American Shared Hospital Services (AMS) 10-Q 13 May 21 2021 Q1 Quarterly report Financial data

Cover Page

Cover Page - shares	3 Months Ended
	Mar. 31, 2021	May 03, 2021
Cover [Abstract]
Document Type	10-Q
Document Quarterly Report	true
Document Period End Date	Mar. 31, 2021
Document Transition Report	false
Entity File Number	001-08789
Entity Registrant Name	American Shared Hospital Services
Entity Incorporation, State or Country Code	CA
Entity Tax Identification Number	94-2918118
Entity Address, Address Line One	Two Embarcadero Center,
Entity Address, Address Line Two	Suite 410
Entity Address, City or Town	San Francisco,
Entity Address, State or Province	CA
Entity Address, Postal Zip Code	94111
City Area Code	415
Local Phone Number	788-5300
Title of 12(b) Security	American Shared Hospital Services Common Stock, No Par Value
Trading Symbol	AMS
Security Exchange Name	NYSEAMER
Entity Current Reporting Status	Yes
Entity Interactive Data Current	Yes
Entity Filer Category	Non-accelerated Filer
Entity Small Business	true
Entity Emerging Growth Company	false
Entity Shell Company	false
Entity Common Stock, Shares Outstanding		5,801,000
Amendment Flag	false
Document Fiscal Year Focus	2021
Document Fiscal Period Focus	Q1
Entity Central Index Key	0000744825
Current Fiscal Year End Date	--12-31

CONDENSED CONSOLIDATED BALANCE

CONDENSED CONSOLIDATED BALANCE SHEETS (Unaudited) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Current assets:
Cash and cash equivalents	$ 4,895	$ 3,961
Restricted cash	118	364
Accounts receivable, net of allowance for doubtful accounts of $100,000 at March 31, 2021 and $100,000 at December 31, 2020	4,792	4,303
Other receivables	280	272
Prepaid expenses and other current assets	1,364	1,950
Total current assets	11,449	10,850
Property and equipment:
Medical equipment and facilities	70,718	75,657
Office equipment	394	330
Construction in progress	1,178	170
Property and equipment, gross	72,290	76,157
Accumulated depreciation and amortization	(41,944)	(45,739)
Net property and equipment	30,346	30,418
Land	19	19
Goodwill	1,265	1,265
Right of use assets	812	886
Intangible asset	78	78
Other assets	78	137
Total assets	44,047	43,653
Current liabilities:
Accounts payable	885	683
Employee compensation and benefits	432	405
Other accrued liabilities	2,712	1,574
Asset Retirement Obligation, Current	1,214	1,270
Income taxes payable	399	373
Working capital payment due	197	197
Short term financing	355	471
Current portion of lease liabilities	310	305
Current portion of long-term debt	782	1,157
Current portion of finance leases	0	5,945
Total current liabilities	7,286	12,380
Long-term lease liabilities, less current portion	502	581
Long-term debt, less current portion	11,820	3,440
Long-term finance leases, less current portion	0	2,974
Deferred revenue, less current portion	193	210
Deferred income taxes	402	418
Shareholders' equity:
Common stock, no par value (10,000,000 authorized; 5,801,000 and 5,791,000 shares issued and outstanding at March 31, 2021 and at December 31, 2020, respectively)	10,753	10,753
Additional paid-in capital	7,131	7,024
Retained earnings	1,526	1,497
Total equity-American Shared Hospital Services	19,410	19,274
Non-controlling interests in subsidiaries	4,434	4,376
Total shareholders' equity	23,844	23,650
Total liabilities and shareholders' equity	$ 44,047	$ 43,653

CONDENSED CONSOLIDATED BALANC_2

CONDENSED CONSOLIDATED BALANCE SHEETS (Unaudited) [Parenthetical] - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Statement of Financial Position [Abstract]
Allowance for doubtful accounts (in dollars)	$ 100	$ 100
Common stock, par value (in dollars)	$ 0	$ 0
Common stock, shares authorized (in shares)	10,000,000	10,000,000
Common stock, shares issued (in shares)	5,801,000	5,791,000
Common stock, shares outstanding (in shares)	5,801,000	5,791,000

CONDENSED CONSOLIDATED STATEMEN

CONDENSED CONSOLIDATED STATEMENTS OF OPERATIONS (Unaudited) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Income Statement [Abstract]
Revenues	$ 4,364	$ 4,568
Costs of revenue:
Maintenance and supplies	672	633
Depreciation and amortization	1,198	1,647
Other direct operating costs	1,060	894
Costs of revenue	2,930	3,174
Gross margin	1,434	1,394
Selling and administrative expense	1,084	1,211
Interest expense	260	282
Operating income (loss)	90	(99)
Interest and other income	3	3
Income (loss) before income taxes	93	(96)
Income tax expense (benefit)	6	(28)
Net income (loss)	87	(68)
Less: Net (income) attributable to non-controlling interest	(58)	(67)
Net income (loss) attributable to American Shared Hospital Services	$ 29	$ (135)
Net income (loss) per share:
Earnings (loss) per common share - basic (in USD per share)	$ 0	$ (0.02)
Earnings (loss) per common share - diluted (in USD per share)	$ 0	$ (0.02)

CONDENSED CONSOLIDATED STATEM_2

CONDENSED CONSOLIDATED STATEMENT OF SHAREHOLDERS' EQUITY (Unaudited) - USD ($) $ in Thousands	Total	Common Stock	Additional Paid-in Capital	Retained Earnings	Sub-Total ASHS	Non-controlling Interests in Subsidiaries
Beginning balance (in shares) at Dec. 31, 2019		5,817,000
Beginning balance at Dec. 31, 2019	$ 31,811	$ 10,753	$ 6,725	$ 8,555	$ 26,033	$ 5,778
Increase (Decrease) in Stockholders' Equity
Stock-based compensation expense	56		56		56
Stock options, exercised (in shares)		(129,000)
Cash distributions to non-controlling interests	(326)					(326)
Net (loss) income	(68)			(135)	(135)	67
Ending balance (in shares) at Mar. 31, 2020		5,688,000
Ending balance at Mar. 31, 2020	$ 31,473	$ 10,753	6,781	8,420	25,954	5,519
Beginning balance (in shares) at Dec. 31, 2020	5,791,000	5,791,000
Beginning balance at Dec. 31, 2020	$ 23,650	$ 10,753	7,024	1,497	19,274	4,376
Increase (Decrease) in Stockholders' Equity
Stock-based compensation expense (in shares)		10,000
Stock-based compensation expense	107		107		107
Net (loss) income	$ 87			29	29	58
Ending balance (in shares) at Mar. 31, 2021	5,801,000	5,801,000
Ending balance at Mar. 31, 2021	$ 23,844	$ 10,753	$ 7,131	$ 1,526	$ 19,410	$ 4,434

