Credit rating downgrades for several health systems were tied to capital expenditures and cash flow issues in recent months.
The following five health system credit rating downgrades occurred since July:
1. Tower Health (West Reading, Pa.) — lowered in September from “B+” to “CCC+” (Fitch Ratings) “The three-notch downgrade to ‘CCC+’ reflects Tower’s ongoing significant financial losses in fiscal 2022 … with an operating loss of $195 million, or a negative 1.8% operating EBITDA margin,” Fitch said. “Tower Health’s unrestricted liquidity position is also rapidly weakening, falling to just $341.5 million (when excluding $27.9 million in Medicare Advance funding), which results in a very weak cash-to-debt ratio of just 19%.”
2. ProMedica (Toledo, Ohio) — lowered in September from “Baa3” to “Ba2” (Moody’s Investors Service) “The downgrade to ‘Ba2’ reflects material cashflow losses this year, which exceeded Moody’s prior expectations, a significant drain of liquidity even with one-time cash infusions, and narrowing headroom to quarterly bank covenants,” Moody’s said. “In addition to severe losses in the nursing home and assisted living business, the provider business will need to reverse the year-to-date cashflow loss following solid margins in fiscal 2021. Both operations will continue to be challenged by high labor costs and related capacity constraints.”
3. Premier Health (Dayton, Ohio) — lowered in September from “A” to “A-” (Fitch Ratings) “The downgrade of [Premier Health’s] revenue bond rating and IDR to ‘A-‘ is driven by multiple years of weak operating cash flow generation … and coronavirus pandemic-related operating challenges that delayed the realization of improvements expected at Fitch’s last review,” the credit rating agency said.
4. MultiCare (Tacoma, Wash.) — lowered in August from “Aa3” to “A1” (Moody’s Investors Service) “The downgrade to A1 and the revision of the outlook to negative reflect a number of pressures which weaken MultiCare’s credit profile, including: an unexpected 24% increase in debt; a material decline in liquidity; very significant operating losses through the first six months of fiscal 2022; a pending acquisition which would initially be dilutive to credit metrics; and an ambitious capital plan which will entail sizable capital expenditures over the next five years,” Moody’s said. “Operations are expected to improve through the second half of fiscal 2022, but nevertheless full year results will remain weak, providing at best thin headroom to MultiCare’s debt service coverage covenant.”
5. Memorial Health System (Marietta, Ohio) — lowered in July from “BB-” to “B+” (Fitch Ratings) “The downgrade of the IDR to ‘B+’ reflects MHS’s weak net leverage profile through Fitch’s forward-looking scenario analysis given stated growth and spending objectives,” Fitch said. “While operating performance has stabilized over the past three years … and reflects cost efficiency strategies and pandemic relief funding, improved cash flow funded higher levels of capital spending in fiscals 2020 and 2021.”
Newport Beach, Calif.-based Hoag Memorial Hospital Presbyterian has received a $106 million donation from the Audrey Steele Burnand estate, The Orange County Reporter reported Sept. 14.
It is the largest donation in the hospital’s history. The estate has donated $134 million to the hospital throughout the years.
The donation will be used for innovation, growth and expansion of the hospital as well as research and improved patient care, according to the report.
“The Steele family’s decades of generosity, continued by the Audrey Steele Burnand estate, have benefited the Orange County community in immeasurable ways,” Flynn Andrizzi, PhD, president of the Hoag Hospital Foundation, said in a statement shared with the publication. “Through this remarkable gift, they once again have demonstrated their compassion for everyone who needs outstanding medical care.”
Hoag broke off a 10-year partnership with Renton, Wash.-based Providence earlier this year to place more focus on the community it serves, according to the publication.
St. Vincent Charity Medical Center in Cleveland will lay off 978 workers when it ends many services in November, according to a notice filed with state regulators.
The hospital, part of Sisters of Charity Health System, is ending inpatient care and most other services in November. After the transition, the facility will offer outpatient behavioral health, urgent care and primary care.
