12 hospitals laying off workers in response to COVID-19

https://www.beckershospitalreview.com/finance/12-hospitals-laying-off-workers-in-response-to-covid-19.html?utm_medium=email

Facing a financial squeeze, hospitals nationwide are cutting jobs

To address the financial fallout from the COVID-19 pandemic, hospitals across the nation are looking to cut costs by implementing furloughs, layoffs or pay cuts. 

U.S. hospitals are expected to lose $323.1 billion this year due to the pandemic, according to a recent report from the American Hospital Association. The total includes $120.5 billion in financial losses that hospitals are projected to see from July through December, as well as $202.6 billion in losses that were projected between March and June. The losses were largely due to a lower patient volume after canceling elective procedures. 

Although Congress allocated $175 billion to help hospitals offset some of the revenue losses and expense increases to prepare for the pandemic, hospitals have said it is not enough.

Nearly 270 hospitals and health systems have furloughed workers in response to the pandemic and several others have implemented layoffs. 

Below are 12 hospitals and health systems that have announced layoffs since June 1:

1. Trinity Health furloughs, lays off another 1,000 workers
Trinity Health, a 92-hospital system based in Livonia, Mich., will lay off and reduce work schedules of 1,000 employees.

2. Ohio children’s hospital cuts jobs
Dayton (Ohio) Children’s Hospital said it has cut jobs to help offset financial losses due to the COVID-19 pandemic.

3. Munson Healthcare to cut 25 leadership positions
Traverse City, Mich.-based Munson Healthcare cut 25 leadership positions to help offset financial losses amid the COVID-19 pandemic.

4. Erlanger lays off 93 nonclinical employees
Chattanooga, Tenn.-based Erlanger Health System has cut 93 nonclinical positions to help offset financial damage from the COVID-19 pandemic. The layoffs come after the health system cut 11 leadership positions June 12, including the CEO of Erlanger Western Carolina Hospital in Murphy, N.C., and made staff and pay cuts in March.

5. Michigan Medicine to lay off 738 employees by end of June
Ann Arbor-based Michigan Medicine planned to eliminate 738 positions by the end of June amid financial challenges from the COVID-19 pandemic.

6. Pennsylvania health system cuts 10% of workforce amid pandemic losses
As part of a restructuring effort to cut pandemic-related losses, State College, Pa.-based Mount Nittany Health System plans to lay off 10 percent of its workforce, or about 250 employees.

7. TriHealth eliminates 440 positions to cut costs
Cincinnati-based TriHealth cut 440 positions as part of a plan to trim at least $140 million in expenditures this year.

8. Layoffs hit U of Kansas Health System
The University of Kansas Health System St. Francis Campus in Topeka laid off employees after previously implementing furloughs.

9. Tower Health to cut 1,000 jobs
Citing a $212 million loss in revenue through May due to the COVID-19 pandemic, West Reading, Pa.-based Tower Health plans to cut 1,000 jobs.

10. Colorado hospital cuts 22 positions
Parkview Medical Center in Pueblo, Colo., eliminated 22 positions in response to the COVID-19 pandemic.

11. Arkansas Children’s cuts 42 positions
Little Rock-based Arkansas Children’s Hospital said it is eliminating 42 jobs as part of cost-savings measures in response to the COVID-19 pandemic.

12. North Carolina health system cuts 10% of workforce, closes clinics
Citing a financial hit from the COVID-19 pandemic, Lumberton, N.C.-based Southeastern Health will permanently close several clinics, cut 10 percent of its workforce and reduce executive pay.

 

 

COVID-19 to cost hospitals $323 billion, American Hospital Association says

https://www.beckershospitalreview.com/finance/covid-19-to-cost-hospitals-323-billion-american-hospital-association-says.html?utm_medium=email

Catastrophic financial impact of COVID-19 expected to top $323 ...

Hospitals will lose $323.1 billion this year because of the COVID-19 pandemic, according to a new report from the American Hospital Association. 

The total includes $120.5 billion in financial losses the association predicts hospitals will see from July through December on top of $202.6 billion in losses they estimated between March and June. The losses are in large part due to lower patient volumes.

“While potentially catastrophic, these projected losses still may underrepresent the full financial losses hospitals will face in 2020, as the analysis does not account for currently increasing case rates in certain states, or potential subsequent surges of the pandemic occurring later this year,” the AHA said.