CONDENSED CONSOLIDATED STATEM_3

CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS (Unaudited) - USD ($) $ in Thousands	3 Months Ended		12 Months Ended
	Mar. 31, 2021	Mar. 31, 2020	Dec. 31, 2019
Operating activities:
Net income (loss)	$ 87	$ (68)
Adjustments to reconcile net income (loss) to net cash from operating activities
Depreciation and amortization	1,231	1,676
Non cash lease expense	74	67
Deferred income taxes	(16)	(28)
Stock-based compensation expense	107	56	$ 108
Interest expense associated with lease liabilities	12	17
Changes in operating assets and liabilities:
Receivables	(497)	848
Prepaid expenses and other assets	551	557
Accounts payable, accrued liabilities and deferred revenue	1,294	383
Income taxes payable (receivable)	26	(35)
Lease liabilities	(86)	(84)
Net cash provided by operating activities	2,783	3,389
Investing activities:
Payment for purchase of property and equipment	(1,065)	(195)
Net cash used in investing activities	(1,065)	(195)
Financing activities:
Principal payments on long-term debt	(276)	(554)
Principal payments on finance leases	(638)	(912)
Principal payments on short-term financing	(116)	(158)
Distributions to non-controlling interests	0	(326)
Net cash used in financing activities	(1,030)	(1,950)
Net change in cash, cash equivalents, and restricted cash	688	1,244
Cash, cash equivalents, and restricted cash at beginning of period	4,325	1,779
Cash, cash equivalents, and restricted cash at end of period	5,013	3,023	$ 1,779
Supplemental cash flow disclosure:
Interest	260	282
Income taxes (refunded) paid	(4)	34
Schedule of non-cash investing and financing activities
Lease reassessment right of use assets and lease liabilities	0	67
Interest capitalized to property and equipment	0	32
Acquisition of equipment with long-term debt financing	$ 0	$ 1,184