The health system attributed the changes to several factors, including the rise in demand for outpatient care, declining inpatient volume and shifts in the healthcare industry over the last 10 years that have made it challenging to continue operating St. Vincent Charity Medical Center as an acute care hospital.
The changes will result in 978 employees being laid off on Nov. 15, according to the notice filed with state regulators.
“This extremely difficult decision is being made with deep respect and gratitude for our caregivers, and we regret the direct impact this decision will have on those individuals,” reads the layoff notice from the hospital. “Unfortunately, the COVID pandemic, the changing health care landscape, and declining inpatient volumes have led to significant financial challenges that became impossible to overcome.”
The layoffs will affect 446 full-time workers, 264 part-time employees and 268 workers who are called into work as needed, a spokesperson for Sisters of Charity Health System told Becker’s Hospital Review.
St. Louis-based Ascension reported higher expenses in the 12 months ended June 30 and closed out the year with a loss, according to recently released financial documents.
The 144-hospital system reported operating revenue of $27.98 billion in the year ended June 30, up from $27.24 billion a year earlier.
Ascension’s operating expenses climbed to $28.77 billion in the 12 months ended June 30, up from $26.69 billion last year. The increase was attributed to several factors, including higher salaries, wages and benefits due to staffing challenges and increased use of contract and premium labor.
Ascension ended the most recent fiscal year with an operating loss of $879.2 million, compared to an operating income of $676.3 million a year earlier.
After factoring in nonoperating items, Ascension reported a net loss of $1.8 billion for the 12 months ended June 30. A year earlier, the health system posted net income of $5.7 billion.
Ascension is facing many of the same financial pressures as other health systems across the U.S. More than half of hospitals — 53 percent — are projected to have negative margins for the rest of the year.
A lawsuit filed last week accuses RWJBarnabas Health of “a years-long systemic effort” to hamper competition and monopolize acute care hospital services in northern New Jersey.
The case brought by CarePoint Health to a U.S. District Court accuses the state’s largest integrated healthcare delivery system of “aiming to destroy the three hospitals operated by CarePoint as independent competitors” with the support of healthcare real estate investors and Horizon Blue Cross Blue Shield, the state’s largest health insurer.
CarePoint Health includes the 349-bed Christ Hospital, 224-bed Bayonne Medical and 348-bed Hoboken University Medical Center (HUMC).
The group said RWJBarnabas intended to force the first two hospitals to shut down but acquire the third due to its more profitable payer mix.
“RWJBarnabas Health’s] goal explicitly disregarded the needs of the poor, underinsured and charity care patients which CarePoint serves in its role as the safety net hospital system in Jersey City and surrounding areas,” CarePoint wrote in the lawsuit.
The slew of alleged tactics listed in the lawsuit largely surround RWJBarnabas Health’s “serial acquisitions” of hospitals, providers and real estate that “has gone unchecked by the state and [New Jersey Department of Health],” CarePoint wrote.
This included an alleged bad faith proposal to acquire Christ Hospital and HUMC, the true intent of which CarePoint said was to “gain market knowledge and gather competitive intelligence, and use this newly-acquired information to freeze programmatic growth and any significant hiring or construction at Christ Hospital.” The process had a negative impact on CarePoint’s employee retention and staffing, according to the suit.
The plaintiff also alleged that RWJBarnabas used its political connections to influence whether state departments granted CarePoint Certificates of Need for multiple revenue-generating projects as well as COVID-19 relief funding.
Further, CarePoint accused RWJBarnabas of strategically adjusting its service offerings in competitive markets to drive uninsured or underinsured patients to CarePoint facilities while using its relationships with Horizon and ambulance operators to drive emergency room traffic and well-insured patients, respectively, to competing locations.
These collective actions constitute violations of the Sherman Antitrust Act as well as the New Jersey Antitrust Act, CarePoint wrote.
“The idea that [RWJBarnabas Health] would use its influence to jeopardize the health of that community and the care providers of a competing hospital not only directly contradicts its own vision, but clearly demonstrates that [RWJBarnabas Health] is far more interested in anti-competitive and predatory business activities than serving the New Jersey community,” CarePoint wrote.
