The Operators Who Regret Building and the Ones Who Don't

There is a consistent pattern in the conversations that happen after a project is done. Operators who built successfully talk about their facility the way they talk about a hiring decision that worked out: it changed the trajectory of the practice, it's hard to imagine operating without it, they wish they'd done it sooner. Operators who built and regret it tell a different story. Usually it's a story about debt that doesn't feel justified, a building that doesn't work the way they thought it would, or a project that took far longer and cost far more than planned.

The difference between those two outcomes is rarely the building itself. It's the framework the operator brought to the decision.

The operators who regret building almost always made the decision as an expense. They were comparing the cost of a new facility to the cost of staying put, and the calculation was essentially about what they were willing to spend. How much can I afford to borrow? How much will my mortgage payment be? How much is this going to hurt? That frame produces a project optimized for minimizing visible cost — which tends to mean building too small, cutting scope on things that matter, choosing the cheapest contractor available, and proceeding before the underlying economics of the practice actually support the investment.

The operators who don't regret it made the decision as an investment. They were comparing the revenue capacity of the new facility against the cost of debt service. How many more patients or clients can I see in the new space? What does that translate to in annual production? How long does it take for the new revenue to cover the new debt? That frame produces a project optimized for return — which tends to mean building the right size, not cutting the things that drive production capacity, choosing a team that can execute rather than just the cheapest quote, and waiting until the practice is actually ready to support the growth.

The expense mindset treats the building as overhead. The investment mindset treats the building as a revenue engine that happens to have a construction phase.

This isn't semantic. It produces different decisions at every stage. An operator who sees their facility as overhead asks "how can I spend less?" at every decision point. An operator who sees their facility as a revenue investment asks "what's the right thing here to maximize the return?" at every decision point. The first operator cuts operatories because they're expensive to build. The second operator adds operatories because each one is a revenue-generating asset. The first operator skips the architect-driven design process because it takes longer. The second operator invests in the design process because a building that operates efficiently generates more revenue per square foot.

Dr. Skjei built a practice that now sees 10,000 patients and generates over $4 million a year. That started with a design decision, made before ground was broken, about what the practice needed to grow. Dr. Titus tripled his new patient flow after moving into a purpose-built facility. Dr. Gleason saw production jump 50 to 60 percent. These outcomes don't happen by accident, and they didn't happen because these operators found the cheapest way to add square footage. They happened because the facility was designed and built as a production system, not as a cost center.

The expense vs. investment mindset also shows up in how operators approach financing. An operator who sees the building as expense treats the down payment requirement as a barrier — money out of the practice, gone. An operator who sees it as investment treats the financing question as: what structure allows me to preserve operating capital while still capturing the full return from the new facility? The answer to that question sometimes involves SBA financing, sometimes 100 percent construction-to-permanent programs, sometimes a structure the operator hadn't considered. The point is the question itself is different.

If you're trying to decide whether to build, the first question worth asking isn't "can I afford this?" It's "what does this build give me the capacity to produce, and does that production justify the investment?" Start with the return. The cost question becomes cleaner once you know the answer to that one.

For a real conversation about the economics of a project in your specific situation, primus-companies.com is the starting point.