Hospitals and health systems are reporting an average decline of 19.5 percent in inpatient volume and 34.5 percent in outpatient volume when compared to baseline levels from last year. Most hospitals don’t expect to return to last year’s levels in 2020.

Read the full report here.

 

 

 

Nonprofit health systems — despite huge cash reserves — get billions in CARES funding

https://www.healthcaredive.com/news/nonprofit-health-systems-despite-huge-cash-reserves-get-billions-in-car/580078/

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Healthcare Dive’s findings revive concerns that greater examination of hospital finances is needed before divvying up COVID-19 rescue funding allocated by Congress.
The nation’s largest nonprofit health systems, led by Kaiser Permanente, Ascension and Providence, have received more than $7.1 billion in bailout funds from the federal government so far, as the novel coronavirus forced them to all but shutter their most profitable business lines.

At the same time, some of these same behemoth systems sit on billions in cash, and even greater amounts when taking into account investments that can be liquidated over time. That raises questions about how much money these systems actually need from the federal government given they have hundreds of days worth of cash on hand. Indeed, some big systems, like Kaiser Permanente, are already returning some of the funds.

And it revives concerns that greater examination of hospital finances is needed before divvying up rescue packages.

Nonprofits with more cash and greater net income tend to have received less funding — but not always

This is the second story of a Healthcare Dive series examining the bailout funds health systems received amid the COVID-19 pandemic. In this report, we focus on the 20 largest nonprofits by revenue and the amount of Coronavirus Aid, Relief, and Economic Security (CARES) Act funding they have received compared to the amount of cash on hand and recent financial performance. Healthcare Dive used bond filings filed as of June 12 to compile the amount of CARES funding received by health systems. In some instances, we relied on data from Good Jobs First, which also tracks the money. In addition to bond filings, we relied on annual audited financial statements and analyst reports to compile financial performance and days cash on hand.

Cash reserves

The cash hospitals have on hand has become an important metric to watch over the past few months as many have seen reserves dwindle to pay everyday expenses as revenue has dried up. At the same time, hospital volumes have plunged due to the economy grinding to a halt.

“You can’t write a payroll check off of accounts receivables, you have to write it off your cash and cash equivalents.” Rick Gundling, senior vice president of healthcare financial practices for Healthcare Financial Management Association, told Healthcare Dive.

In the early days of the outbreak in the U.S., some hospital executives sounded the alarm over dire financial straits, particularly small, rural hospitals whose executives warned they were weeks away from not making payroll. These pleas helped push Congress to pass massive rescue packages, with providers earmarked for $175 billion thus far.

Nonprofit health systems tend to keep more cash on hand than publicly-traded hospital chains. That’s because investor-owned facilities can raise capital more quickly, mainly through the stock market, while nonprofits have to rely on the bond market and their own operations, Gundling said.

Another important avenue that can boost cash is investments. It’s common for large nonprofits to rake in more in net income than they do from their core operations of running hospitals and caring for patients, in large part due to their investments in the stock market.

For example, Chicago-based CommonSpirit posted an operating loss of $602 million during its fiscal year 2019 but net income far exceeded that, totaling $9 billion. It was buoyed by investments and its recent merger, bringing together Catholic Health Initiatives and Dignity Health, according to its audited financial statement for the year ended June 30, 2019.

Many nonprofit health systems rake in more in net income than they do from their core operations

Ascension, the second-largest nonprofit system, received about $492 million in CARES funding, according to Good Jobs First. Ascension reported having 231 days cash on hand. Its unrestricted cash and investments totaled a sum of $15.5 billion as of March 31.

Kaiser, the nation’s largest nonprofit system, has about 200 days of cash on hand as of its fiscal year end, Dec. 31, according to a recent report from Fitch Ratings.

Providence, the third-largest nonprofit and first U.S. health system to treat a COVID-19 patient, reported 182 days of cash on hand as of March 31, according to a May bond filing.

However, Cleveland Clinic has the most cash on hand when measured in days among the top 20 nonprofits.

Cleveland Clinic had 337 days of cash on hand at the end of March, according to an unaudited financial statement from May. That’s nearly an entire year’s worth of operating expenses. The system has received $199 million in CARES funding, according to that same filing.

