Financial leadership for Missouri clinics operating in a post-CON-repeal capital deployment environment

How has the 2019 CON repeal actually played out for ASC owners?

Capital deployment timelines compressed (no CON application, no contested hearings, no delays from competing applicants). Competition increased correspondingly, particularly in orthopedics, GI, and ophthalmology across St. Louis County and Western Missouri. Practices that built ASCs in 2020 and 2021 in markets that have since seen multiple competing entrants need to refresh utilization assumptions and consider whether their original financial model accounts for a denser competitive environment. Joint-venture economics with BJC, SSM, Mercy, or HCA Midwest also work differently now because the systems no longer hold CON gatekeeping power.

We operate clinics in both Kansas City, MO and Overland Park, KS. What changes?

Almost everything. Provider licensure is state-specific. Medicaid enrollment differs (MO HealthNet versus KanCare). Payer contracts may be issued separately by state. State income tax filings and nexus rules require entity-level apportionment. Sales tax on medical supplies differs. Even practical things like jurisdictional limits on certain practice patterns differ between the two states. We treat each side of State Line Road as its own reporting unit and consolidate at the parent level so you get one strategic view of the business while preserving the state-level operational and tax detail.

Should we make the Missouri PTE election?

For most clinic owners with material Missouri-source income, yes, but the math should be modeled annually. The PTE election converts non-deductible state income tax into a deductible business expense at the entity level, restoring federal SALT-cap deductibility. The federal benefit depends on owners' federal marginal rates and the Missouri liability size. The election is generally beneficial for high-income owners, can be neutral for lower-income partners in mixed groups, and interacts with the federal QBI deduction in ways that need to be checked at the partner level.