U.S. healthcare stocks seen maintaining momentum after strong 2018


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One of the rare market bright spots last year, the U.S. healthcare sector remains a Wall Street darling despite a slow start to 2019.

As 2019 begins, healthcare .SPXHC is the most favored of the 11 main S&P 500 sectors, according to a Reuters review of ratings from 13 large Wall Street research firms, which recommend how to weigh those groups in investment portfolios.

Healthcare shares overall rose 4.7 percent last year, one of only two S&P 500 sectors, along with utilities, to post positive returns in 2018 as the benchmark index fell 6.2 percent.

Proponents cite the healthcare sector’s reasonable valuations, strong balance sheets and dividend payments among many companies, as well as the group’s upbeat outlook for earnings, which are less susceptible to economic cycles than other businesses.

If economic growth is slowing, some investors are wary of being too invested in cyclical sectors that thrive during an upswing, but do not want to be too defensive either.

“We are trying to find things that skirt both of those two categorizations, and healthcare is a really nice diversified earnings stream,” said Noah Weisberger, managing director for U.S. portfolio strategy at Bernstein.

Such diversity stems from the variety of companies comprising the sector: manufacturers of prescription medicines, makers of medical devices, such as heart valves and knee replacements, health insurers, hospitals and providers of tools for scientific research.

From a stock perspective, that means the sector includes potential fast-growing stocks, such as biotechs that can carry more risk and more reward, or large pharmaceutical companies and others that offer steadier, slower growth.

Investment advisory firm Alan B. Lancz & Associates sold some pharmaceutical holdings late last year that had posted big gains, such as Merck & Co (MRK.N), to move into biotech stocks it believed were undervalued, said Alan Lancz, the firm’s president.

“We have maintained our overweighting, which is unusual for us with a sector that has outperformed so dramatically,” Lancz said. “But mainly there are segments within the sector that still offer opportunity.”

For 2019, healthcare companies in the S&P 500 are expected to increase earnings by 7.5 percent, ahead of the 6.3 percent growth estimated for S&P 500 companies overall, according to IBES data from Refinitiv.

Health insurer UnitedHealth Group Inc (UNH.N), the sector’s third-largest company by market value, kicks off fourth-quarter earnings season for healthcare on Tuesday.

“Healthcare is one of the few sectors with high quality, above-market growth and it’s relatively immune to the array of macro headwinds that we see out there,” said Martin Jarzebowski, sector head of healthcare for Federated Investors.

Healthcare shares could also benefit from anticipation of increased dealmaking activity after two large acquisitions of biotechs were already announced this year.

Despite healthcare’s outperformance last year, the sector is trading at the same valuation as the S&P 500 – 14.5 times earnings estimates for the next 12 months – whereas healthcare on average has held a premium over the market for the past 20 years, according to Refinitiv data.

The sector also is valued at a discount, by such price-to-earnings measures, to defensive sectors, including consumer staples .SPLRCS, which trades at 16.6 times forward earnings, and utilities .SPLRCU, which trades at 15.8 times.

According to the Reuters review of sector weightings, healthcare is followed by financials .SPSY, then technology .SPLRCT. Real estate .SPLRCR ranks as the most negatively rated group.

The healthcare sector has lagged in the early days of 2019, rising less than 1 percent against a 3 percent rise for the S&P 500.

Some investors doubt healthcare will maintain its outperformance. JP Morgan strategists downgraded the sector to “underweight” last month, pointing in part to political rhetoric possibly turning “more negative on healthcare leading up to the 2020 presidential elections.”

The healthcare sector struggled ahead of the 2016 election, with the high U.S. cost of prescription medicines a prominent issue during the presidential campaign. With renewed scrutiny on drug pricing, such concerns linger.

The sector could suffer if investors become more optimistic about economic growth and flee defensive stocks, while the popularity of healthcare as an investment could work against it if the trade becomes overly crowded.

“There is risk there,” said Walter Todd, chief investment officer at Greenwood Capital in South Carolina. But given issues affecting other sectors, he said, “when you look around the market…you arrive by default at healthcare, and so I think that’s why a lot of people are interested in the sector.”




