PRIVATE EQUITY: In Podiatric Surgery

Dr. David Edward Marcinko MBA MEd

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Why podiatry surgery volume matters so much?

Podiatry Management Service Organizations typically rely on three revenue pillars:

  1. Office visits (high volume, low margin)
  2. Ancillaries (DME, orthotics, imaging)
  3. Surgery (low volume, high margin)

Surgery is the only pillar that reliably moves EBITDA in a meaningful way. Buyers know this, so they scrutinize surgical volume harder than anything else.

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🔍 What “surgery volume” really means in podiatry

It’s not just the number of cases. Buyers look at:

  • Case mix (forefoot vs. rearfoot vs. trauma)
  • Site of service (ASC vs. hospital vs. office)
  • Provider concentration (is one surgeon doing 40% of cases?)
  • Payer mix (Medicare vs. commercial)
  • Seasonality (podiatry has real seasonal swings)
  • Referral stability (orthopedics, PCPs, wound care centers)

If any of these look unstable, the MSO’s valuation drops fast.

🚧 What happens to surgery volume when an MSO misses its exit window

1. Surgeons become less motivated

When the exit stalls:

  • Equity feels less valuable
  • Surgeons may slow down elective cases
  • Some shift cases back to hospitals
  • Others reduce ASC utilization
  • A few may even explore leaving the MSO

This is one of the biggest hidden risks.

2. Case mix often deteriorates

High‑value cases (rearfoot, reconstructive, trauma) may decline, while:

  • Nail procedures
  • Callus debridements
  • Routine diabetic care

…take up more of the schedule. This drags down EBITDA even if total visit volume stays stable.

3. Referral patterns weaken

If the MSO is perceived as unstable:

  • Orthopedic groups may stop referring
  • PCPs may shift to independent podiatrists
  • Wound care centers may diversify referrals

Referral leakage is subtle but devastating.

4. ASC strategy becomes strained

Many podiatry MSOs depend on:

  • Owning ASCs
  • Leasing block time
  • Negotiating better payer rates

If surgery volume softens:

  • ASC utilization drops
  • Fixed costs become painful
  • Lenders get nervous
  • Buyers discount the valuation

ASC underperformance is one of the top reasons podiatry MSOs fail to exit.

5. Productivity gaps widen between providers

Podiatry MSOs often have:

  • A few high‑volume surgeons
  • Many low‑volume generalists

When the exit stalls:

  • High performers may feel under‑rewarded
  • Low performers may drag down averages
  • Buyers see concentration risk

If one surgeon leaves, the MSO’s EBITDA can collapse.

6. Compliance scrutiny increases

Surgical coding in podiatry is a known risk area. When an MSO can’t sell, buyers often dig deeper into:

  • Modifier usage
  • Global period billing
  • Site‑of‑service documentation
  • Medical necessity for certain procedures

If anything looks aggressive, the deal dies.

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🎯 The bottom line

Podiatry surgery volume is the core value driver of a podiatry MSO. When an MSO fails to sell at its vintage year, surgery volume usually:

  • Softens
  • Becomes more concentrated
  • Shifts toward lower‑margin cases
  • Shows referral instability
  • Raises compliance questions

Buyers interpret this as EBITDA fragility, which is why podiatry MSOs often end up in continuation funds or sell at discounted multiples.

COMMENTS APPRECIATED

EDUCATION: Books

SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit an RFP for speaking engagements: CONTACT: Ann Miller RN MHA at MarcinkoAdvisors@outlook.com -OR- http://www.MarcinkoAssociates.com

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PRIVATE EQUITY: Terms and Definitions

By Staff Reporters

SPONSOR: http://www.MarcinkoAssociates.com

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Capital Call: Definition and Explanation

A capital call is a notice sent to investors requesting that they contribute additional capital to a private equity fund. Capital calls are made when the fund manager has identified a new investment opportunity that requires additional funds.

Investors must be prepared to respond to capital calls with the required funds in a timely manner, as failure to do so could result in penalties or even the loss of their investment.

Carried Interest: Understanding the Concept

Carried interest is a form of incentive fee paid to private equity fund managers. This fee is calculated as a percentage of the profits generated by the fund’s investments.

