landlord for TI $3,200,000

Loan Repayment ‐ (1,000,000) (3,000,000) Total Cash Flow from Financing $14,100,000 (1,000,000) (3,000,000)

Net Increase / (Decrease) in Cash 1,409,670 374,107 1,338,099

Beginning Cash Balance ‐ 1,409,670 1,783,777

Ending Cash Balance 1,409,670$ 1,783,777$ 3,121,876$

37 | P a g e

3) Three-Year Projected Income: Below is a projected 3-year income statement for the Center for Advanced Medicine.

Note:

1. Visits per day are based on current trend and available capacity 2. Visit Collection rate based on current rate plus 2% annual escalator

2020 2021 2022

Net FFS Revenue 20,491,196$ 26,449,020$ 31,924,244$

Revenue Metrics

Visits Per Day ‐ Current Specialists 385 440 490

Visits Per Day ‐ Specialists 2020 and after January 1 66 72 78

Visits Per Day ‐ Specialists 2021 and after January 1 ‐ 44 48

Visits Per Day ‐ Specialists 2022 and after January 1 ‐ ‐ 44

Less adjustment for start date ‐ new docs (33) (22) (22)

Total Visits Per Day 418 534 638

# of Business Days 254 254 254

Visits per day Per Specialist 13.06 13.70 13.83

Total Visits 106,172 135,636 162,052

Visit Collection Rate $193 $195 $197

Totals 20,491,196 26,449,020 31,924,244

38 | P a g e

4) Projected Balance Sheet: Below is a projected 3-year balance sheet for the Center for Advanced Medicine.

12/31/2020 12/31/2021 12/31/2022

Summary Balance Sheet

Cash $1,409,670 $1,783,777 $3,121,876

FFS AR Receivable $2,258,872 $2,915,640 $3,519,208

Other Receivables

Fixed Assets, net 8,316,483$ 7,789,060$ 7,315,971$

Other Assets

Total Assets $11,985,025 $12,488,477 $13,957,055

Accounts Payable $132,638 $143,899 $156,225

Accrued Payroll $477,391 $534,094 $600,124

Other liabilities

Bank Loans $10,900,000 $9,900,000 7,900,000

Equity $474,996 $1,910,484 $5,300,706

Total Liabilities & Equity $11,985,025 $12,488,477 $13,957,055

Metrics

Days in AR 28 28 28

FFS A/R Receivable Calculation

FFS Revenue $20,491,196 $26,449,020 $31,924,244

# of Operating Days 254 254 254

Average Revenue per day $80,674 $104,130 $125,686

Days of Revenue in A/R 28 28 28

FFS A/R Receivaable $2,258,872 $2,915,640 $3,519,208

Accrued Payroll Calculation

Annual Compensation 17,322,474 19,379,989 21,775,924

# of Operating Days 254 254 254

Compensation Per Operating Day $68,199 $76,299 $85,732

Payroll Days Outstanding 7 7 7

Accrued Payroll $477,391 $534,094 $600,124

Accounts Payable Calculation

Non‐Payroll/Rent Expenses $1,591,653 $1,726,783 $1,874,705

Accounts Payable $132,638 $143,899 $156,225

39 | P a g e

5) Break Even Analysis: Below is a 3-year break even analysis for the Center for Advanced Medicine.

2020 % 2021 % 2022 %Net FFS Revenue at Break-Even 20,491,196 100.0% 25,507,950 100.0% 28,071,318 100.0%

Clinical Expenses Total Compensation 17,322,474 84.54% 19,379,989 75.98% 21,775,924 77.57% Total Facility 2,900,825 14.16% 2,987,850 11.71% 3,077,485 10.96% Total Supplies $1,380,834 6.74% $1,509,639 5.92% $1,651,047 5.88% Total Outside Services 135,997 0.66% 140,077 0.55% 144,279 0.51% Total Other 74,822 0.37% 77,067 0.30% 79,379 0.28%

Total Clinical Expense 21,814,952 106.5% 24,094,622 94.5% 26,728,114 95.2%Contribution Margin (1,323,756) -6.5% 1,413,328 5.5% 1,343,204 4.8%

Depreciation Expense (692,747) (720,301) (761,503) Interest Expense (708,500) (676,000) (578,500)

