Prepared for lenders, CDCs, and federal agencies to SBA SOP 50 10 8, USDA 7 CFR Part 5001, and conventional underwriting standards. Fiduciary duty runs to the lender and the agency, never the borrower. 4,000+ engagements since 1998 covering $41.2 billion in evaluated project value. So far in 2026: 41 engagements and $1.54 billion evaluated — 17 SBA, 11 USDA.
Dialysis feasibility is census-driven and demographically anchored: end-stage renal disease prevalence in the service area, the nephrology referral base that directs patients, and station capacity arithmetic against treatment schedules. The study sizes the patient census from prevalence data and the local nephrology landscape, models station utilization across shifts, and prices treatments through the payer reality the category lives with — Medicare's bundled rate dominating volume while commercial patients carry the margin, a mix the pro forma must state explicitly rather than blend.
Census modeling from ESRD prevalence and referral analysis, station-capacity mathematics — patients per station across treatment shifts — payer-mix yield with the commercial share's outsized margin contribution quantified, and staffing builds at the nurse-and-technician ratios the modality requires.
Every Wert-Berater financial model is fully linked with no hardcoded values, so any reviewer can stress any input. Deliverables comprise a complete narrative report and the linked Excel model, with ten-year pro forma, sensitivity analysis at ±5, 10, and 15 percent, interest-rate stress from +0.5 to +3.0 percent, and ratio analysis benchmarked against RMA and IBISWorld data.
SBA engagements are prepared to SOP 50 10 8, including its debt-service-coverage minimums of 1.15x operating and 1.00x global. USDA engagements follow RD Staff Instruction 5001 across the Business & Industry, Community Facilities, REAP, and Value-Added Producer Grant programs. Conventional engagements are built to the lender's stated coverage standard, typically 1.20x. Independent and physician-affiliated centers fit SBA structures; the specialized buildout — water treatment, medical gas, generator — takes special-purpose treatment in collateral analysis across all programs.
The firm's clinical-facility practice supplies the specialized-infrastructure costing — water systems and redundancy engineering — the modality demands. Independence is non-negotiable: determinations follow the evidence and are not revised under pressure, and studies are built to pass lender, agency, and third-party review without exception items.
A dialysis center feasibility study is not a repurposed medical-office analysis. The scope is built around the operational realities of outpatient hemodialysis: fixed treatment schedules, station-constrained throughput, a narrow payer universe, and a physical plant that carries infrastructure costs no other ambulatory category matches. Every engagement addresses each of those dimensions explicitly before a single revenue line is projected.
Demand analysis for a dialysis center begins with epidemiology, not traffic counts. ESRD is a diagnosed, registered condition: patients are enrolled in the Medicare ESRD program, assigned to a network, and tracked by CMS. That enrollment data, cross-referenced with county-level prevalence estimates and state health department chronic-disease surveillance files, forms the quantitative foundation of the patient-census projection.
Competitive supply is assessed through the CMS Provider of Services file, which lists every Medicare-certified dialysis facility by address, certification date, and station count. State health department licensing registries and certificate-of-need databases — where the state maintains CON authority over dialysis facilities — identify approved-but-not-yet-open competitors that a simple facility count would miss. Planned facilities that have filed CON applications or received conditional approval represent forward supply and are treated as competitive constraint in the model.
The nephrology referral landscape is assessed through physician-level Medicare claims data and state medical board licensure files, which together identify the practicing nephrologists whose patient panels represent the realistic referral universe for the proposed center. Drive-time and road-network analysis establishes the service area boundary and tests whether the proposed site is accessible to the patient population it intends to serve — a material consideration given that dialysis patients travel to treatment three times per week. All source data is documented in the report appendix so any reviewer can trace every input to its origin.
Four inputs account for the majority of coverage-ratio movement in a dialysis center pro forma. Identifying them is straightforward; testing them rigorously is the work. Each is isolated in the fully linked Excel model so a reviewer can move any one independently and observe the effect on debt-service coverage without touching the others.
SBA underwriters reviewing a dialysis center under SOP 50 10 8 apply the standard 1.15x operating and 1.00x global debt-service-coverage minimums, but the asset-class characteristics that draw additional scrutiny are specific. The specialized buildout — water treatment, medical gas, emergency generator — is classified as special-purpose collateral, which affects the liquidation value assigned in the collateral analysis and raises the bar on the income-approach support the feasibility study must provide. An independent or physician-affiliated center must demonstrate that its referral base is durable and not concentrated in a single referring physician whose departure would impair census.