RWJBarnabas Health discounted the allegations in an email statement.
“This is yet another in a series of baseless complaints filed by CarePoint, an organization whose leadership apparently prefers to assign blame to others rather than accept responsibility for the unsatisfactory results of their own poor business decisions and actions over the years,” a spokesperson for the system told Fierce Healthcare. “RWJBarnabas Health has a longstanding commitment to serve the residents of Hudson County, and is proud of the significant investments we have made in technology, facilities and clinical teams as we advance our mission.”
RWJBarnabas Health treats over 3 million patients per year and employs 37,000 people. The academic healthcare system runs 12 acute care hospitals and four specialty hospitals alongside other locations and services. It disclosed more than $6.6 billion in total operating revenues across 2021.
The system’s merger and acquisition activity placed it in the federal spotlight this past year after the Federal Trade Commission moved to block its planned integration of New Brunswick-based Saint Peter’s Healthcare System. The deal was called off in June.
About 15,000 nurses in Minnesota walked off the job Monday to protest understaffing and overwork — marking the largest strike of private-sector nurses in U.S. history.
Slated to last three days, the strike spotlights nationwide nursing shortages exacerbated by the coronavirus pandemic that often result in patients not receiving adequate care. Tensions remain high between nurses and health-care administrators across the country, and there are signs that work stoppages could spread to other states.
Minnesota nurses charge that some units go without a lead nurse on duty and that nurses fresh out of school are delegated assignments typically held by more experienced nurses, across some 16 hospitals where strikes are expected.
The nurses are demanding a role in staffing plans, changes to shift scheduling practices and higher wages.
“I can’t give my patients the care they deserve,” said Chris Rubesch, the vice president of the Minnesota Nurses Association and a nurse at Essentia Health in Duluth. “Call lights go unanswered. Patients should only be waiting for a few seconds or minutes if they’ve soiled themselves or their oxygen came unplugged or they need to go to the bathroom, but that can take 10 minutes or more. Those are things that can’t wait.”
Paul Omodt, a spokesman for the Twin Cities Hospital Group, which represents four hospital systems where nurses are striking in the Minneapolis-St. Paul area, said that the nurses union did not do everything it could to avoid a strike.
“Nurses have steadfastly refused to go to mediation,” Omodt said. “Their choice is to strike. This strike is on the nurses.”
Conny Bergerson, a spokeswoman for Allina Health, another hospital system in the Twin Cities where nurses are on strike, said “rushing to a strike before exhausting all options such as engaging a neutral federal mediator does not benefit our employees, patients or the communities we serve.”
The Minnesota Nurses Association, the nurses union, said hospital administrators have continued to “refuse solutions” on understaffing and safety in contract negotiations. It said nurses have increasingly been asked to take on more patients for bedside care to make up for labor shortages, exacerbating burnout and high turnover.
Some hospitals have offered increased safety protocols for reporting security incidents in negotiations, but have not budged on other safety- and staffing-related demands.
The union has proposed new mechanisms for nurses to have a stronger say in how wards are staffed, including a committee made up of nurses and management at each hospital that would determine appropriate staffing levels. It has also proposed protections against retaliation for nurses who report understaffing. Striking nurses at some hospitals said their shifts are often short five to 10 nurses, forcing nurses to take on more patients than they can handle.
Omodt said that while there was a rise in understaffing reports during the height of covid, conditions have improved, and nurses have made contradictory claims when it comes to staffing at their hospitals since then.
In the lead-up to the strike, Minnesota hospital groups filed unfair labor practices charges against the union for refusing to go to mediation, and asked the National Labor Relations Board to block the strike for a failure to provide enough notice. The NLRB has thrown out at least some of those charges.
Hospitals facing strikes have been recruiting traveling nurses from across the region and plan to maintain staffing levels during the strike, though they are preparing for reduced operations, according to some of the hospital groups facing strike activity.