Basis of Presentation

Basis of Presentation	3 Months Ended
	Mar. 31, 2021
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Basis of Presentation	Basis of Presentation In the opinion of management, the accompanying unaudited condensed consolidated financial statements contain all adjustments necessary for the fair presentation of American Shared Hospital Services’ consolidated financial position as of March 31, 2021, the results of its operations for the three-month periods ended March 31, 2021 and 2020, and the cash flows for the three-month periods ended March 31, 2021 and 2020. The results of operations for the three-months ended March 31, 2021 are not necessarily indicative of results on an annualized basis. Consolidated balance sheet amounts as of December 31, 2020 have been derived from audited consolidated financial statements. These unaudited condensed consolidated financial statements should be read in conjunction with the audited consolidated financial statements for the year ended December 31, 2020 included in American Shared Hospital Services’ Annual Report on Form 10-K filed with the Securities and Exchange Commission. These condensed consolidated financial statements include the accounts of American Shared Hospital Services and its subsidiaries (the “Company”) as follows: the Company wholly-owns the subsidiaries American Shared Radiosurgery Services (“ASRS”), PBRT Orlando, LLC (“Orlando”), OR21, Inc., and MedLeader.com, Inc. (“MedLeader”); the Company is the majority owner of Long Beach Equipment, LLC (“LBE”); ASRS is the majority-owner of GK Financing, LLC (“GKF”) which wholly-owns the subsidiary Instituto de Gamma Knife del Pacifico S.A.C. (“GKPeru”) and HoldCo GKC S.A. (“HoldCo”). GKF is the majority owner of the subsidiaries Albuquerque GK Equipment, LLC (“AGKE”) and Jacksonville GK Equipment, LLC (“JGKE”). GKF acquired Gamma Knife Center Ecuador S.A. (“GKCE”) through HoldCo in June 2020. The Company (through ASRS) and Elekta AB, the manufacturer of the Gamma Knife (through its wholly-owned United States subsidiary, GKV Investments, Inc.), entered into an operating agreement and formed GKF. As of March 31, 2021, GKF provides Gamma Knife units to thirteen medical centers in the United States in the states of Arkansas, California, Florida, Illinois, Indiana, Mississippi, Nebraska, New Mexico, New York, Ohio, Oregon, and Texas. GKF also owns and operates single-unit Gamma Knife facilities in Lima, Peru and Guayaquil, Ecuador. The Company through its wholly-owned subsidiary, Orlando, provided proton beam radiation therapy (“PBRT”) and related equipment to a customer in the United States. The Company formed the subsidiaries GKPeru and acquired GKCE for the purposes of expanding its business internationally; Orlando and LBE to provide PBRT equipment and services in Orlando, Florida and Long Beach, California, respectively; and AGKE and JGKE to provide Gamma Knife equipment and services in Albuquerque, New Mexico and Jacksonville, Florida, respectively. LBE is not expected to generate revenue within the next two years. On June 12, 2020, GKF purchased approximately 98% of the total outstanding shares of GKCE, from GKCE’s majority shareholders (the “Acquisition”). As of March 31, 2021, the Company had acquired approximately 99.3% of the total outstanding shares of GKCE. The base purchase price for the Acquisition, including acquisition of the minority shares was approximately $2,000,000. This purchase price was paid with $575,000 in cash and a $1,425,000 loan from the United States International Development Finance Corporation (“DFC”). The purchase price is subject to certain post-closing adjustments, including adjustment for GKCE's working capital and excess cash. The DFC loan is denominated in U.S. dollars, which is also the currency of Ecuador. See “Note 9. GKCE Acquisition” for further discussion. The Company continues to develop its design and business model for The Operating Room for the 21st Century SM through its 50% owned OR21, LLC (“OR21 LLC”). The remaining 50% is owned by an architectural design company. OR21 LLC is not expected to generate significant revenue for at least the next two years. MedLeader was formed to provide continuing medical education online and through videos for doctors, nurses, and other healthcare workers. This subsidiary is not operational at this time. All significant intercompany accounts and transactions have been eliminated in consolidation. The COVID-19 pandemic, the resulting recession in the United States and its follow-on effects have impacted and will likely continue to impact business activity across industries, including the Company’s. During 2020, due to factors related to the COVID-19 pandemic such as delays in service at medical facilities and restrictions imposed by government agencies, and the Company’s customers in response to the spread of COVID-19, the Company experienced some delays in delivering certain Gamma Knife procedures and PBRT treatments. Similarly, the Company’s ability to conduct commercial efforts with its customers have been and are likely to continue to be disrupted as customers have turned their focus to dealing with the impact of the COVID-19 pandemic on their operations and have restricted access to their sites in efforts to contain the spread of the virus. The global nature of the pandemic has resulted in authorities implementing numerous measures designed to contain the virus, including travel bans and restrictions, border closures, quarantines, shelter-in-place orders, business limitations and shutdowns. The impact of the COVID-19 pandemic on the global economy and capital markets is significant, and on June 8, 2020 the National Bureau of Economic Research announced that the United States was in an economic recession. An extended economic recession in the United States or elsewhere could have a material adverse effect on the Company’s ability to conduct its business and to access financing, as well as on the Company’s results of operation, financial condition, liquidity and cash flows. The prioritization of COVID-19 treatment and containment has resulted in delays in decisions by the Company’s customers and their patients, obstacles to the Company’s ability to market and deliver its services, declines in treatment volumes and adverse impacts to revenues for both Gamma Knife procedures and PBRT treatments. As a result of the pandemic and related governmental actions, Gamma Knife procedures and PBRT treatments, which currently make up all of the Company’s revenue, may be impacted differently at each of the Company’s various locations and may take longer to recover than other areas of the economy, which may have a material impact on the Company's business. The Company’s Gamma Knife operations in Latin America have experienced a decline in procedures due to the COVID-19 pandemic. Our Gamma Knife and PBRT operations in the United States have also experienced negative impacts from the COVID-19 pandemic. As the COVID-19 pandemic continues to develop, additional impacts may arise that we are not aware of currently. Based on the guidance provided in accordance with ASC 280 Segment Reporting (“ASC 280”), the Company analyzed its subsidiaries which are all in the business of leasing radiosurgery and radiation therapy equipment to healthcare providers, and concluded there are two reportable segments, domestic and foreign. The Company provides Gamma Knife and PBRT equipment to fourteen hospitals in the United States and owns and operates two single-unit facilities in Lima, Peru and Guayaquil, Ecuador as of March 31, 2021. The Company determined two reportable segments existed due to similarities in economics of business operations and geographic location. The operating results of the two reportable segments are reviewed by the Company’s CEO and President, Chief Operating and Financial Officer, who are also deemed the Company’s Chief Operating Decision Makers (“CODMs”). As of March 31, 2020, the Company had one reportable segment. Following the Company's acquisition of GKCE in June 2020, the Company concluded it had two reportable segments. The revenues and profit or loss, allocations for the Company's two reportable segments as of March 31, 2021 consists of the following: March 31, 2021 Revenues Domestic $ 3,699,000 Foreign 665,000 Total $ 4,364,000 Profit or (loss) Domestic $ 73,000 Foreign (44,000) Total $ 29,000 Accounting Pronouncements Issued and Adopted In December 2019, the FASB issued ASU 2019-12 Income Taxes (Topic 740): Simplifying the Accounting for Income Taxes (“ASU 2019-12”) which removes specific exceptions to the general principles in Topic 740 and eliminates the need for an organization to analyze whether the following apply in a given period: exception to the incremental approach for intraperiod tax allocation; exceptions to accounting for basis differences when there are ownership changes in foreign investments; exception in interim period income tax accounting for year-to-date losses that exceed anticipated losses. The new guidance is effective for fiscal years and interim periods beginning after December 15, 2020. The Company adopted ASU 2019-12 on January 1, 2021. There was no significant impact on its condensed consolidated financial statements and related disclosures.

Property and Equipment

Property and Equipment	3 Months Ended
	Mar. 31, 2021
Property, Plant and Equipment [Abstract]
Property and Equipment	Property and Equipment Property and equipment are stated at cost less accumulated depreciation. Depreciation for Gamma Knife units and other equipment is determined using the straight-line method over the estimated useful lives of the assets, which for medical and office equipment is generally 3 – 10 years, and after accounting for salvage value on the equipment where indicated. Salvage value is based on the estimated fair value of the equipment at the end of its useful life. Depreciation for PBRT equipment is determined using the modified units of production method, which is a function of both time and usage of the equipment. This depreciation method allocates costs considering the projected volume of usage through the useful life of the PBRT unit, which has been estimated at 20 years. The estimated useful life of the PBRT unit is consistent with the estimated economic life of 20 years. The following table summarizes property and equipment as of March 31, 2021 and December 31, 2020: March 31, December 31, 2021 2020 Medical equipment and facilities $ 70,718,000 $ 75,657,000 Office equipment 394,000 330,000 Construction in progress 1,178,000 170,000 72,290,000 76,157,000 Accumulated depreciation (41,944,000) (45,739,000) Net property and equipment $ 30,346,000 $ 30,418,000

Long-Term Debt Financing

Long-Term Debt Financing	3 Months Ended
	Mar. 31, 2021
Debt Disclosure [Abstract]
Long-term Debt Financing	Long-Term Debt Financing Long-term debt consisted of five notes with three financing companies collateralized by the Gamma Knife units, the individual customer contracts, and related accounts receivable at March 31, 2021. The Company’s loan with DFC for the Acquisition was obtained through the Company’s wholly-owned subsidiary, HoldCo and is guaranteed by GKF. As of March 31, 2021, long-term debt on the Condensed Consolidated Balance Sheets, before the refinancing, was $4,321,000. On April 9, 2021, the Company refinanced its existing debt and finance lease obligations, with the exception of its loan with DFC. A total of $8,281,000 of the Company’s finance leases were refinanced by long-term debt. Total long-term debt following this transaction was $12,602,000. The classification on the Condensed Consolidated Balance Sheets as of March 31, 2021 reflect the terms of the refinancing. See further details on the refinancing under Note 10 - Subsequent Event.