Moody’s: Preliminary nonprofit healthcare profitability margins at 10-year low


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The nonprofit hospital median operating cash flow margin decreased to 8.1 percent in fiscal year 2017, marking the lowest level seen since the 2008-09 recession, according to preliminary financial data from Moody’s Investors Service.

The revenue decline comes amid expense growth and pinched revenue growth.

Here are five report insights to know.

1. The nonprofit hospital median operating cash flow margin was 8.1 percent in fiscal year 2017 compared to 9.5 percent the year prior.

2. The nonprofit hospital annual median revenue growth rate decreased by 2.2 percent in fiscal year 2017 compared to the year prior, while the median expense growth rate fell by 1.7 percent. Pinched revenue growth was attributed to factors such as declining reimbursement from payers, as well as median growth in outpatient visits (2.2 percent) outpacing median growth in inpatient hospitalizations (1.2 percent). Moody’s expects nonprofit hospitals’ credits to continue to be stressed by the aging population and declining reimbursement.

3. Nonprofit hospital’s median absolute unrestricted cash and investments increased by 8.2 percent in fiscal year 2017, partially due to strong market returns, according to Moody’s. This compares to 3.8 percent in fiscal year 2016. But the agency reported this growth was offset by median days cash on hand, which only increased 1.5 percent as organizations were pressured by labor, technology and supply costs. Moving forward, Moody’s expects limited liquidity improvement as expenses grow and capital spending needs increase.

4. Due to weaker operating performance, nonprofit hospitals generally saw tempered leverage ratios. This is despite the fact median total absolute debt decreased 1.7 percent in fiscal year 2017, according to Moody’s. “Operating challenges and increased debt issuance in the fourth quarter of calendar year 2017 will keep debt service coverage measures subdued,” the agency wrote.

5. The fiscal year 2017 preliminary financial data from Moody’s is in line with the agency’s negative outlook on the nonprofit healthcare and hospital sector. The data was based on audited fiscal year 2017 financial statements for 160 nonprofit healthcare organizations, including freestanding hospitals as well as single- and multi-state health systems.

Access the full data here.

Healthcare megadeals may have major long-term impact, Moody’s says


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Dive Brief:

  • CVS Health’s plan to buy Aetna could have a significant impact on hospitals, health insurers and pharmacy benefit managers (PBMs), according to Moody’s Investors Service’s Healthcare Quarterly.
  • Payers’ vertical integration strategies are credit negative for hospitals, but hospitals’ plans to make generic drugs and other new strategies are positives, Moody’s said.
  • On the payer side, Moody’s said mergers between health insurers and PBMs are credit negative in the short-term because of increased debt and risk associated with integration. However, in the long run, these deals may lower costs.

Moody’s said hospitals may feel the impact of UnitedHealth’s Optum buying DaVita Medical and Humana investing in Kindred Healthcare. However, Cigna’s purchase of Express Scripts won’t have much of an effect on hospitals.

Payers’ vertical integration strategies, such as buying physician groups and non-acute care providers, are credit negative for nonprofit and for-profit hospitals and put more pressure on hospital volumes and margins, Moody’s said.

The issue comes from payer vertical integration being able to offer preventive, outpatient and post-acute care for lower costs than acute care hospitals. These initiatives will have an increasingly disruptive impact to hospitals’ credit quality, according to the report.

“These strategies would place insurers in direct competition with hospitals, which offer the same services and are also seeking to align with physician groups,” Moody’s said.

On the payer side, two recently announced megadeals, CVS-Aetna and Cigna-Express Scripts, are both designed to control rising medical costs and target drug prescriptions, which now account for nearly one-fifth of total health spending. While payers have been able to limit growth in utilization, medical inflation and sources of medical care, prescription drug costs continue to rise, Moody’s said.