Rochester, Minnesota-based Mayo Clinic had the second most days of cash on hand with 252. Mayo Clinic has received $220 million in grant money, according to a May financial filing.

“You would never see that much cash on an investor-owned hospital,” Gundling said. “Generally, they want to pour that cash back into the services,” he said.

NYC Health + Hospitals, also the nation’s largest municipal health system, had the fewest days of cash on hand and it received $745 million in CARES funding, the second-most compared to other systems.

How health systems’ funding and cash on hand compare

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Risks of accepting bailout money

Sitting on a pile of money and accepting the bailout funds is already raising eyebrows.

“There is significant headline risk,” Michael Abrams, co-founder and partner at Numerof & Associates, told Healthcare Dive.

Worried about the optics, other institutions with considerable reserves or endowments have returned federal bailout funds, including Harvard University and major health insurers.

Providers are returning relief funds, too. Kaiser Permanente, the nation’s largest nonprofit by revenue, told the San Francisco Business Times it has returned more than $500 million in CARES funding. CEO Greg Adams the system “will do fine” despite the setback from the pandemic.

Mara McDermott, vice president of McDermott+Consulting, agrees there is a risk in accepting the grant money if systems possess such large reserves. Yet, she also cautioned that the healthcare ecosystem is so much more complicated.

“Regardless of the structure, it requires a deeper dive into need and that’s not what HHS did. They just wrote checks,” McDermott told Healthcare Dive.

Just because a parent company has a large cash reserve, it doesn’t mean that the money is readily available on a daily basis to a smaller practice it may own down the chain and one that hasn’t had any patients since March, she said.

“It’s easy to point the finger… but it’s much more complex than that,” she said.

The first tranche of money HHS sent to hospitals was based on Medicare fee-for-service business, and later on net patient service revenue. These formulas were criticized for putting some hospitals at an advantage compared to others, particularly those with larger shares of Medicaid patients. HHS has since released more targeted funding for providers in hot spots such as New York and plans to funnel funding to those serving a large share of Medicaid members in an attempt to address earlier concerns.

Still, without certainty of how long this public health crisis will last, no one knows how much cash on hand will ultimately be enough.

“A year’s cash on hand sounds like a lot of money but when you expend hundreds of millions of dollars a month, it won’t take you long to burn through that,” Scott Graham, CEO of Three Rivers Hospital, a 25-bed facility in rural Washington state, told Healthcare Dive.

Graham had feared in March that without quick intervention from the government, his hospital was near closure with just a few weeks cash on hand. The federal grant money has bought his hospital some time, about six months if volumes stay where they are, longer if they tick back up.

“I think what HHS did was right at the moment because we needed to ensure that the healthcare system survived this. It’s one thing for a small rural hospital to close, it’s another thing for the entire health system to collapse,” he said.

 

Trinity Health expects $2B revenue plunge as it cuts, furloughs more staff

https://www.healthcaredive.com/news/trinity-health-cutting-cost-cutting-2-billion-revenue-shortfall/580738/

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Dive Brief:

  • Trinity Health, one of the nation’s largest nonprofit health systems, said Monday it will take more measures to cut costs due to the downturn spurred by the novel coronavirus. The restructuring plan includes eliminating positions, extending furloughs, severances and reductions in schedules. The decisions are being “customized” across the system based on factors that include volume projections and the cost and revenue challenges in each market.
  • The Livonia, Michigan-based hospital operator said it continues to treat COVID-19 patients, however, it has “for now seen declining numbers of very sick patients with COVID-19.”
  • The system said it expects revenue to be depressed or “below historical levels” for the remainder of this fiscal year and much of the next. It projects revenue to drop by $2 billion to $17.3 billion for fiscal year 2021, which starts after its June 30 year end.

Dive Insight:

In May, Trinity said it planned to furlough nearly 12% of its workforce — or 15,000 employees out of the 125,000 nationally.  

Trinity, one of the nation’s largest hospital operators with 92 facilities and operations across 22 states, is now broadening that restructuring, extending and adding new furloughs.

In a Monday bond filing, Trinity said its operations were “significantly” impacted by the effects of the pandemic as many operators saw depressed volumes due to shelter-in-place orders, which started in most of Trinity’s markets during the last two weeks of March.