Finance Leases

Finance Leases	3 Months Ended
	Mar. 31, 2021
Debt Disclosure [Abstract]
Finance Leases	Finance Leases Finance lease obligations, before the refinancing, of $8,281,000 consisted of six leases with two financing companies, collateralized by Gamma Knife units and PBRT equipment, the individual customer contracts, and related accounts receivable at March 31, 2021. On April 9, 2021, the Company's finance lease obligations were refinanced by long-term debt. The classification on the Condensed Consolidated Balance Sheets as of March 31, 2021 reflect the terms of the refinancing. See further details on the refinancing under Note 10 - Subsequent Event.

Leases

Leases	3 Months Ended
	Mar. 31, 2021
Leases [Abstract]
Leases	Leases The Company determines if a contract is a lease at inception. Under ASC 842 Leases (“ASC 842”), the Company is a lessor of equipment to various customers. Leases that commenced prior to ASC 842 adoption date were classified as operating leases under historical guidance. As the Company has elected the package of practical expedients allowing it to not reassess lease classification, these leases are classified as operating leases under ASC 842 as well. All of the Company’s lessor arrangements entered into after ASC 842 adoption are also classified as operating leases. Some of these lease terms have an option to extend the lease after the initial term, but do not contain the option to terminate early or purchase the asset at the end of the term. The Company’s Gamma Knife and PBRT contracts with hospitals are classified as operating leases under ASC 842. The related equipment is included in medical equipment and facilities on the Company’s condensed consolidated balance sheets. As all income from the Company’s lessor arrangements is solely based on procedure volume, all income is considered variable payments not dependent on an index or a rate. As such, the Company does not measure future operating lease receivables. The Company’s lessee operating leases are accounted for as right-of-use (“ROU”) assets, other current liabilities, and lease liabilities on the condensed consolidated balance sheets. Operating lease ROU assets and liabilities are recognized based on the present value of the future minimum lease payments over the lease term at commencement date. The Company’s operating lease contracts do not provide an implicit rate for calculating the present value of future lease payments. The Company determined its incremental borrowing rate, to be in the range of approximately 4.0% and 6.0%, by using available market rates and expected lease terms. The operating lease ROU assets and liabilities also include any lease payments made and excludes lease incentives and initial direct costs incurred. Lease expense for minimum lease payments is recognized on a straight-line basis over the lease term. The Company’s lessee operating lease agreements are for administrative office space and related equipment, and the agreement to lease clinic space for its stand-alone facility in Lima, Peru. These leases have remaining lease terms between 2 and 3 years, some of which include options to renew or extend the lease. As of March 31, 2021, operating ROU assets and liabilities were $812,000. The following table summarizes maturities of lessee operating lease liabilities as of March 31, 2021: Year ending December 31, Operating Leases 2021 (excluding the three-months ended March 31, 2021) $ 261,000 2022 353,000 2023 248,000 2024 8,000 Total lease payments 870,000 Less imputed interest (58,000) Total $ 812,000

Per Share Amounts

Per Share Amounts	3 Months Ended
	Mar. 31, 2021
Earnings Per Share [Abstract]
Per Share Amounts	Per Share Amounts Per share information has been computed based on the weighted average number of common shares and dilutive common share equivalents outstanding. The computation for the three-month periods ended March 31, 2021 and 2020 excluded approximately 370,000 and 430,000, respectively, of the Company's stock options because the exercise price of the options was higher than the average market price during those periods. On March 31, 2020, the Company’s Award Agreements (as defined below) expired and the unvested performance share awards were returned to the Company’s stock incentive plan - see Note 7 for further discussion. Based on the guidance provided in accordance with ASC 260 Earnings Per Share (“ASC 260”), the weighted average common shares for basic earnings per share, for the three-month period ended March 31, 2020, excluded the weighted average impact of the unvested performance share awards. These awards were legally outstanding but not deemed participating securities and therefore were excluded from the calculation of basic earnings per share. The unvested shares were also excluded from the denominator for diluted earnings per share because they were considered contingent shares not deemed probable as of March 31, 2020. The following table sets forth the computation of basic and diluted earnings per share for the three-month periods ended March 31, 2021 and 2020: Three Months ended March 31, 2021 2020 Net income (loss) attributable to American Shared Hospital Services $ 29,000 $ (135,000) Weighted average common shares for basic earnings per share 6,254,000 6,126,000 Diluted effect of stock options and restricted stock awards 68,000 27,000 Weighted average common shares for diluted earnings per share 6,322,000 6,153,000 Basic earnings (loss) per share $ 0.00 $ (0.02) Diluted earnings (loss) per share $ 0.00 $ (0.02)

