Return on investment (ROI) is the money you'll get back minus what you invested; it can be calculated as net income per share divided by share price. For publicly traded healthcare facilities, the average ROI for common shareholders is 14.45 percent. One-third of ASCs operate at a loss, and another one-third break even. Yet some management firms promise ROIs over 30 percent and as high as 100, 150 and even 200 percent. However, you can accurately estimate your future ROI and arrive at a reasonable and satisfying figure. Here's what to do.

Articulate your objectives
Clearly state professional and personal goals, because the physicians' operating philosophy directly influences the center's ROI. If the main goal is financial success, even centers without a unique market position or surgical service may achieve very high ROIs. For example, the high ROIs promised by some management firms rely on strategies that require surgeons to send only the most profitable cases to the surgery center. But this is risky, potentially unethical and a hindrance to the surgeon's efficiency. (See "What's Behind Those Lofty ROIs?") Conversely, if surgeon efficiency and more universal patient service are as important as financial success, you can expect a more moderate ROI.

This doesn't mean finances or patient care have to suffer; it just means you should set your priorities. I've found most surgeons open ASCs to make money and work in a patient-friendly environment - while improving their quality of life.

Establish a need
The next step is to maximize ROI potential within these goals. In my experience, the biggest mistake many surgeons make is that they view revenue and volume as predicators to success. They assume they are doing well if case volume is steady, and they have some money in the bank and take home a check. In healthcare, however, it doesn't matter how high your volume is if your reimbursement is inadequate.

Therefore, I recommend determining the legitimate leverage you have and using it to ensure decent reimbursement for your services. This will give you greater pricing flexibility and will maximize ROI potential. To determine leverage point(s), evaluate your market position with these three common laws of business:

• How many other providers in this market are offering this same service?
• Do I offer a unique skill or service?
• Will patients return time and time again, or is this a one-time service?

The answers will determine your reimbursement leverage irrespective of the center's size or the number or type of specialties. Even small single-specialty centers can maximize reimbursement if they establish a need for their services. For example, I recently worked with three GI surgeons who were performing procedures in a large local hospital. Initially, the hospital had a lock on GI cases because it belonged to a large health network that had established an exclusive referral arrangement and fee schedule with the area's top health plan. However, the surgeons comprised the majority of GI specialists in the market, which enabled us to negotiate with the health plan. Now this GI group treats most of its GI cases in its own ASC for rates lower than those previously paid to the hospital - but that are nevertheless very good.

Not everyone will find a point of leverage. In Southern California, for example, the ASC market is so saturated that some are now accepting Medicare rates at 100 percent rather than at the multiples seen in other parts of the country.

Integrate efficiencies
In business, managers maximize stock prices by running an efficient, low-cost business that produces high-quality goods at the lowest possible prices. The same is true for ASCs. The ROI you achieve will depend on how efficiently you run your operation.

This is particularly important when making initial capital outlays. Many physicians want the newest, most state-of-the-art equipment when they open a new center, yet they expect a high ROI, which is often unrealistic. If you plan to finance equipment, the best measure of whether the equipment will pay off is to compare the cost of the equipment to the return expected from that equipment. These calculations can be complicated but are worthwhile.

Long-term vision
Running a healthcare facility is often like running any other company. The key difference, however, is that decisions and actions can have life-and-death consequences, so the business decisions you make require a higher level of social consciousness. Given the huge investment ASCs require, it's possible to lose sight of this. But by keeping your long-term vision at the fore, establishing a market need and working to run the center efficiently, you can achieve an ROI as high as 20 to 30 percent after a two-year ramp up. By any measure, this is a healthy return.