Carried interest is often criticized as a tax loophole, as it is treated as capital gains, which are taxed at a lower rate than ordinary income.

Deal Flow: What it Means for Investors

Deal flow refers to the number of potential investment opportunities that a private equity firm evaluates. A robust deal flow is important for private equity firms, as it provides a pipeline of potential investments to consider.

Investors may want to investigate a private equity firm’s deal flow as part of their due diligence process, as a strong deal flow can indicate the firm has a good track record of finding attractive investment opportunities.

Due Diligence: A Key Step in Private Equity Investing

Due diligence is the process of evaluating a potential investment opportunity to assess its viability. This process involves a thorough investigation of the company’s financials, operations, and management team.

Due diligence is a critical step in the private equity investment process, as it helps to identify potential risks associated with an investment opportunity. Investors who skip due diligence do so at their own risk.

Exit Strategy: How Private Equity Firms Make Money

Exit strategy refers to the plan that private equity firms have in place to cash out of their investments. Private equity firms typically exit investments through an initial public offering (IPO), a sale to another company, or a management buyout.

Exit strategy is critical to the private equity investment process, as it is how investors ultimately make returns on their investments.

Fund of Funds: An Overview

A fund of funds is a type of investment fund that invests in other investment funds. In the private equity space, fund of funds typically invest in a portfolio of private equity funds.

Fund of funds can be a good way for investors to gain exposure to a wider range of private equity investments with less risk than investing in individual funds.

General Partner vs Limited Partner: What’s the Difference?

The general partner is the party responsible for managing the private equity fund and making investment decisions. Limited partners, on the other hand, are typically passive investors who provide capital but have little involvement in the investment process.

The distinction between general partners and limited partners is important for investors to understand, as it can impact their level of involvement in the investment process.

Investment Horizon: A Crucial Factor in Private Equity Investments

Investment horizon refers to the length of time an investor plans to hold an investment. In the private equity space, investment horizons can be several years or even a decade.

Investment horizon is a critical factor for investors to consider, as it impacts the level of liquidity they will have and the returns they can expect to make on their investment.

Leveraged Buyout (LBO): Definition and Examples

A leveraged buyout is a type of acquisition where the acquiring company uses a significant amount of debt to finance the purchase. The idea is that the acquired company’s assets will be used as collateral to secure the debt.

Leveraged buyouts can be an effective way for private equity firms to acquire companies with minimal capital investment. However, the use of leverage also increases the risk associated with these types of acquisitions.

Management Fee vs Performance Fee: Understanding the Two

The management fee is the fee paid to the general partner for managing the private equity fund. The performance fee, or carried interest, is paid based on the fund’s performance and returns generated for investors.

The distinction between management fees and performance fees is important for investors to understand, as it affects the level of fees they will be responsible for paying.

Pitchbook: A Guide to Creating an Effective Pitchbook

A pitchbook is a presentation used by private equity firms to pitch their investment strategy to potential investors. An effective pitchbook should be clear, well-organized, and provide a compelling rationale for why investors should consider investing in the fund.

Investors reviewing a fund’s pitchbook should look for evidence of a well-thought-out investment strategy and a track record of successful investments.

Private Placement Memorandum (PPM): What it is and Why It Matters

A private placement memorandum is a legal document provided to potential investors that details the terms of the private equity fund. It includes information on the fund’s investment strategy, expected returns, fees, and risks associated with the investment.

Reviewing a fund’s private placement memorandum is a critical step in the due diligence process, as it provides investors with a comprehensive understanding of the investment opportunity.

Recapitalization: A Strategy for Restructuring a Company

Recapitalization is a strategy used by private equity firms to restructure a company’s capital structure. This can involve issuing debt to pay off equity holders or issuing equity to pay off debt holders.

Recapitalization is often used to improve a company’s financial position and increase its value, making it a key tool in the private equity arsenal.

Valuation Techniques Used in Private Equity Investing

Valuation techniques are used to determine the value of a private company. These techniques can include discounted cash flow analysis, market multiples analysis, and asset-based valuation.

Understanding valuation techniques is important for investors, as it allows them to evaluate the relative value of investment opportunities and make informed investment decisions.

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