Stock-based Compensation

Stock-based Compensation	3 Months Ended
	Mar. 31, 2021
Share-based Payment Arrangement [Abstract]
Stock-based Compensation	Stock-based Compensation In June 2010, the Company’s shareholders approved an amendment and restatement of the Company’s stock incentive plan, renaming it the Incentive Compensation Plan (the “Plan”), and among other things, increasing the number of shares of the Company’s common stock reserved for issuance under the Plan to 1,630,000. The Plan provides that the shares reserved under the Plan are available for issuance to officers of the Company, other key employees, non-employee directors, and advisors. No further grants or share issuances will be made under the previous plans. On June 21, 2019, the Company’s shareholders approved an amendment and restatement of the Plan in order to extend the term of the Plan by two years to February 22, 2022. Stock-based compensation expense associated with the Company’s stock options to employees is calculated using the Black-Scholes valuation model. The Company’s stock awards have characteristics significantly different from those of traded options, and changes in the subjective input assumptions can materially affect the fair value estimates. The estimated fair value of the Company’s option grants is estimated using assumptions for expected life, volatility, dividend yield, and risk-free interest rate which are specific to each award. The estimated fair value of the Company’s options is expensed over the period during which an employee is required to provide service in exchange for the award (requisite service period), usually the vesting period. Accordingly, stock-based compensation cost before income tax effect for the Company’s options and restricted stock awards in the amount of $107,000 and $56,000 is reflected in net income (loss) for the three-month periods ended March 31, 2021 and 2020, respectively. At March 31, 2021, there was approximately $10,000 of unrecognized compensation cost related to non-vested share-based compensation arrangements granted under the Plan. This cost is expected to be recognized over a period of approximately three years. On January 4, 2017, the Company entered into a Performance Share Award Agreement with three executive officers of the Company (the “Award Agreements”) for 161,766 restricted stock awards which vest upon the achievement of certain performance metrics. The Award Agreements expired on March 31, 2020. Based on the guidance in ASC 718 Stock Compensation (“ASC 718”), the Company concluded these were performance-based awards with vesting criteria tied to performance metrics. As of December 31, 2019, the Company achieved one of those certain performance metrics under the Award Agreements and recognized stock compensation expense of approximately $108,000 related to these awards. The unrecognized stock-based compensation expense for these awards was approximately $434,000 and the unvested awards of approximately 129,000 shares were returned to the Plan as of March 31, 2020. The following table summarizes stock option activity for the three-month periods ended March 31, 2021 and 2020: Stock Grant Date Weighted- Intrinsic Outstanding at January 1, 2020 450,000 $ 2.78 2.44 $ 27,000 Outstanding at March 31, 2020 450,000 $ 2.78 2.20 $ — Exercisable at March 31, 2020 425,000 $ 2.79 2.00 $ — Outstanding at January 1, 2021 417,000 $ 2.79 1.61 $ 2,000 Outstanding at March 31, 2021 417,000 $ 2.79 1.36 $ 19,000 Exercisable at March 31, 2021 407,000 $ 2.80 1.27 $ —

Income Taxes

Income Taxes	3 Months Ended
	Mar. 31, 2021
Income Tax Disclosure [Abstract]
Income Taxes	Income TaxesThe Company generally calculates its effective income tax rate at the end of an interim period using an estimate of the annualized effective income tax rate expected to be applicable for the full fiscal year. However, when a reliable estimate of the annualized effective income tax rate cannot be made, the Company computes its provision for income taxes using the actual effective income tax rate for the results of operations reported within the year-to-date periods. The Company’s effective income tax rate is highly influenced by relative income or losses reported and the amount of the nondeductible stock-based compensation associated with grants of its common stock options and from the results of foreign operations. A small change in estimated annual pretax income (loss) can produce a significant variance in the annualized effective income tax rate given the expected amount of these items. As a result, the Company has computed its provision for income taxes for the three-month periods ended March 31, 2021 and 2020 by applying the actual effective tax rates to income or (loss) reported within the condensed consolidated financial statements through those periods.

GKCE Acquisition

GKCE Acquisition	3 Months Ended
	Mar. 31, 2021
Business Combinations [Abstract]
GKCE Acquisition	GKCE Acquisition On June 18, 2019, the Company entered into a Stock Purchase Agreement (the “Agreement”) to acquire Gamma Knife Center Ecuador S.A. (“GKCE”) from GKCE’s selling majority shareholders. GKCE is a well-established Gamma Knife operation founded in 2009 as a private clinic to introduce advanced stereotactic radiosurgery into Ecuador and continues to operate the only Gamma Knife unit in the country. The Company acquired GKCE for the continued expansion of its business internationally. The Acquisition has been accounted for according to ASC 805 Business Combinations (“ASC 805”) using the acquisition method of accounting. Under the acquisition method of accounting, all assets acquired, including goodwill and other intangible assets, should be stated at fair value at the time of acquisition. The allocation of purchase price consideration is preliminary, pending the completion of the fair value of certain tangible, intangible assets, and residual goodwill. During the measurement period, which can be no more than one year from June 12, 2020 (the “Closing Date”), the Company expects to continue to obtain information to assist in determining the final fair value of assets acquired. The assets acquired were recorded based on valuations derived from estimated fair value assessments and assumptions used by the Company. Thus, the provisional measurements of fair value discussed below are subject to change. As of March 31, 2021, accounting for the Closing Date accounts receivable balances, allowance on the uncollected accounts receivable balances, and related liabilities, was not complete. The accounting for these amounts will be complete following the twelve-month period after the Closing Date, per the terms of the Agreement. The Company expects to finalize the valuation as soon as practicable, but no later than one year from the Closing Date. While the Company believes its estimates and assumptions underlying the valuations are reasonable, different estimates and assumptions could result in different valuations assigned to the individual assets acquired, and the resulting amount of goodwill.