For years, hospitals in the United States have faced understaffing problems. A surge in demand and increased safety risks for nurses during the pandemic accelerated those trends. The number of health-care workers in the United States has still not recovered to its pre-pandemic levels, down 37,000 workers compared with February 2020.
At the same time, demand for health-care services has steadily increased during the pandemic, with a backlog of people who delayed care now seeking medical attention. During the covid wave that swept across the United States this summer, states such as New York and Florida reported the worst nursing shortages in decades. Research shows that patients are more likely to die because of preventable reasons when health-care providers are overworked.
Nurses, who risked their lives during the pandemic, are quitting and retiring early in droves, because of increased workloads caused by short staffing and demanding schedules that make finding child care and having a life outside of work exceedingly difficult. The understaffing crisis is pronounced in Minnesota in part because of its aging population and its record low unemployment rate.
There are some signs that nurse- and other health-care-worker strikes could spill over to other states in the coming weeks. Four thousand nurses with the Michigan Nurses Association voted earlier this month to authorize a strike related to understaffing concerns, and 7,000 health-care workers in Oregon have also authorized a work stoppage. University of Wisconsin nurses narrowly averted a strike this week. Therapists and clinicians in Hawaii and California are currently in the fourth week of what has become the longest-running mental health care strike, over inadequate staffing levels.
In Minnesota, the Minnesota Nurses Association recorded a 300 percent increase in nurses’ reports of unsafe staffing levels on their shifts since 2014, up to 7,857 reports in 2021.
Kelley Anaas, 37, a nurse who works in the ICU at Abbott Northwestern in Minneapolis said nurses in her unit have been forced to double up on patient assignments and work with lead nurses who have less than a year of experience.
“It eats away at you. If that was my family member in that bed, I wouldn’t want to leave their side,” said Anaas, adding that her workload has increased steadily over her 14 years at Abbott Northwestern.
While the nurses say their main impetus for striking is staffing levels and not pay, they are also at odds with hospitals over wages. The Minnesota Nurses Association has proposed a 30 percent pay increase over the next three years, noting inflation is at a 40-year high, while health-care groups have proposed a pay increase of 10 to 12 percent.
“The union’s wage demands remain at 29 and 30 percent increases over three years, which we’ve told them is unrealistic and unaffordable,” Omodt said, noting that the average Minnesota nurse makes $80,960 a year.
Contracts expired in May and June, and the union has been in negotiations since March.
Nurses said they are frustrated the strike is happening, but the stakes are high for them and their patients.
“We’re really sad and disappointed that it has come to a strike,” said Brianna Hnath, a nurse at North Memorial in Robbinsdale. “But we feel like this is the only thing we can do to show administration how incredibly important a strong nursing core is to a hospital. Hospitals tell us it’s our fault, but we’ve been actively involved and getting nowhere.”
Many health systems are wondering if consumers are now leveraging new access points, including telemedicine, for low-acuity urgent care instead of going to the emergency department (ED), something which many experts are forecasting. For the graphic above, we partnered with healthcare software and analytics firm Strata Decision Technology to try to answer this question.
Using their national StrataSphere dataset for short-term acute care hospitals, we found that ED patient acuity levels in July 2022 were virtually identical to those in July 2019, though 2022 volumes were down by four percent.Admission and observation decisions across the two groups were also largely the same. We’ll be keeping our eye on the data to see if the story changes, as individuals who have delayed care over the last two and a half years now return, presenting to the ED with more advanced disease.
While current ED patients may not be more acute than before, the ongoing shortage of clinical labor may explain why some hospitals tell us that their EDs feel busier than ever. Measured by total worked hours of ED employees per adjusted patient day, the amount of labor dedicated to each patient requiring an overnight ED stay isdown around forty percent from 2019 across hospital EDs of all staffing levels. With fewer labor hours to go around, each team member on the floor now has more to do.
Here are 14 health systems with strong operational metrics and solid financial positions, according to reports from Fitch Ratings and Moody’s Investors Service.