Though Moody’s expects both deals to be credit negative in the short-term, they have the potential to turn credit positive in the long run, especially CVS-Aetna. “The combined company has the potential to lower medical costs as Aetna will be better able to engage with its members as they purchase drugs at CVS retail pharmacies or through its prescription drug programs,” Moody’s said.

These deals will result in most payers having to contract with a PBM owned by a competitor. Moody’s expects PBM competition to remain high. Payer-owned PBMs must still offer the same cost savings to competitors to keep customers.

Out of the recent megadeals, only CVS buying Aetna is expected to have “more significant impact” for payers. The other announced transactions aren’t expected to cause many problems for insurance companies, Moody’s said.

Looking at initiatives that are in development, Moody’s said none of the big-name plans are expected to have much of an impact on the healthcare segments. These include the Amazon, Berkshire Hathaway and J.P. Morgan Chase’s partnership, Apple opening medical clinics and entering the medical record business or nonprofit hospitals forming a generics company.


Moody’s: Nonprofit hospital rating downgrades rose sharply in 2017


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Despite a strong economy and low uninsured population, nonprofit hospital rating downgrades sharply outpaced upgrades throughout 2017 — creating a downgrade-to-upgrade ratio of 3.4 to 1.0, which is more than double the 2016 ratio of 1.5 to 1.0, according to a new report by Moody’s Investors Service.

In 2017, there were 41 credit downgrades and 12 credit upgrades for nonprofit hospitals, compared to 32 credit downgrades and 21 credit upgrades in 2016.

Moody’s attributed the credit stress in 2017 to rising labor and supply costs coupled with a low revenue growth environment.

“An acute nursing shortage in many markets, along with rising supply and pharmaceutical costs, resulted in expense growth outpacing revenue growth for many hospitals and health systems,” the Moody’s report reads.

While hospitals of all sizes were downgraded, 60 percent of the downgrades in 2017 affected smaller health systems with less than $1 billion in total operating revenue. In addition, 12 of the downgrades occurred in Pennsylvania and Ohio, reflecting the lagging economy, aging demographics, competitive service area and commercial payer challenges in the Rust Belt area.

Although downgrades outpaced upgrades in 2017, Moody’s affirmed the vast majority of ratings in 2017, which is in line with historical trends.

Moody’s: Aggressive insurer growth strategies threaten nonprofit hospitals


Dive Brief:

  • Disruptive growth strategies among health insurers threaten the future margins and volumes of nonprofit hospitals, a new Moody’s Investor Services report maintains.
  • Vertical integrations — such as the proposed CVS Health-Aetna merger and UnitedHealth/Optum-DaVita deal — put insurers “in direct competition” with hospitals for outpatient volume and revenue and could allow payers to carve out hospitals or specific services from their contracts, according to the report.
  • Moody’s warns that the embrace of value-based payment models by insurers is also a threat, as it shifts patients from high-cost inpatient care to cheaper outpatient settings.

Dive Insight:

Hospitals are already feeling the squeeze from cuts in Medicare reimbursements, which are driving patients with less serious ailments to urgent care and other outpatient treatment facilities. Depressed patient admissions and payments have providers searching for cost savings. The result has been a near constant stream of divestitures, mergers and layoffs that shows no signs of abating. At the same time, hospitals have been acquiring physician practice and outpatient care sites to diversify their revenue streams as demand shifts.

Those efforts could be undermined as insurers move into the provider space by buying up professional practices, for example.

“As the insurer owns more non-acute healthcare providers — particularly physician groups — it would be better able to carve out hospitals or certain services from its contracts, which would translate into lower volume and revenue for hospitals,” the report said.

Vertically integrated private payers will cut into hospital revenues by offering similar outpatient and post-acute care to members at lower costs than hospitals can afford, Moody’s says. With enough integration, they could siphon more patients and revenue from struggling hospitals.

Optum’s physician acquisitions and similar deals will also cut into hospitals’ referral volumes. “The acquisition of relatively large physician groups is noteworthy because these providers are the key decision makers in determining what type of treatment the patient will receive and where the care is provided,” the report said.