Subsequent Event

Subsequent Event	3 Months Ended
	Mar. 31, 2021
Subsequent Events [Abstract]
Subsequent Event	Subsequent Event On April 9, 2021 the Company entered into a five year $22.0 million credit agreement with Fifth Third Bank, N.A. (the “Credit Agreement”). The Credit Agreement includes three loan facilities. The first facility is a $9.5 million term loan of which $6.8 million was used to refinance the domestic Gamma Knife debt and finance leases, and associated closing costs, $1.6 million was used to finance two Gamma Knife reloads in the first quarter of 2021, with the remaining $1.1 million available for future projects. The second loan facility of $5.5 million was used to refinance the Company's PBRT finance leases, as well as to provide additional working capital. The third loan facility provides for a $7.0 million revolving line of credit available for future projects and general corporate purposes. The facilities carry a floating interest of LIBOR plus 3.0% and are collateralized by a blanket lien on substantially all of the Company's assets. The Credit Agreement contains customary covenants and representations, including without limitation, a minimum fixed charge coverage ratio of 1.25 and maximum funded debt to EBITDA ratio of 3.0 to 1.0 (tested on a trailing twelve-month basis at the end of each fiscal quarter), reporting obligations, limitations on dispositions, changes in ownership, mergers and acquisitions, indebtedness, encumbrances, distributions, investments, transactions with affiliates and capital expenditures

Basis of Presentation (Policies

Basis of Presentation (Policies)	3 Months Ended
	Mar. 31, 2021
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Basis of Presentation	Basis of Presentation In the opinion of management, the accompanying unaudited condensed consolidated financial statements contain all adjustments necessary for the fair presentation of American Shared Hospital Services’ consolidated financial position as of March 31, 2021, the results of its operations for the three-month periods ended March 31, 2021 and 2020, and the cash flows for the three-month periods ended March 31, 2021 and 2020. The results of operations for the three-months ended March 31, 2021 are not necessarily indicative of results on an annualized basis. Consolidated balance sheet amounts as of December 31, 2020 have been derived from audited consolidated financial statements. These unaudited condensed consolidated financial statements should be read in conjunction with the audited consolidated financial statements for the year ended December 31, 2020 included in American Shared Hospital Services’ Annual Report on Form 10-K filed with the Securities and Exchange Commission. These condensed consolidated financial statements include the accounts of American Shared Hospital Services and its subsidiaries (the “Company”) as follows: the Company wholly-owns the subsidiaries American Shared Radiosurgery Services (“ASRS”), PBRT Orlando, LLC (“Orlando”), OR21, Inc., and MedLeader.com, Inc. (“MedLeader”); the Company is the majority owner of Long Beach Equipment, LLC (“LBE”); ASRS is the majority-owner of GK Financing, LLC (“GKF”) which wholly-owns the subsidiary Instituto de Gamma Knife del Pacifico S.A.C. (“GKPeru”) and HoldCo GKC S.A. (“HoldCo”). GKF is the majority owner of the subsidiaries Albuquerque GK Equipment, LLC (“AGKE”) and Jacksonville GK Equipment, LLC (“JGKE”). GKF acquired Gamma Knife Center Ecuador S.A. (“GKCE”) through HoldCo in June 2020. The Company (through ASRS) and Elekta AB, the manufacturer of the Gamma Knife (through its wholly-owned United States subsidiary, GKV Investments, Inc.), entered into an operating agreement and formed GKF. As of March 31, 2021, GKF provides Gamma Knife units to thirteen medical centers in the United States in the states of Arkansas, California, Florida, Illinois, Indiana, Mississippi, Nebraska, New Mexico, New York, Ohio, Oregon, and Texas. GKF also owns and operates single-unit Gamma Knife facilities in Lima, Peru and Guayaquil, Ecuador. The Company through its wholly-owned subsidiary, Orlando, provided proton beam radiation therapy (“PBRT”) and related equipment to a customer in the United States. The Company formed the subsidiaries GKPeru and acquired GKCE for the purposes of expanding its business internationally; Orlando and LBE to provide PBRT equipment and services in Orlando, Florida and Long Beach, California, respectively; and AGKE and JGKE to provide Gamma Knife equipment and services in Albuquerque, New Mexico and Jacksonville, Florida, respectively. LBE is not expected to generate revenue within the next two years. On June 12, 2020, GKF purchased approximately 98% of the total outstanding shares of GKCE, from GKCE’s majority shareholders (the “Acquisition”). As of March 31, 2021, the Company had acquired approximately 99.3% of the total outstanding shares of GKCE. The base purchase price for the Acquisition, including acquisition of the minority shares was approximately $2,000,000. This purchase price was paid with $575,000 in cash and a $1,425,000 loan from the United States International Development Finance Corporation (“DFC”). The purchase price is subject to certain post-closing adjustments, including adjustment for GKCE's working capital and excess cash. The DFC loan is denominated in U.S. dollars, which is also the currency of Ecuador. See “Note 9. GKCE Acquisition” for further discussion. The Company continues to develop its design and business model for The Operating Room for the 21st Century SM through its 50% owned OR21, LLC (“OR21 LLC”). The remaining 50% is owned by an architectural design company. OR21 LLC is not expected to generate significant revenue for at least the next two years. MedLeader was formed to provide continuing medical education online and through videos for doctors, nurses, and other healthcare workers. This subsidiary is not operational at this time. All significant intercompany accounts and transactions have been eliminated in consolidation.
Accounting Pronouncements Issued and Adopted	Accounting Pronouncements Issued and Adopted In December 2019, the FASB issued ASU 2019-12 Income Taxes (Topic 740): Simplifying the Accounting for Income Taxes (“ASU 2019-12”) which removes specific exceptions to the general principles in Topic 740 and eliminates the need for an organization to analyze whether the following apply in a given period: exception to the incremental approach for intraperiod tax allocation; exceptions to accounting for basis differences when there are ownership changes in foreign investments; exception in interim period income tax accounting for year-to-date losses that exceed anticipated losses. The new guidance is effective for fiscal years and interim periods beginning after December 15, 2020. The Company adopted ASU 2019-12 on January 1, 2021. There was no significant impact on its condensed consolidated financial statements and related disclosures.

