Capital constraints, CON laws, and the shift to ambulatory care are reshaping value-based delivery. Leaders must hit the trinity of clinical outcomes, operational throughput, and financial performance while preserving ratings and liquidity. One question we’re hearing: How should our health system balance ambulatory expansion with acute-care investment to maximize capital efficiency and population health impact?
As healthcare-exclusive strategists since 1989—validated by our acquisition by Duke Realty—we integrate operations, population health, and capital planning to turn strategy into execution. Bremner leads strategic portfolio optimization that repositions underutilized space, frees trapped capital, and improves access—linking ROIC to care models and system goals. What follows is a CFO-ready, fiduciary playbook you can take to the board.
Health system leaders are confronting a trilemma: protect margins, expand access, and modernize facilities under value-based care and persistent capital constraints. The fastest ROI increasingly comes from repositioning underutilized space, right-sizing ambulatory networks, and embedding digital into the care model. As a healthcare-exclusive platform since 1989—validated by our acquisition by Duke Realty—and a partner to national health systems on $100M+ on and off-campus developments, Bremner translates strategy into measurable outcomes. What follows is a fiduciary, operations-forward playbook a CFO can take to the board.
Define Underutilized Asset ROI
Underutilized Asset ROI is the incremental return generated when a health system repositions, disposes, or reprograms space to a higher-value, mission-consistent use, net of capital and operating costs. In practice, this means aligning bricks and mortar with value-based service lines, expanding ambulatory capacity with convenient access, and standardizing rooms and flows that enable faster, safer throughput. The goal is simple: protect margins, free trapped capital, and improve patient access without compromising quality. Underutilized Asset ROI measures the incremental return from repurposing or monetizing space after all capital and operating costs.
Across markets, ambulatory volume growth continues to outpace inpatient by a factor of two, and telehealth utilization remains materially above pre-2020 baselines. More than two-thirds of U.S. states maintain Certificate of Need oversight, shaping both timing and sequencing. Ambulatory demand is growing roughly twice as fast as inpatient volume in most markets. What would your leadership team do differently if a predictive model could simulate service-line EBITDA by site, payer mix, and access elasticity before committing capital?
When fragmented scheduling and idle exam rooms constrain productivity, a unified access model and right-sized clinic layouts rapidly relieve bottlenecks and unlock margin, and care teams report fewer handoffs and higher patient satisfaction.
Portfolio Baseline and Data
A defensible portfolio strategy begins with a clear baseline: geospatial demand mapping, population health analytics, service-line leakage, and competitive encroachment. Layer in the cost of capital, current fair value by parcel, and a facilities condition index that quantifies deferred maintenance and renewal backlog. From there, utilization data—room turns, no-shows, throughput by hour—reveals where access and scheduling are the constraints rather than bricks and mortar.
We combine payer mix forecasts with submarket growth rates to prioritize sites that will win under value-based care. The result is a transparent heat map of where to densify, where to monetize, and where to exit. A practical definition emerges: the right asset is the one that advances the care model, clears hurdle rates after risk adjustment, and preserves balance-sheet flexibility. If the baseline shows material underperformance at a flagship clinic, cost of capital and fair value help determine whether to reinvest or redeploy.
How to stand up a portfolio baseline that drives action:
1) Map demand and leakage at the block-group level and tie to service-line economics.
2) Quantify asset health: FCI, fair value, lease terms, remaining useful life, and capex backlog.
3) Model scenarios by site for EBITDA, access elasticity, and risk-adjusted ROIC under multiple payer mixes.
4) Prioritize a 12–24 month action plan by densify/monetize/exit, sequenced to CON and capital availability.
For more on our approach and case examples, visit Bremner Healthcare Real Estate.
Health System Finance Priorities
Financial stewardship is the ultimate goal: balance-sheet-light positioning, disciplined ROIC targets, and public ratings optics that preserve debt capacity for mission-critical projects. We model expense-to-revenue ratios by site to expose where labor, lease obligations, or utilities are out of step with peer benchmarks, then evaluate productivity by room, by hour, and by care team. The objective is to sequence capital so that each tranche improves cash-to-debt, days cash on hand, and coverage metrics.
The practical question is which sites earn new dollars and which must release capital. Selective monetization can retire higher-cost debt or fund densification where access is constrained. A ratings-minded approach emphasizes predictable lease structures, proven operators, and risk-sharing where appropriate. By aligning ROIC targets with service-line economics, finance and operations can move together, not at cross-purposes. Sale-leaseback is best for non-core sites with durable demand, modest tenant improvements, and limited strategic control needs.
When a portfolio carries aging clinics with rising op ex, restructuring leases and reprogramming to higher-yield ambulatory services stabilizes the P&L, and the outcome is better ratings commentary and resilient margins.
CON and Regulatory Strategy
In CON-governed states, strategy is both a sequencing exercise and a narrative discipline. We plan densification through phased filings that logically connect to access needs, quality outcomes, and cost control. That often pairs inpatient right-sizing with ambulatory expansion so the clinical case and the community benefit are self-evident. Compliance extends to lease structures and JV models; alignment with fair market value and Stark/Anti-Kickback frameworks must be designed in, not inspected after.