Increasing scale fueled by more Medicare and Medicaid managed care members, coupled with market concentration, will also give insurers the edge in price negotiations, according to the report. Meanwhile, reduced government payments will make hospitals more dependent on private insurance to cover their costs.

“Insurers flexing their negotiating power by offering lower rate increases will likely result in more standoffs and terminations of contracts between insurers and hospitals,” Diana Lee, a vice president at Moody’s, said in the report. “To gain leverage, we expect hospitals to continue M&A and consolidation.”


Moody’s: Nonprofit hospitals face volume, margin declines as insurers acquire physicians


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As commercial payers swallow up more physician groups and nonacute care services, nonprofit hospitals will see greater pressure on their volumes and margins, according to Moody’s Investors Service.

Moody’s analysts predict insurers will be able to provide preventive, outpatient and post-acute care to their members through acquired providers at a lower cost than hospitals. As a result, insurers will begin carving out hospitals and select services from their contracts, leaving nonprofit hospitals with fewer patients and less revenue.

CVS Health’s $69 billion bid for Aetna and Optum’s takeover of Surgical Care Affiliates are examples of integrations that could threaten nonprofit hospitals’ bottom lines, Moody’s said.

On another front, nonprofit hospitals face increasing pressure from insurers moving quickly to value-based payment programs. Payers will also leverage their growing scale, driven by Medicare and managed Medicaid expansions, in rate negotiations.

“Insurers flexing their negotiating power by offering lower rate increases will likely result in more standoffs and terminations of contracts between insurers and hospitals,” according to Diana Lee, a Moody’s vice president. “To regain leverage, we expect hospitals to continue [merger and acquisition] and consolidation.”


Outlook Darkens for Not-for-Profit Hospitals


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The revised outlook from Moody’s comes amid a larger-than-expected drop in cash flow this year and the ongoing uncertainty regarding federal healthcare policy for public and not-for-profit hospitals.

Moody’s Investors Service has downgraded from stable to negative its 2018 outlook for the not-for-profit hospital sector based on an expected drop in operating cash flow.

“Operating cash flow declined at a more rapid pace than expected in 2017, and we expect continued contraction of 2%-4% through 2018,” said Eva Bogaty, a Moody’s vice president.

“The cash flow spike from insurance expansion under the Affordable Care Act in 2014 and 2015 has largely worn off, but cash flow has not stabilized as expected because of a low revenue and high expense growth environment,” Bogaty said.

In a briefing released Monday, Moody’s said hospital revenue growth is slowing and is expected to remain slightly above medical inflation, which declined to a low of 1.6% in September. Hospitals can’t translate volume growth into stronger revenue growth because of the lower reimbursement rate increases across all insurance providers and higher expense growth.

In addition, rising exposure to governmental payers will dampen revenue growth for the foreseeable future due to a rapidly aging population and low reimbursement rates. Medicare and Medicaid, represent 60% of gross patient revenue in 2017, Moody’s said.

Key drivers of expense growth include rising labor costs, driven by an acute nursing shortage and ongoing physician and medical specialist hiring. Technology costs are also rising as systems are upgraded and IT staff is needed for training and maintenance. While the ACA’s arrival heralded a drop in bad debt from 2014-16, bad debt rebounded in 2017 and will continue to grow at a rate of 6%-7% in 2018, Bogaty said.

“Rising copays and use of high deductible plans will increase bad debt for both expansion and non-expansion states,” she said.

In the near-term, uncertainty regarding federal healthcare policy will have a marginal fiscal impact on NFP hospitals. Bogaty said ambiguity surrounding the ACA does affect the planning and modelling of long-term strategies, while recent federal tax proposals will add to rising costs for hospitals.

The outlook could be revised to stable if operating cash flow resumes growth of 0%-4%. A change to positive could result from expectations of accelerated operating cash flow growth of more than 4% after inflation, Moody’s said.

Fitch: Rating downgrades will likely outweigh upgrades for US healthcare companies in 2018


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US healthcare companies will likely see more credit rating downgrades than upgrades in 2018, according to Fitch Ratings.