Basis of Presentation (Tables)

Basis of Presentation (Tables)	3 Months Ended
	Mar. 31, 2021
Organization, Consolidation and Presentation of Financial Statements [Abstract]
Schedule of Revenue from External Customers and Long-Lived Assets, by Geographical Areas	The revenues and profit or loss, allocations for the Company's two reportable segments as of March 31, 2021 consists of the following: March 31, 2021 Revenues Domestic $ 3,699,000 Foreign 665,000 Total $ 4,364,000 Profit or (loss) Domestic $ 73,000 Foreign (44,000) Total $ 29,000

Property and Equipment (Tables)

Property and Equipment (Tables)	3 Months Ended
	Mar. 31, 2021
Property, Plant and Equipment [Abstract]
Summary of property and equipment	The following table summarizes property and equipment as of March 31, 2021 and December 31, 2020: March 31, December 31, 2021 2020 Medical equipment and facilities $ 70,718,000 $ 75,657,000 Office equipment 394,000 330,000 Construction in progress 1,178,000 170,000 72,290,000 76,157,000 Accumulated depreciation (41,944,000) (45,739,000) Net property and equipment $ 30,346,000 $ 30,418,000

Leases (Tables)

Leases (Tables)	3 Months Ended
	Mar. 31, 2021
Leases [Abstract]
Summary of maturities of lessee operating lease	The following table summarizes maturities of lessee operating lease liabilities as of March 31, 2021: Year ending December 31, Operating Leases 2021 (excluding the three-months ended March 31, 2021) $ 261,000 2022 353,000 2023 248,000 2024 8,000 Total lease payments 870,000 Less imputed interest (58,000) Total $ 812,000

Per Share Amounts (Tables)

Per Share Amounts (Tables)	3 Months Ended
	Mar. 31, 2021
Earnings Per Share [Abstract]
Schedule of earnings per share, basic and diluted	The following table sets forth the computation of basic and diluted earnings per share for the three-month periods ended March 31, 2021 and 2020: Three Months ended March 31, 2021 2020 Net income (loss) attributable to American Shared Hospital Services $ 29,000 $ (135,000) Weighted average common shares for basic earnings per share 6,254,000 6,126,000 Diluted effect of stock options and restricted stock awards 68,000 27,000 Weighted average common shares for diluted earnings per share 6,322,000 6,153,000 Basic earnings (loss) per share $ 0.00 $ (0.02) Diluted earnings (loss) per share $ 0.00 $ (0.02)

Stock-based Compensation (Table

Stock-based Compensation (Tables)	3 Months Ended
	Mar. 31, 2021
Share-based Payment Arrangement [Abstract]
Summary of stock option activity	The following table summarizes stock option activity for the three-month periods ended March 31, 2021 and 2020: Stock Grant Date Weighted- Intrinsic Outstanding at January 1, 2020 450,000 $ 2.78 2.44 $ 27,000 Outstanding at March 31, 2020 450,000 $ 2.78 2.20 $ — Exercisable at March 31, 2020 425,000 $ 2.79 2.00 $ — Outstanding at January 1, 2021 417,000 $ 2.79 1.61 $ 2,000 Outstanding at March 31, 2021 417,000 $ 2.79 1.36 $ 19,000 Exercisable at March 31, 2021 407,000 $ 2.80 1.27 $ —

Basis of Presentation (Details)

Basis of Presentation (Details) $ in Thousands	Jun. 12, 2020USD ($)	Mar. 31, 2021segmentmedicalCenter
Medical centers | medicalCenter		13
Number of reportable segments | segment		2
GKCE acquisition
Asset acquisition, percentage of shares acquired	98.00%	99.30%
Asset acquisition, consideration transferred	$ 2,000
Payments for asset acquisitions	575
Asset acquisition, transaction costs	$ 1,425
OR21 LLC
Equity method investment, ownership percentage		50.00%
Architectural design company
Equity method investment, ownership percentage		50.00%

Basis of Presentation - Schedul

Basis of Presentation - Schedule of Revenue from External Customers and Long-Lived Assets, by Geographical Areas (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Accounting Policies [Line Items]
Revenues	$ 4,364	$ 4,568
Net income (loss)	29	$ (135)
Revenues
Accounting Policies [Line Items]
Revenues	4,364
Net Income (Loss)
Accounting Policies [Line Items]
Net income (loss)	29
Domestic | Revenues
Accounting Policies [Line Items]
Revenues	3,699
Domestic | Net Income (Loss)
Accounting Policies [Line Items]
Net income (loss)	73
Foreign | Revenues
Accounting Policies [Line Items]
Revenues	665
Foreign | Net Income (Loss)
Accounting Policies [Line Items]
Net income (loss)	$ (44)

Property and Equipment (Details

Property and Equipment (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2021	Dec. 31, 2020
Property, Plant and Equipment [Line Items]
Net property and equipment	$ 30,346	$ 30,418
Outside of the United States
Property, Plant and Equipment [Line Items]
Net property and equipment	$ 3,064
Medical equipment and facilities | Minimum
Property, Plant and Equipment [Line Items]
Useful life	3 years
Medical equipment and facilities | Maximum
Property, Plant and Equipment [Line Items]
Useful life	10 years
PBRT equipment
Property, Plant and Equipment [Line Items]
Useful life	20 years

Property and Equipment - Summar

Property and Equipment - Summary of Property and Equipment (Details) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Property, Plant and Equipment [Line Items]
Property and equipment, gross	$ 72,290	$ 76,157
Accumulated depreciation	(41,944)	(45,739)
Net property and equipment	30,346	30,418
Medical equipment and facilities
Property, Plant and Equipment [Line Items]
Property and equipment, gross	70,718	75,657
Office equipment
Property, Plant and Equipment [Line Items]
Property and equipment, gross	394	330
Construction in progress
Property, Plant and Equipment [Line Items]
Property and equipment, gross	$ 1,178	$ 170

Long-Term Debt Financing (Detai

Long-Term Debt Financing (Details) $ in Thousands	Apr. 09, 2021USD ($)	Mar. 31, 2021USD ($)note
Debt Instrument [Line Items]
Number of debt instruments | note		5
Long-term debt		$ 4,321
Finance lease obligations		$ 8,281
Subsequent Event
Debt Instrument [Line Items]
Long-term debt	$ 12,602

Finance Leases (Details)

Finance Leases (Details) $ in Thousands	Mar. 31, 2021USD ($)financingCompanylease
Debt Disclosure [Abstract]
Finance lease obligations | $	$ 8,281
Number of financing leases | lease	6
Number of financing companies | financingCompany	2

Leases (Details)