Operating Income (2,725,004) 17,026 3,201

Revenue Metrics at Break‐Even 2020 2021 2022

Visits Per Day ‐ Current Specialists 385 440 490

Visits Per Day ‐ Specialists 2020 and after January 1 66 72 78

Visits Per Day ‐ Specialists 2021 and after January 1 ‐ 44 48

Visits Per Day ‐ Specialists 2022 and after January 1 ‐ ‐ 44

Less adjustment for start date ‐ new docs (33) (22) (22)

Total Visits Per Day 418 515 561

# of Business Days 254 254 254

Visits per day Per Specialist 13.06 13.70 13.83

Total Visits 106,172 130,810 142,494

Visit Collection Rate $193 $195 $197

Totals 20,491,196 25,507,950 28,071,318

40 | P a g e

6) Profit and Loss Statement: Below is a projected 3-year profit and loss income statement for the Center for Advanced Medicine.

2020 % 2021 % 2022 %Net FFS Revenue 20,491,196 100.0% 26,449,020 100.0% 31,924,244 100.0%

Clinical Expenses Total Compensation $17,322,474 84.54% 19,379,989 73.27% 21,775,924 68.21% Total Facility 2,900,825 14.16% 2,987,850 11.30% 3,077,485 9.64% Total Supplies 1,380,834 6.74% 1,509,639 5.71% 1,651,047 5.17% Total Outside Services 135,997 0.66% 140,077 0.53% 144,279 0.45% Total Other 74,822 0.37% 77,067 0.29% 79,379 0.25%

Total Clinical Expense 21,814,952 106.5% 24,094,622 91.1% 26,728,114 83.7%Contribution Margin (1,323,756) -6.5% 2,354,398 8.9% 5,196,130 16.3%

Depreciation Expense (692,747) (720,301) (761,503) Interest Expense (708,500) (676,000) (578,500)

Operating Income (2,725,004) 958,097 3,856,127

Expense Metrics

Compensation FTE Count 2020 FTE Count 2021 FTE Count 2022Salary and Wages avg.salaries avg.salaries avg. salaries# of Specialists 33 335,000 $11,055,000 37 341,700 $12,642,900 41 348,534 $14,289,894# of Mid-Level Providers 7 83,856 $586,992 7 85,533 $598,731 9 87,235 $785,114# of Clinical Support Staff + Ancillary 44 39,687.04 $1,746,230 48 40,480.78 $1,943,077 52 41,290.39 $2,147,100# of Clerical Support Staff 29 38,411.70 $1,113,939 30 39,179.93 $1,175,398 32 39,963.52 $1,278,833Admin Support (Centralized Clerical Support) 26 46,785.40 $1,216,420 29 47,721.11 $1,383,912 33 48,675.53 $1,606,292P/R Taxes $497,410 $507,358 $517,505Insurance $690,283 $704,089 $718,170401k $131,966 $134,605 $137,297other benefits $284,234 $289,919 $295,717Total S & W $17,322,474 $19,379,989 $21,775,924

Facility Rentable Square Footage 64,000 64,000 64,000Price Per Square Feet $37.00 $38.11 $39.25Bldg Rent $2,368,000 $2,439,040 $2,512,211Bldg Maint. $284,971 $293,520 $302,326FF&E Leases $247,854 $255,290 $262,948

$2,900,825 $2,987,850 $3,077,485

SuppliesDrugs & Medications $644,067 $708,474 $779,321Med Supplies $604,223 $664,645 $731,110Office Supplies, Postage & Copying $66,345 $68,335 $70,385IT Supplies $29,275 $30,153 $31,058Tangible Equipment <$2500.00 $36,924 $38,032 $39,173

$1,380,834 $1,509,639 $1,651,047

Outs ide ServicesCollection Expense $2,785 $2,869 $2,955Recruiting $70 $72 $74Outside Services $62,414 $64,286 $66,215IT Services $70,728 $72,850 $75,035

$135,997 $140,077 $144,279

OtherTravel & Entertainment $25,064 $25,816 $26,590Other Expense $49,758 $51,251 $52,788

