Capital constraints, Certificate of Need scrutiny, and the accelerating shift to ambulatory, value-based care are forcing health systems to rewire networks for population health. The bar is triple: clinical integration, operational throughput, and financial resilience. Executive prompt: How should our health system balance ambulatory expansion with acute care investment to optimize capital efficiency and strategic portfolio performance?
Bremner Healthcare Real Estate is a healthcare-exclusive strategist and developer, translating care models into access, cost, and growth—since 1989 and validated by the Duke Realty acquisition. We align service lines, finance, and market execution, treating real estate as the operating system for integration and site-of-care shift. From JV ASCs to $100M+ campuses, we build board-ready, rating-agency-transparent plans that advance population health while protecting the balance sheet.
Health systems are retooling their portfolios to support clinical integration, value-based care, and margin resiliency. Real estate is the operating system for these ambitions, translating strategy into daily workflows and patient access. The right facilities plan improves network integrity, protects the balance sheet, and accelerates growth in the settings patients prefer. With decades as a healthcare-exclusive partner since 1989—validated by the Duke Realty acquisition and national health system partnerships—Bremner helps boards align capital, care models, and market execution, from ambulatory nodes to $100M+ campuses.
Why Clinical Integration Needs Real Estate
Clinical integration is the deliberate design of coordinated care processes, supported by data, governance, and facilities, to deliver the right care in the right setting across the continuum. Strategy only becomes real when pathways are hardwired into the physical network—placing diagnostics next to specialty clinics, embedding care management inside ambulatory hubs, and making it easy for clinicians to collaborate across service lines. More than half of health system encounters now occur in ambulatory settings, and that percentage continues to rise. Real estate is often the second-largest non-labor expense, which means facility choices have enterprise-level implications.
When assets are aligned with strategic service lines, referral friction drops and throughput improves. Where one cardiac service line faced leakage and extended waits, consolidating diagnostics, rehab, and clinic teams in one access point solved the bottleneck and produced lower patient travel time with improved downstream retention. Most patients choose sites within a 20-minute drive for routine care, so proximity and co-location are clinical levers as much as operational ones. For health systems pursuing tight network integrity, the facility plan is the operating system for care transitions.
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Health System Finance Alignment
Capital allocation must protect the mission while defending ratings and optimizing debt capacity. That requires disciplined modeling of lease versus own, on- versus off-balance sheet vehicles, and JV structures so that flexibility is preserved without eroding enterprise value. Lease-versus-own decisions can materially influence debt-to-capitalization and days cash on hand, and the right answer often varies by market, asset complexity, and service-line volatility. Transparent pro formas help boards weigh trade-offs between capital efficiency today and long-term control tomorrow.
We work with finance and treasury leaders to sequence projects by cash flow, align with service-line P&Ls, and phase commitments to reduce NPV risk. Stress-tested scenarios—reimbursement shifts, rate escalators, and construction inflation—ensure the real estate plan is resilient under multiple futures. When a new ambulatory cluster is paired with a divestiture of non-core sites, balance sheet pressure can ease while access expands. As a healthcare-exclusive developer-operator since 1989 with execution capacity strengthened through Duke Realty, Bremner brings capital agility and rating-agency-ready transparency to each decision.
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Value-Based Care Readiness
Value-based care favors sites designed for prevention, earlier intervention, and continuous patient engagement. Risk-bearing networks need facilities that integrate primary care, behavioral health, pharmacy, and social support with embedded care management and analytics hubs. ASCs, urgent care, and home-enabled programs require reliable handoffs; facilities should make it easy to close care gaps and monitor rising-risk cohorts, not just host episodic visits.
A VBC-ready footprint prioritizes lower total cost of care without compromising experience or outcomes. That means transitional care pods near EDs, population health command centers, and flexible rooms that can pivot between consult, infusion, or remote-monitoring setup. When chronic care teams and data analysts share space, insights flow faster and care plans change in real time, reducing avoidable admissions and readmissions. The result is a physical network that supports attribution growth and medical-cost trend control.
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Population Health Access Network
Population health demands access where need is highest, not just where existing facilities sit. Right-sizing the ambulatory footprint by acuity ensures high-touch services (imaging, infusion, rehab) are co-located with primary care in neighborhoods with leakage or poor chronic disease control. Capital should be deployed to ZIP codes with the greatest gap between demand and access, targeting travel-time and appointment-lag reductions that matter to patients and payers.
Extending hours, integrating telehealth suites, and enabling virtual-first triage inside clinics opens the front door wider without adding unsustainable fixed costs. When clinics serve as both in-person and digital hubs, provider productivity climbs and patients experience fewer handoffs. The problem of fragmented access is solved by a network that routes each need to the lowest-cost, highest-value setting, producing improved equity and measurable margin protection.