“The effect of COVID-19 on the operating margins and financial results of Trinity Health is adverse and significant and, at this point, the duration of the pandemic and the length of time until Trinity Health returns to normal operations is unknown,” according to Monday’s bond filing.

The system said relief funds provided by the federal government have not been enough to cover its operating losses. Trinity has received $600 million in relief funds that do not have to be repaid and more in loans through the advanced Medicare payment program, according to a previous analysis by Healthcare Dive.

Still, the system said it has drawn on credit facilities totaling $1 billion to provide adequate liquidity during the pandemic. Trinity reported having 178 days cash on hand as of March 30.

Some nonprofits are faring better than Trinity and pulling back on earlier staffing cuts.

Mayo Clinic said last week it will call back its furloughed workers by the end of August and restore pay that had been cut due to the pandemic.

Mayo has some of the most cash on hand in terms of days when comparing other major nonprofit systems. Mayo had 252 days of cash on hand as of March 30, more than the other 20 largest nonprofits except Cleveland Clinic and New York-Presbyterian.

 

 

5 health systems cutting physician salaries

https://www.beckershospitalreview.com/compensation-issues/5-health-systems-cutting-physician-salaries.html?utm_medium=email

Pay Cuts, Furloughs, Redeployment for Doctors and Hospital Staff ...

To help offset revenue losses attributed to the COVID-19 pandemic, many hospitals have implemented pay cuts for staff, including physicians.

Below are five hospitals or health systems that have announced pay cuts for clinicians, reported by Becker’s Hospital Review in the last month.

1. ThedaCare physicians, advanced practice clinicians take pay cuts
ThedaCare physicians and advanced practice clinicians will take a 10 percent pay cut to help reduce the Appleton, Wis.-based health system’s financial hit due to the COVID-19 pandemic.

2. Providence to cut salaries of 1,200 providers
Renton, Wash.-based Providence plans to reduce the salaries of 1,200 high-paid medical providers in its Oregon division to help offset losses from the COVID-19 pandemic. Providence told Becker’s Hospital Review that the decision to cut salaries was made by local leadership and is limited to Oregon-based providers.

3. Cleveland’s University Hospitals to cut all physician, clinical leader pay
University Hospitals, based in Cleveland, said it will temporarily cut pay for all physicians and clinical leaders in the organization to help offset losses driven by the pandemic.

4. Sentara executives, physicians take pay cuts
Senior leaders, executives and physicians at Norfolk, Va.-based Sentara Healthcare are taking pay cuts to help address an anticipated $778 million shortfall against projected revenue due to COVID-19, the organization confirmed to Becker’s Hospital Review.

5. Loyola Medicine CEO, physicians take pay cuts amid pandemic
Leadership and faculty physicians at Maywood, Ill.-based Loyola Medicine will take three-month pay cuts in response to the COVID-19 pandemic, CEO Shawn Vincent said in an interview with Becker’s Hospital Review.

 

 

 

 

Navigating a Post-Covid Path to the New Normal with Gist Healthcare CEO, Chas Roades

https://www.lrvhealth.com/podcast/?single_podcast=2203

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Healthcare is Hard: A Podcast for Insiders; June 11, 2020

Over the course of nearly 20 years as Chief Research Officer at The Advisory Board Company, Chas Roades became a trusted advisor for CEOs, leadership teams and boards of directors at health systems across the country. When The Advisory Board was acquired by Optum in 2017, Chas left the company with Chief Medical Officer, Lisa Bielamowicz. Together they founded Gist Healthcare, where they play a similar role, but take an even deeper and more focused look at the issues health systems are facing.

As Chas explains, Gist Healthcare has members from Allentown, Pennsylvania to Beverly Hills, California and everywhere in between. Most of the organizations Gist works with are regional health systems in the $2 to $5 billion range, where Chas and his colleagues become adjunct members of the executive team and board. In this role, Chas is typically hopscotching the country for in-person meetings and strategy sessions, but Covid-19 has brought many changes.