USDA Business & Industry and Community Facilities reviewers apply 7 CFR Part 5001 and are attentive to whether the proposed facility serves a genuinely underserved rural population. The study documents drive-time gaps to the nearest certified facility and quantifies the access burden on the existing patient population. That documentation is not supplementary; it is the rural-need finding the program requires.
Conventional lenders typically require 1.20x coverage and focus on the payer-mix assumption as the single most contestable input. A commercial-share assumption that exceeds the local market reality will be challenged; the study supports the assumed mix with market-specific data rather than national averages. Across all programs, lenders examine the ramp period: a center that projects full census in month three will not survive underwriting scrutiny, and the study models a realistic ramp supported by the referral-base analysis rather than an optimistic straight-line assumption.
The fixed fee is quoted within one business day of inquiry. There is no contingency arrangement and no fee structure tied to the study’s conclusion. The fiduciary duty runs to the lender and the reviewing agency; the borrower is the data source, not the client whose preferred outcome shapes the analysis.
The engagement begins with a data room request. For a dialysis center, the relevant materials include the proposed site address and service area definition, any executed or letter-of-intent lease or purchase documents, the business plan or operator profile, existing financial statements if the sponsor operates other facilities, the proposed loan amount and structure, and any CON filing or state licensing correspondence. A complete data room is the clock-start for the standard delivery window of 10 to 15 business days. Rush delivery is available and is quoted at the time of engagement. Incomplete data rooms extend the timeline; the engagement letter states what constitutes completeness.
Every financial model is published to a secure client portal as a live, fully linked Excel workbook with no hardcoded values. When a lender’s credit officer wants to test a different payer-mix assumption or a higher interest rate, the model recalculates in real time without requiring a revised deliverable request. The narrative report, the ten-year pro forma, the sensitivity tables, and the explicit statement of conditions are all delivered together. The statement of conditions is not a disclaimer; it is a precise enumeration of what must remain true for the projections to hold, written so that a reviewing agency can evaluate it as a standalone document.
The fee is fixed and quoted within one business day of inquiry. It does not vary with the study’s conclusion, and no portion is contingent on loan approval or a favorable finding. Because dialysis centers involve specialized infrastructure costing and a more complex payer-mix model than general medical office, the scope — and therefore the fee — reflects that additional analytical work.
Standard delivery is 10 to 15 business days from receipt of a complete data room. The clock starts when all required materials are in hand, not at engagement signing. Rush delivery is available and is priced and confirmed at the time of engagement. Incomplete submissions — missing CON correspondence, unresolved site questions, or absent operator financials — extend the timeline.
Three factors set dialysis apart. First, revenue is almost entirely determined by a federally administered bundled rate, so the commercial payer-mix assumption carries disproportionate weight and is heavily scrutinized. Second, the specialized buildout — water treatment, reverse osmosis, medical gas, emergency generator — is classified as special-purpose collateral with limited liquidation value. Third, census depends on a concentrated nephrology referral base whose stability must be independently assessed.
CON requirements for dialysis facilities vary by state; some states retain active CON authority over outpatient dialysis, others have eliminated it. Where CON applies, any approved-but-unopened competitor represents forward supply and is treated as a constraint in the demand model. The study documents the applicable regulatory environment and incorporates CON filings into the competitive-supply analysis rather than relying solely on currently licensed facilities.
Yes. Both independent and physician-affiliated centers fit SBA 7(a) and USDA Business & Industry structures. The feasibility study addresses the independence-specific underwriting concern directly: because an independent center lacks a corporate parent’s referral infrastructure, the study documents the depth and durability of the local nephrology referral base and models the effect of referral concentration on census stability.
The core data room includes the proposed site address and defined service area, any executed or letter-of-intent lease or purchase agreement, the business plan or operator profile, financial statements for any existing facilities the sponsor operates, the proposed loan amount and structure, and any state CON filing or licensing correspondence. The engagement letter specifies what constitutes a complete submission and is the clock-start for the delivery window.
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Wert-Berater, Inc. is an independent provider of feasibility studies and other related services. The firm does not provide financing or equity investment advice, and does not arrange, broker, or place debt or equity capital of any kind.
All appraisal assignments are performed by Bruce E. Jones, MAI, ASA-GC, BCA, CMEA, a member of the Appraisal Institute since 2006, a staff member of Wert-Berater, Inc. and owner of Special Purpose Realty Valuation.