1. Advocate Aurora Health has an “AA” rating and stable outlook with Fitch. The health system, dually headquartered in Milwaukee and Downers Grove, Ill., has a strong financial profile and a leading market position over a broad service area in Illinois and Wisconsin, Fitch said. The health system’s fundamental operating platform is strong, the credit rating agency said.
2. AnMed Health has an “AA-” rating and stable outlook with Fitch. The Anderson, S.C.-based system has a leading market share in most service lines, strong operating performance and very solid EBITDA margins, Fitch said.
3. Banner Health has an “AA-” rating and stable outlook with Fitch. The Phoenix-based health system’s core hospital delivery system and growth of its insurance division combine to make it a successful highly integrated delivery system, Fitch said. The credit rating agency said it expects Banner to maintain operating EBITDA margins of about 8 percent on an annual basis, reflecting the growing revenues from the system’s insurance division and large employed physician base.
4. Bon Secours Mercy Health has an “AA-” rating and stable outlook with Fitch. The Cincinnati-based health system has a broad geographic footprint as one of the five largest Catholic health systems in the U.S., a good payer mix and a leading or near leading market share in eight of its eleven markets in the U.S., Fitch said.
5. Lincoln, Neb.-based Bryan Health has an “AA-” rating and stable outlook with Fitch. The health system has a leading and growing market position, very strong cash flow and a strong financial position, Fitch said. The credit rating agency said Bryan Health has been resilient through the COVID-19 pandemic and is well-positioned to accommodate additional strategic investments.
6. Franciscan Alliance has an “AA” rating and stable outlook with Fitch. The Mishawaka, Ind.-based health system has a very strong cash position and maintains leading market shares in seven of its nine defined primary service areas, Fitch said. The health system benefits from a good payer mix, the credit rating agency said.
7. Gundersen Health System has an “AA-” rating and stable outlook with Fitch. The La Crosse, Wis.-based health system has strong balance sheet metrics and a leading market position and expanding operating platform in its service area, Fitch said. The credit rating agency expects the health system to return to strong operating performance as it emerges from disruption related to the COVID-19 pandemic.
8. Hackensack Meridian Health has an “AA-” rating and stable outlook with Fitch. The Edison, N.J.-based health system has shown consistent year-over-year increases in market share and has a solid liquidity position, Fitch said.
9. Falls Church, Va.-based Inova Health System has an “Aa2” rating and stable outlook with Moody’s. The health system has a consistently strong operating cash flow margin and ample balance sheet resources, Moody’s said. Inova’s financial excellence will remain undergirded by its favorable regulatory and economic environment, the credit rating agency said.
10. Salt Lake City-based Intermountain Healthcare has an “Aa1” rating and stable outlook with Moody’s. The health system has exceptional credit quality, which will continue to benefit from its leading market position in Utah, Moody’s said. The credit rating agency said the health system’s merger with Broomfield, Colo.-based SCL Health will give Intermountain greater geographic reach.
11. Omaha-based Nebraska Medicine has an “AA-” rating and stable outlook with Fitch. The health system has a strong market position and is the only public academic provider in Nebraska with high acuity services, Fitch said. The health system continues to generate positive operating cash flow levels, and it has modest flexibility to absorb additional debt, according to the credit rating agency.
12. Fort Wayne, Ind.-based Parkview Health has an “Aa3” rating and stable outlook with Moody’s. The health system has a leading market position with expansive tertiary and quaternary clinical services in northeastern Indiana and northwestern Ohio, Moody’s said. The credit rating agency said the stable outlook reflects management’s ability to generate strong operating performance during the pandement and with less favorable reimbursement rates.
13. UnityPoint Health has an “AA-” rating and stable outlook with Fitch. The Des Moines, Iowa-based health system has strong leverage metrics and cash position, Fitch said. The credit rating agency expects the health system’s balance sheet and debt service coverage metrics to remain robust.
14. Yale New Haven (Conn.) Health has an “AA-” rating and stable outlook with Fitch. The health system’s turnaround efforts, brand recognition and market presence will help it return to strong operating results, Fitch said.