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Certificate of Need Strategy
CON success follows a sequenced plan that matches network growth and service-line timing. A Certificate of Need (CON) is a state regulatory approval required before certain healthcare facilities or services can be established or expanded. Phasing filings—starting with ambulatory, then advancing to imaging or bed capacity—can reduce capital at risk while demonstrating incremental need. Early throughput and staffing utilization studies substantiate the case and de-risk approval by showing realistic ramp-up, productivity benchmarks, and regional alignment.
Regulatory strategy should be integrated with market development, physician alignment, and payer negotiations. When boards see that approvals map to service-line milestones and JV structures, governance confidence increases. The right data narrative—travel-time gaps, avoidable outmigration, and quality variance—translates community need into compelling CON evidence. As approvals progress in stages, systems preserve optionality while building momentum.
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Site-of-Care Shift
Shifting appropriate procedures to lower-cost sites is essential to margin resiliency and patient preference. ASCs, micro-hospitals, and purpose-built MOBs can offload hospital fixed costs while improving access and experience. ASCs typically deliver procedures at materially lower cost than hospital outpatient departments, and carefully designed programs can protect inpatient capacity for acuity that truly requires it.
The key is not just building boxes but designing programs: surgeons with block-time governance, anesthesia and supply chain integration, and perioperative pathways that minimize delays. When joint replacement moves to an ASC with standardized prehab and post-op telemonitoring, inpatient burden falls and total episode cost declines. Done well, the site-of-care shift is a clinical win, a financial win, and a patient-experience win.
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Capital Program Prioritization
A credible capital plan stages investments by cash flow and clinical impact, funding mission-critical, margin-accretive projects first. Portfolio leaders can standardize templates and stage-gate approvals so that feasibility, underwriting, and design converge on the same thesis: the asset must earn its place on the balance sheet. Programmatic delivery—replicable imaging suites, urgent care pods, ASC room standards—speeds time-to-market and reduces design variance.
Sequencing matters. Start with quick-turn, revenue-positive ambulatory growth, then recycle gains into more complex expansions. Mitigate inflation risk with alternate bid packages and supply chain lock-ins; mitigate demand risk with modular designs that flex by specialty. When governance sees a disciplined, repeatable process, confidence rises and execution accelerates.
How to stage a capital program in four steps: 1) Establish a portfolio baseline with service-line P&Ls, market demand heatmaps, and capacity constraints. 2) Prioritize projects using a scorecard that weights strategic fit, EBITDA lift, access impact, and risk. 3) Stage-gate each project—feasibility, schematic, GMP, and pre-opening—tied to updated pro formas and sponsor sign-offs. 4) Operate a quarterly refresh that reorders and rightsizes projects based on cash flow, inflation, and competitor moves.
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Partnerships and JVs
Payer, physician, and post-acute partnerships can amplify scale and risk-sharing, but only when governance and economics are right. JV models should align incentives on quality, access, and cost, not just dividends. Clear performance rights, non-compete parameters, and dispute resolution playbooks reduce friction and safeguard continuity of care. The right JV turns a competitive threat into a growth engine.
Physician alignment is strongest when JV boards control block time, standardize implants where appropriate, and share performance data transparently. Payers can co-invest in access points that reduce avoidable ED use, tying incentives to medical-cost savings. With national health system partnerships, execution lessons travel quickly across markets, shortening ramp and standardizing results.
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Bremner Healthcare-Exclusive Advantage
Healthcare is our only business. Bremner has been healthcare-exclusive since 1989—built around fiduciary, clinical, and operational priorities—not mixed-use distractions. Our team was acquired by Duke Realty, validating market leadership and bringing the scale, capital agility, and rigor that complex systems require. That combination of focus and scale allows us to solve problems at system speed.
Decades of national health system partnerships mean we bring pattern recognition to your market while tailoring to local realities. We’ve structured JV ASCs, MOB programs, and micro-hospitals, and we’ve delivered $100M+ campus developments that anchor integrated service lines. The difference is not a project but a portfolio: network strategy tied to balance-sheet discipline, executed by a team that has done it repeatedly. Explore how we operate at bremnerrealestate.com.
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$100M+ Campus Developments
Large campuses must function as integrated hubs, not isolated buildings. Our $100M+ developments are programmed around service-line adjacency—imaging next to specialty clinics, rehab near orthopedics, labs within quick reach—so care pathways are literally built into the site plan. Phased financing preserves optionality: early phases drive access and revenue; later phases add acuity and specialized capacity as demand proves in.
Maintaining operations during construction is an execution discipline. Detailed decanting plans, swing spaces, and construction logistics that respect infection control and patient experience are non-negotiables. The problem of campus downtime is solved by phasing and temporary capacity solutions, yielding a smooth transition and avoided revenue loss. With program-level ROI and risk-managed schedules, campuses become durable growth platforms.