“Almost overnight, Chas went from in-depth sessions about long-term five-year strategy, to discussions about how health systems will make it through the next six weeks and after that, adapt to the new normal. He spoke to Keith Figlioli about many of the issues impacting these discussions including:

  • Corporate Governance. The decisions health systems will be forced to make over the next two to five years are staggeringly big, according to Chas. As a result, Gist is spending a lot of time thinking about governance right now and how to help health systems supercharge governance processes to lay a foundation for the making these difficult choices.
  • Health Systems Acting Like Systems. As health systems struggle to maintain revenue and margins, they’ll be forced to streamline operations in a way that finally takes advantage of system value. As providers consolidated in recent years, they successfully met the goal of gaining size and negotiating leverage, but paid much less attention to the harder part – controlling cost and creating value. That’s about to change. It will be a lasting impact of Covid-19, and an opportunity for innovators.
  • The Telehealth Land Grab. Providers have quickly ramped-up telehealth services as a necessity to survive during lockdowns. But as telehealth plays a larger role in the new standard of care, payers will not sit idly by and are preparing to double-down on their own virtual care capabilities. They’re looking to take over the virtual space and own the digital front door in an effort to gain coveted customer loyalty. Chas talks about how it would be foolish for providers to expect that payers will continue reimburse at high rates or at parity for physical visits.
  • The Battleground Over Physicians. This is the other area to watch as payers and providers clash over the hearts and minds of consumers. The years-long trend of physician practices being acquired and rolled-up into larger organizations will significantly accelerate due to Covid-19. The financial pain the pandemic has caused will force some practices out of business and many others looking for an exit. And as health systems deal with their own financial hardships, payers with deep pockets are the more likely suitor.”

 

 

 

 

7 health systems report $1B+ losses in Q1

https://www.beckershospitalreview.com/finance/7-health-systems-report-1b-losses-in-q1.html?utm_medium=email

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Health systems across the U.S. saw revenue decline, expenses rise and investment gains dwindle in the first quarter of this year due to the COVID-19 pandemic. 

For the three months ended March 31, some of the biggest nonprofit health systems in the U.S. reported losses. Below are seven health systems that reported net losses of $1 billion or more. 

Ascension (St. Louis)
Revenue: $6.1 billion
Operating loss: $429.4 million
Net loss: $2.7 billion

CommonSpirit Health (Chicago)
Revenue: $7.8 billion
Operating loss: $145 million
Net loss: $1.4 billion

Kaiser Permanente (Oakland, Calif.)
Revenue: $22.6 billion
Operating income: $1.3 billion
Net loss: $1.1 billion

Providence (Renton, Wash.)
Revenue: $6.3 billion
Operating loss: $276 million
Net loss: $1.1 billion

Sutter Health (Sacramento, Calif.)
Revenue: $3.2 billion
Operating loss: $236 million
Net loss: $1.1 billion

Advocate Aurora Health (Downers Grove, Ill., and Milwaukee)
Revenue: $3.1 billion
Operating loss: $85.6 million
Net loss: $1.3 billion

Intermountain Healthcare (Salt Lake City)
Revenue: $2.3 billion
Operating income: $115 million
Net loss: $1 billion

 

 

Tower Health cutting 1,000 jobs as COVID-19 losses mount

https://www.inquirer.com/business/health/tower-health-hospital-layoffs-covid-19-20200616.html

Tower Health cutting 1,000 jobs as COVID-19 losses mount

Tower Health on Tuesday announced that it is cutting 1,000 jobs, or about 8 percent of its workforce, citing the loss of $212 million in revenue through May because of the coronavirus restrictions on nonurgent care.

Fast-growing Tower had already furloughed at least 1,000 employees in April. It’s not clear how much overlap there is between the furloughed employees, some of whom have returned to work, and the people who are now losing their jobs permanently. Tower employs 12,355, including part-timers.

“The government-mandated closure of many outpatient facilities and the suspension of elective procedures caused a 40 percent drop in system revenue,” Tower’s president and chief executive, Clint Matthews, wrote in an email to staff. “At the same time, our spending increased for personal protective equipment, staff support, and COVID-related equipment needs.”

Despite the receipt of $66 million in grants through the federal CARES Act, Tower reported an operating loss of $91.6 million in the three months ended March 31, according to its disclosure to bondholders.

Tower, which is anchored by Reading Hospital in Berks County, expanded most recently with the December acquisition of St. Christopher’s Hospital for Children in a partnership with Drexel University. Tower paid $50 million for the hospital’s business, but also signed a long-term lease with a company that paid another $65 million for the real estate.