$74,822 $77,067 $79,379

Financing NeedsCapital to fund Operations $3,400,000 0 0Capital to fund First Year Deficit $1,700,000Capital to fund Lease Hold Improvements $3,200,000Capital for fixed Assets $2,600,000 $192,878 funded through operations $288,414 funded through operationsTotal Debt Outstanding - original $10,900,000Total Debt Outstanding - end of year $10,900,000 $9,900,000 $7,900,000Average Debt Outstanding $10,900,000 $10,400,000 $8,900,000Interest Rate (Prime plus 2%) 6.50% 6.50% 6.50%Interest Expense $708,500 $676,000 $578,500

41 | P a g e

Notes: Given the amount of providers projected for 2020, and based on 1500 Sq. Ft. per

provider, we will be close to maxing out our space. We do have an additional 7800 Sq. Ft. of expansion space available.

The lease rate at $37.00 per Sq. Ft. is market rate for this area and is built in to the rent. The additional $50.00 per Sq. Ft. given by the building owner will be paid back over the life of the lease.

42 | P a g e

INNOVATIVE ELEMENTS AND EXPECTED BUSINESS OUTCOMES

43 | P a g e

Innovative elements and expected business outcomes

1) Positive impact on the health of our population and the organization: Once The Center for Advanced Medicine is open and fully operational, the impact that the innovative model of care will have on the health of our patient population as well as the business impact to the organization will be: Medical care that is better coordinated and cost effective for our patients Reduction in Emergency Room visits, Hospital admissions and re-admissions Increased access to specialists, spreading to secondary markets Increased HEDIS star rating from 4.95 to 5.0 as a result of improved access and

coordinated care for our patients resulting in better health outcomes CountyHealthRatings.org rated us 27 out of 67 in 2015 for positive health outcomes

in this community, and in 2017 rated us 15 out of 67. The lower the rating indicates improved health outcomes.

Currently ranked the #1 Physician Group in North and Central Florida Region, our goal is to be ranked the #1 Physician Group in all of Florida

Value-based, full-risk model offers higher quality which can relate to lower medical costs for patients and lowered costs for providers/practices.

Advisory group within the Center consisting of our Specialists and the Tenant Partners will be working together to achieve better quality outcomes.

Tenant partners receptive to capitated reimbursement for at risk patients. Will contract by group to receive Per Member Per Month payments.

Gain share arrangements with some groups, such as Oncology. Surgeons will have incentives to do procedures in the outpatient setting, which drives more value.

Aligned incentives can be implemented through an Independent Practice Association or Management Services Organization arrangements.

Organization will be firmly positioned to take on additional at-risk insurance plans that in turn will allow us to continue to offer higher quality care, which can relate to lower medical costs for patients and lowered costs for providers/practices.

2) Challenges and lessons learned: Going through the process of creating this business plan was eye opening in many ways. Some areas that were particularly challenging were figuring out how to make this innovative idea a reality. For instance, finding providers that would buy in to the model of care that we want to deliver and share a similar vision of creating a healthcare delivery system that offers high quality, better coordinated, cost-effective healthcare presented its own set of challenges. However, we were able to find those providers and have secured letters of intent from various specialty practices to obtain space within The Center for Advanced Medicine. Additionally, putting the timeline in place and outlining each step that needs to happen, and when, was challenging to forecast, but we feel confident that we have outlined a clear, realistic operations plan. Preparing the financials for a project of this size took a great deal of work. Much time was spent trying to determine what we needed to make the numbers work and have it make sense, and what we needed for start-up capital to help cover the first year of expenses. It forced us to really look at this project from every angle so that we could determine the best possible scenario that would allow us to make this venture profitable in a realistic period of time. Other challenges were around marketing and looking at creative ways of how we can reach target markets, again, keeping in mind that we want to make the Center a destination point for patients

44 | P a g e

not just in our own community but all over the State of Florida, and also thinking big picture of how can this model can one day be replicated across the country. We believe our marketing plan is strong and will have the desired outcomes we are looking for.

3) Next Steps to put project in action: Listed below are the critical steps that need to take place in order get this project off the ground and in motion. Obtain board approval

Recruit executive director

Secure financing

Complete tenant leases (execute)

Develop a collaborative charter (rules of engagement) for all tenants.

Participate in the design and build components of the project.

Once we have these steps are completed, we can follow our operations plan and work towards a successful build and grand opening of the Center for Advanced Medicine.