We routinely reprogram obsolete beds into ambulatory surgery, infusion, or imaging suites where acuity and demand support the shift. This keeps the care model and the regulatory story coherent: higher-value settings, improved access, and lower total cost of care. A thorough early engagement with regulators, physicians, and community stakeholders reduces surprises at approval and opening.
When regulatory ambiguity slowed a campus plan, we reframed filings around ambulatory need, rephased inpatient modernization, and secured approvals faster, leading to a synchronized opening and stronger payer negotiations.
Care Model and Clinical Integration
Facilities are an operating system for care. Co-locating teams for integrated pathways—from primary care to specialty consult to procedure—reduces avoidable referrals, cuts cycle times, and strengthens outcomes. Incentives must align across clinically integrated networks so that scheduling, capacity allocation, and quality metrics reinforce value rather than volume alone. Standardized rooms, flows, and technology reduce training time, enable float coverage, and allow clinics to flex supply to demand.
We map the end-to-end patient journey and design spaces where handoffs are visible, room turns are predictable, and telehealth is embedded. Reliability improves when exam rooms are universal, pods are scalable, and diagnostics are adjacent to decision points. With this platform in place, network steering becomes a lever, not a constraint.
When specialists were scattered and consult waits crept higher, consolidating into an integrated hub with shared diagnostics solved the bottleneck, and the result was faster time-to-diagnosis and improved patient satisfaction scores.
Monetization Options and Timing
Monetization is a tool, not a thesis. Selective sale-leasebacks of non-core assets can surface equity, improve liquidity, and fund clinical priorities—provided the leases are aligned with service-line durability and contain renewal optionality. Where strategic control is paramount, joint ventures preserve decision rights while spreading capital requirements, balancing return with influence. Timing matters: market windows open and close, and interest rate dynamics shift the calculus between fixed and floating structures.
We evaluate each asset’s role in the care model, remaining useful life, and local demand signals. Assets supporting risk-bearing primary care or procedural growth often warrant control; legacy offices in saturated submarkets may be candidates for monetization. Clear communication to ratings agencies and bondholders supports the narrative that monetization enhances resilience, not short-term optics. Sale-leaseback is best used for non-core assets with stable demand and limited strategic control needs.
When a suburban MOB outgrew its clinical role, a sale-leaseback replaced deferred maintenance with cash and shifted capex to a new ASC; operating margins rose as payer-mix improved.
Redevelopment and Adaptive Reuse
The fastest way to create capacity is often within your own walls. Converting underused inpatient units to ambulatory hubs—ASC, endoscopy, infusion—places care where staff, utilities, and parking already exist. We assess structural grids, floor-to-floor heights, and MEP capacity to determine fit, then unlock air rights or adjoining parcels to densify campuses without disrupting critical operations. Phased construction with well-planned swing space keeps clinics open and revenue intact.
Adaptive reuse turns stranded assets into productive ones while minimizing greenfield risk. Standardizing modules across projects accelerates design and approvals, and procurement strategies can compress lead times for critical equipment. The community benefits when care moves closer, faster, and often at lower cost to patients and payers. With entitled sites and standardized designs, ambulatory facilities can open in 12–18 months.
When a legacy tower had chronic under-occupancy, repurposing two floors to procedural suites and imaging solved both the space and access issues, and the outcome was higher throughput with shorter patient travel times.
Ambulatory Network Optimization
An optimized ambulatory network is calibrated to population needs at the block group level. We right-size sites to match panel growth, acuity, and transit patterns, then align hours and staffing to demand curves by daypart. The aim is lower per-visit cost and a shift to appropriate sites of care, without sacrificing experience. Same-day and next-day scheduling capacity is designed into the portfolio, not improvised on the fly.
Clinic formats span micro-sites for access, standard hubs for diagnostics and procedures, and destination centers for complex ambulatory services. Each format carries a role in value-based contracts: steerable, measurable, and scalable. By placing services where leakage is highest, we reclaim revenue while improving community health metrics.
When appointment lag drove avoidable ED visits, embedding urgent access slots and coordinating transit routes solved avoidable utilization, and the result was a measurable decline in total cost of care for the attributed population.
Digital and Virtual Integration
Digital-first design reduces capital intensity and extends reach. We embed telehealth rooms, remote monitoring workflows, and asynchronous intake into clinic operations, cutting square footage while improving provider productivity. A flexible shell—with universal room standards, modular walls, and overspec’d pathways for power and data—future-proofs the portfolio as care models evolve.
Virtual care is not a separate network; it is an integrated layer that triages, escalates, and closes the loop on diagnostics and follow-up. By designing for hybrid journeys, we minimize unnecessary visits, right-size parking and lobbies, and free clinical staff to operate at top of license. This improves both patient experience and throughput.
When digital front doors were fragmented, consolidating platforms and dedicating tele-triage bays solved access friction, and the outcome was fuller schedules with fewer no-shows and better clinician utilization.