In 2017, Tower paid $418 million for five community hospitals in Southeastern Pennsylvania — Brandywine in Coatesville, Chestnut Hill in Philadelphia, Jennersville Regional in West Grove, Phoenixville in Phoenixville, and Pottstown Memorial Medical Center, now called Pottstown Hospital, in Pottstown.

Tower’s goal was to remain competitive as bigger systems — the University of Pennsylvania Health System and Jefferson Health from the Southeast, Lehigh Valley Health Network and St. Luke’s University Health Network from the east and northeast, and University of Pittsburgh Medical Center from the west — encroached on its Berk’s county base.

Tower had set itself a difficult task in the best of times, but COVID-19 has made it significantly harder for the nonprofit, which had an operating loss of $175 million on revenue of $1.75 billion in the year ended June 30, 2019.

Because health systems have high fixed costs for buildings and equipment needed no matter how many patients are coming through the door, it’s hard for them to limit the impact of the 30% to 50% collapse in demand caused by the coronavirus pandemic.

“Hospitals and all other health service providers were hit with this disruption with lightning speed, forcing the industry to learn in real time how to handle a situation for which there was no playbook,” Standard & Poor’s analysts David P. Peknay and Suzie R. Desai said in a research report last month.

Tower’s said positions will be eliminated in executive, management, clinical, and support areas.

The cuts include consolidations of clinical operations. Tower plans to close Pottstown Hospital’s maternity unit, which employs 32 nurses and where 359 babies were born in 2018, according to the most recent state data. Tower also has maternity units at Reading Hospital in West Reading and at Phoenixville Hospital.

Tower is aiming to trim expenses by $230 million over the next two years, Matthews told staff.

Like many other health systems, Tower has taken advantage of federal programs to ensure that it has ample cash in the bank to run its businesses. Tower has deferred payroll taxes, temporarily sparing $25 million. It received $166 million in advanced Medicare payments in April.

In the private sphere, Tower obtained a $40 million line of credit in April for St. Chris, which has lost $23.6 million on operations since Tower and Drexel bought it in December. Last month, Tower said it was in the final stages of negotiating a deal to sell and then lease back 24 medical office buildings. That was expected to generate $200 million in cash for Tower.

 

 

 

 

Trinity Health gets $2.2B in bailout funds, advance Medicare payments

https://www.beckershospitalreview.com/finance/trinity-health-gets-2-2b-in-bailout-funds-advance-medicare-payments.html?utm_medium=email

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Trinity Health saw revenue decline in the first nine months of fiscal year 2020, and the Livonia, Mich.-based health system ended the period with an operating loss, according to unaudited financial documents

Trinity Health saw revenue decline less than 1 percent year over year to $14.2 billion in the first nine months of the fiscal year, which ended March 31. The health system attributed the drop in revenue to the COVID-19 pandemic and the divestiture of Camden, N.J.-based Lourdes Health System in June 2019.

The 92-hospital system’s expenses were also up 1.2 percent year over year. Trinity Health ended the first three quarters of fiscal 2020 with expenses of $14.3 billion. Same-hospital expense growth was driven by increases in labor and supply costs, purchased services and costs related to its conversion to the Epic EHR platform in the Michigan region. The health system said the pandemic added $14.1 million of costs in March.

Trinity Health has taken several steps to reduce operating and capital spending in response to the pandemic, including implementing furloughs and reducing salaries for executives. In early April, Trinity Health announced plans to furlough 2,500 employees, most of whom are in nonclinical roles. 

Trinity Health reported an operating loss of $103.5 million for the first nine months of the current fiscal year, compared to operating income of $115.2 million in the same period a year earlier.

After factoring in investments and other nonoperating items, Trinity Health posted a net loss of $883.5 million in the first three quarters of fiscal 2020, down from net income of $457.9 million a year earlier. Nonoperating losses in the first nine months of fiscal 2020 were primarily driven by the pandemic’s effect on global investment market conditions in March, the health system said.

To help offset financial damage, Trinity Health received funds from the $175 billion in relief aid Congress has allocated to hospitals and other healthcare providers to cover expenses and lost revenue tied to the pandemic. The health system said it received a total of $600 million in federal grants in April and May. 

Trinity Health also applied for and received $1.6 billion of Medicare advance payments, which must be repaid.

Though Trinity Health is unable to forecast the pandemic’s impact on its financial position, it said the ultimate effect of COVID-19 on its operating margins and financial results “is likely to be adverse and significant.”