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Data-Driven Market Planning
Demand, leakage, and referral heatmaps reveal where patients seek care today and where capacity should be placed tomorrow. Prioritizing submarkets by margin yield—payer mix, service-line profitability, and growth velocity—creates a sequenced expansion plan that compounds returns. Dynamic scenario modeling and dashboards keep the plan live: when referral patterns shift or competitors move, the system can redeploy capital quickly.
If an AI could continuously re-optimize your site-of-care network based on payer mix, acuity, and travel-time friction, what facility decisions would it surface next quarter? The answer requires clean data, shared governance, and design standards that can pivot without re-litigating basics. Real-time analytics paired with flexible prototypes turn insight into openings, not just memos into meetings.
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Facilities for Care Integration
Facilities should enable team-based care by co-locating multispecialty clinics with diagnostics and rehab, allowing same-day workups and faster starts to therapy. Shared rooms and team pods drive higher utilization and collaboration, and when clinical engineering, pharmacy, and care management sit within the same hub, handoffs compress into minutes, not days. The outcome is greater throughput and fewer redundant visits.
Design details matter: universal exam rooms, on-stage/off-stage flows, embedded telehealth rooms, and patient-centric wayfinding. In one market, consolidating orthopedics, imaging, and PT into a streamlined ASC-MOB program solved referral leakage and yielded shorter pre-op cycles and faster return-to-function. When space serves the care model rather than dictating it, clinical integration becomes the default.
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Governance, Risk, Compliance
Strong governance ties portfolio decisions to strategy, risk appetite, and regulatory guardrails. Boards need clear line-of-sight from capital requests to quality, access, and financial outcomes. Adherence to Stark, the Anti-Kickback Statute, and fair market value standards must be embedded early—physician comps, space leases, and JV distributions aligned to policy and documentation. Project controls and change management keep scope aligned with intent and prevent late-stage drift.
Enterprise risk management should monitor construction cost indices, supply chain exposure, and schedule critical paths. With standard playbooks for procurement, vendor vetting, and scope changes, execution risk declines and predictability increases. Compliance isn’t a constraint; it’s an enabler of confidence that capital is being deployed responsibly.
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Partner with Healthcare Real Estate Strategists
The right partner co-creates a portfolio roadmap with milestones, economics, and accountabilities that your leadership can trust. Transparent economics—development yields, rent levels, escalation, and exit options—align incentives across administration, clinicians, and finance. A national team with turnkey delivery brings depth in planning, entitlement, capital markets, and program management, so portfolios move from concept to ribbon-cutting without loss of intent.
Because Bremner is healthcare-exclusive and backed by the scale validated through the Duke Realty acquisition, we deliver consistency across markets while honoring local nuance. Whether structuring a JV ASC, repositioning legacy campuses, or launching a multi-market ambulatory platform, we start with your objectives and build the path to them.
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Metrics That Matter
Metrics must connect to mission and margin. Network adequacy and market share gain show that access is real; EBITDA lift and capital efficiency confirm investments are earning their place; LOS reduction and access time cuts prove integration is changing outcomes. Dashboards should distinguish between build-phase leading indicators (entitlements, lease-up, schedule adherence) and operating-phase performance (volumes, yields, quality metrics).
A practical cadence might track: time-to-open against plan, first-year ramp versus pro forma, contribution margin by site, and patient travel-time improvement in targeted ZIPs. When leadership reviews these measures monthly, underperformers can be corrected early and top performers can be scaled systemwide. In short, measure what moves strategy—and stop measuring what doesn’t.
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FAQs
How does this impact our balance sheet? Lease-versus-own and JV structures shift capital intensity and control. We model debt-to-capitalization, days cash on hand, and ratings implications so boards can see trade-offs transparently and choose the best path per asset and market.
What CON risks could delay projects? Typical risks include insufficient demand evidence, staffing constraints, and competitive objections. We mitigate them with phased approvals, robust throughput and utilization studies, and community-need narratives supported by travel-time and leakage data.
Buy, lease, or JV for sites? The right structure depends on clinical volatility, capital priorities, and market power. Owning anchors, leasing flex nodes, and using JVs for select ASCs can balance control with agility.
Expected ROI and payback timeline? Ambulatory programs often ramp within 12–24 months; complex campuses phase over multiple years with staged returns. Pro formas link clinical volumes, payer mix, and expense curves to realistic paybacks.
How do we measure integration success? Track access times, care-transition completion rates, readmissions, and contribution margin by pathway, not just by site.
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Partner with Healthcare Real Estate Strategists
Bremner aligns care models, market access, and capital structure into a single, board-ready portfolio plan—leveraging healthcare-exclusive expertise since 1989, national health system partnerships, and the scale validated by the Duke Realty acquisition to deliver predictable outcomes from ambulatory nodes to $100M+ campuses. If your system is preparing for site-of-care shifts, CON filings, or multi-market ambulatory expansion, our fiduciary, data-driven approach turns strategy into open doors and durable returns.
Partner with healthcare real estate specialists for strategic guidance