Capital Allocation and Governance
Governance turns strategy into repeatable outcomes. We establish stage gates that require clinical validation, demand signals, and capital efficiency before green-lighting projects. Hurdle rates reflect service-line risk and payer mix; ROIC is tracked post-opening to confirm that assumptions hold. A transparent PMO cadence, with vendor accountability and escalation paths, keeps delivery on time and on budget.
Board visibility is critical. Dashboards show spend against plan, schedule adherence, contingency draws, and early indicators like access, leakage capture, and staffing stability. Lessons learned cycle back into standards and contracts, reducing variability and improving speed. This is how portfolio transformation becomes an operating rhythm, not a one-off initiative.
When early budget creep surfaced on a multi-site build, enforcing stage-gate discipline and value engineering solved the variance, and the result was on-time delivery with preserved clinical scope.
Risk Management and Controls
Healthcare real estate carries embedded risks that must be modeled upfront. We scenario plan reimbursement shifts, labor inflation, and supply chain volatility, then hedge interest rate and credit exposure where appropriate. Safety, infection control, and downtime mitigation are designed into phasing and construction sequencing—particularly important on occupied campuses.
Contracting strategies distribute risk sensibly among owner, contractor, and vendors. Contingency is sized to complexity, and guarantees are linked to measurable outcomes. Business continuity plans cover IT redundancy, interim wayfinding, and surge capacity so that construction does not become a clinical disruption. The north star is resilience: facilities that perform under stress and adapt as care models and economics evolve.
When a rate spike threatened project feasibility, shifting to a mixed fixed-floating structure and locking materials early solved the financial risk, and the outcome was preserved scope with a stable long-run cost of capital.
Bremner Differentiators in Action
Since 1989, our singular focus has been healthcare. That healthcare-exclusive commitment is why national systems trust us to navigate the intersection of finance, operations, and care delivery. Our acquisition by Duke Realty validated market leadership, scale, and discipline—capabilities we deploy to reduce execution risk and accelerate speed-to-market. The combination of strategic acumen and delivery rigor is how we’ve executed $3.4B+ in healthcare real estate developments that integrate ambulatory, inpatient, and digital layers into one coherent platform.
We bring fiduciary accountability to each project, aligning with your capital plan, ratings strategy, and service-line priorities. Whether structuring JVs to preserve control or reprogramming obsolete beds into productive ambulatory hubs, we focus on measurable outcomes: ROIC, access, leakage reduction, quality, and total cost of care. This is not about buildings; it is about enabling your mission with infrastructure that pays its way.
When a flagship market demanded both densification and liquidity, our phased campus strategy solved the capital puzzle, and the outcome was accelerated growth with maintained ratings strength.
National Partnerships Advantage
Scale matters when speed and certainty are strategic. Our national health system partnerships create a shared playbook: standardized templates, vetted vendors, and payer-aligned strategies that travel across markets. With preferred sites and development-ready entitlements in key submarkets, we compress cycles from plan to opening and reduce soft costs through repetition and learning effects.
Joint ventures with local providers, academic affiliates, and payers are structured for aligned incentives and clear governance. Vendor coordination across regions secures supply, balances labor, and improves pricing. The result is speed-to-market with consistency—an essential advantage when competing for physicians, patients, and employers.
When a system sought simultaneous openings in three growth corridors, national vendor orchestration solved the procurement bottleneck, and the outcome was synchronized launches and rapid panel growth.
Metrics and Outcome Tracking
We measure what matters to finance, operations, and the community. At the asset level, IRR, NPV, and payback are tracked against proformas, while post-occupancy studies verify throughput, room turns, and staff productivity. On the market side, access metrics, leakage capture, and panel growth indicate whether the network is winning. Clinically, quality, readmissions, and total cost trends must confirm that the care model is delivering on value.
Dashboards link real estate actions to outcomes: did the ASC reduce inpatient utilization where appropriate; did a new diagnostic hub shorten time-to-diagnosis; did virtual integration decrease no-shows? Transparent reporting enables course correction and informs the next capital decision. This is ROI as an operating discipline, not an annual report artifact.
When early metrics revealed underutilized morning blocks, recalibrating clinic hours solved the mismatch, and the outcome was higher provider productivity and improved patient access.
Partner with Healthcare Real Estate Strategists
Transforming a portfolio is as much about governance and culture as it is about sites and capital. We co-develop a roadmap with your finance, clinical, and operations leaders, aligning incentives to system goals and establishing the cadence to move fast while de-risking execution. Our healthcare-exclusive focus since 1989, validated by the Duke Realty acquisition, means you access a team that speaks ratings, CON, and care model fluently.
From $100M+ de novo developments to nimble clinic conversions, we bring national partnerships and local execution together. The question is not whether to invest, but where each dollar produces the most mission and margin. With a rigorous baseline, disciplined capital allocation, and integrated delivery, your facilities become strategic assets—purpose-built for value-based care, clinical integration, and sustainable growth.
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