Leases (Details) - USD ($) $ in Thousands	Mar. 31, 2021	Dec. 31, 2020
Operating Leased Assets [Line Items]
Operating lease, right-of-use asset	$ 812	$ 886
Minimum
Operating Leased Assets [Line Items]
Lessee, operating lease, discount rate	4.00%
Remaining lease term	2 years
Maximum
Operating Leased Assets [Line Items]
Lessee, operating lease, discount rate	6.00%
Remaining lease term	3 years

Leases - Summary of Maturities

Leases - Summary of Maturities of Lessee Operating Lease (Details) $ in Thousands	Mar. 31, 2021USD ($)
Leases [Abstract]
2021 (excluding the three-months ended March 31, 2021)	$ 261
2022	353
2023	248
2024	8
Total lease payments	870
Less imputed interest	(58)
Total	$ 812

Per Share Amounts (Details)

Per Share Amounts (Details) - shares shares in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Warrant
Antidilutive Securities Excluded from Computation of Earnings Per Share [Line Items]
Amount of antidilutive securities excluded from computation (in shares)	370	430

Per Share Amounts - Schedule of

Per Share Amounts - Schedule of Earnings Per Share, Basic and Diluted (Details) - USD ($) $ / shares in Units, shares in Thousands, $ in Thousands	3 Months Ended
	Mar. 31, 2021	Mar. 31, 2020
Earnings Per Share [Abstract]
Net income (loss) attributable to American Shared Hospital Services	$ 29	$ (135)
Weighted average common shares for basic earnings per share (in shares)	6,254	6,126
Diluted effect of stock options and restricted stock (in shares)	68	27
Weighted average common shares for diluted earnings per share (in shares)	6,322	6,153
Basic earnings (loss) per share (in USD per share)	$ 0	$ (0.02)
Diluted earnings (loss) per share (in USD per share)	$ 0	$ (0.02)

Stock-based Compensation (Detai

Stock-based Compensation (Details) - USD ($) $ in Thousands	Jan. 04, 2017	Mar. 31, 2021	Mar. 31, 2020	Dec. 31, 2019	Jun. 30, 2010
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Stock-based compensation expense		$ 107	$ 56	$ 108
Nonvested awards, unrecognized stock-based compensation expense		$ 434
Expected term for cost to be recognized (in years)		3 years
Incentive compensation plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Common stock reserved for issuance (in shares)					1,630,000
Nonvested awards, unrecognized stock-based compensation expense		$ 10
Performance share award agreement
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Restricted stock awards (in shares)	161,766
Unvested awards (in shares)		129,000

Stock-based Compensation - Summ

Stock-based Compensation - Summary of Stock Option Activity (Details) - USD ($) $ / shares in Units, shares in Thousands, $ in Thousands	Dec. 31, 2020	Dec. 31, 2019	Mar. 31, 2021	Mar. 31, 2020
Stock Options
Stock options, outstanding beginning balance (in shares)			417	450
Stock options, outstanding ending balance (in shares)	417	450	417	450
Stock options, exercisable (in shares)			407	425
Grant Date Weighted- Average Exercise Price
Grant date weighted-average exercise price, beginning balance (in USD per share)			$ 2.79	$ 2.78
Grant date weighted-average exercise price, ending balance (in USD per share)	$ 2.79	$ 2.78	2.79	2.78
Grant date weighted average exercise price, exercisable (in USD per share)			$ 2.80	$ 2.79
Weighted- Average Remaining Contractual Life (in Years)
Weighted average remaining contractual life (years), beginning balance	1 year 7 months 9 days	2 years 5 months 8 days	1 year 4 months 9 days	2 years 2 months 12 days
Weighted average remaining contractual life (years), ending balance	1 year 7 months 9 days	2 years 5 months 8 days	1 year 4 months 9 days	2 years 2 months 12 days
Weighted average remaining contractual life (years), exercisable			1 year 3 months 7 days	2 years
Intrinsic Value
Intrinsic value, outstanding beginning balance	$ 2	$ 27	$ 19	$ 0
Intrinsic value, outstanding ending balance	$ 2	$ 27	19	0
Intrinsic value, exercisable end of period			$ 0	$ 0

GKCE Acquisition - Narrative (D

GKCE Acquisition - Narrative (Details) - GKCE acquisition $ in Thousands	12 Months Ended
	Dec. 31, 2020USD ($)
Business Acquisition [Line Items]
Asset acquisition, accounts receivable	$ 27
Liabilities assumed	13
Increase in amount of contingent consideration	$ 14

Subsequent Event (Details)

Subsequent Event (Details) $ in Thousands	Apr. 09, 2021USD ($)loan_facility	Mar. 31, 2021USD ($)note	Dec. 31, 2020USD ($)
Subsequent Event [Line Items]
Number of debt instruments | note		5
Short-term debt and finance lease obligations		$ 6,669
Current portion of debt		782	$ 1,157
First Credit Facility
Subsequent Event [Line Items]
Proceeds used to refinance domestic Gamma Knife debt, finance leases and associated costs		$ 1,600
Subsequent Event | Fifth Third Bank Credit Agreement | London Interbank Offered Rate (LIBOR)
Subsequent Event [Line Items]
Basis spread on variable rate	3.00%
Subsequent Event | Fifth Third Bank Credit Agreement | Line of Credit
Subsequent Event [Line Items]
Debt instrument (in years)	5 years
Line of credit facility, maximum borrowing capacity	$ 22,000
Number of debt instruments | loan_facility	3
Fixed charge coverage ratio	1.25
Debt to EBITDA ratio	3
Subsequent Event | First Credit Facility
Subsequent Event [Line Items]
Proceeds used to refinance domestic Gamma Knife debt, finance leases and associated costs	$ 6,800
Remaining available amount that can be borrowed	1,100
Subsequent Event | First Credit Facility | Line of Credit
Subsequent Event [Line Items]
Line of credit facility, maximum borrowing capacity	9,500
Subsequent Event | Second Credit Facility | Line of Credit
Subsequent Event [Line Items]
Line of credit facility, maximum borrowing capacity	5,500
Subsequent Event | Third Credit Facility | Line of Credit
Subsequent Event [Line Items]
Line of credit facility, maximum borrowing capacity	$ 7,000