Fitch attributes the increased pressure on industry credit ratings to the uncertain future of the ACA, a changing tax plan, the adoption of alternative payment models and the potential for outsider disruption, which includes Amazon’s entrance into healthcare and advancements in technology.

Further, Fitch explains that technology is increasingly moving patients away from hospitals and enabling decentralization — thus reshaping the healthcare landscape. Due to this changing landscape, the healthcare industry is, “facing secular challenges to pricing power and profitability and these forces are expected to influence certain segments more than others in 2018,” Fitch notes.

However, despite the higher potential for credit downgrades, the US healthcare sector outlook is stable for 2018 due to sheer demand for services, an overall favorable liquidity profile, and generally consistent leverage and debt coverage.


Moody’s maintains for-profit hospitals’ stable outlook


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Dive Brief:

  • Moody’s Investors Service announced in a recently released report that the outlook for U.S. for-profit hospitals is stable.
  • Outpatient services will drive revenue growth. Moody’s said outpatient service growth will result in EBITDA growth of 2.5-3% for for-profit hospitals over the next 18 months. That growth will be offset somewhat by higher patient costs and more uninsured Americans, which may lead to more bad debt for hospitals.
  • Moody’s warned that recent hurricanes in Florida and Texas, which are the two largest states by revenue among for-profit hospitals, may cause short-term financial issues, but Moody’s expects those hospitals will recover quickly.

Dive Insight:

Payers, both private and public, continue to squeeze hospital margins as they push patients to outpatient services. Moody’s said volumes to lower-cost settings will continue. Revenue growth from outpatient services will rise faster than inpatient services.

Moody’s said patients with high-deductible health plans, who pay more out-of-pocket costs, are going to seek less costly settings than hospitals to save money. Also, the CMS’ proposal to allow several orthopedic procedures on an outpatient basis could cause more financial harm for hospitals. “If finalized, this will further push surgeries out of the inpatient setting.”

For-profit hospitals will capture some of the added outpatient volume through their own outpatient departments and associated ambulatory surgery centers. However, some volume will go to competitors, Moody’s warned.

Moody’s expects payer rates will rise, but lower than usual — 1.5-2% net revenue per adjusted admission over the next 18 months. Some factors that will affect the slower growth include the CMS changing disproportionate share payments and proposing 1.75% rates for hospital outpatient procedures, and private payers implementing cost-controlling policies. These policies include Anthem’s plan to no longer pay for MRIs and CTs scans in hospital outpatient departments. Instead, patients will need to get the services at lower-cost, freestanding imaging centers.

Moody’s also warned that rising bad debt and expenses are pressuring margins.

“Higher patient responsibility and fewer insured patients will lead to lower volumes, but also higher costs of uncompensated care. Even with strong cost controls, given the high fixed costs of operating hospitals, it will be difficult to expand margins in an environment of weak patient volumes and rising bad debt expense. At the same time, nursing shortages and rising fees associated with medical specialists (including outsourced emergency departments) will also pressure margins,” said Moody’s.

However, some for-profit systems may see improved margins in the coming months. Moody’s said Quorum Health and Community Health Systems (CHS) will benefit from shedding less profitable facilities, while LifePoint Health and HCA Healthcare will improve margins over time as they improve efficiencies at recently acquired facilities.

Moody’s also warned that Hurricanes Harvey and Irma, which destroyed portions of Texas and Florida, will affect the largest for-profit hospitals: HCA Healthcare, Tenet Healthcare and CHS, which all have “significant presence” in those areas. For those states, Moody’s expects “incremental expenses,” such as cleanup and remediation, staffing and overtime, as well as transporting critically ill patients to other facilities, will play a financial role for those systems in the next two quarters.

Fitch: Failed ACA replacement efforts add to healthcare sector uncertainty


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As ACA repeal and replace efforts stall, significant uncertainty remains surrounding how federal policy will affect nonprofit healthcare organizations, leading to a negative sector outlook for healthcare, according to Fitch Ratings.

The uncertainty and negative outlook comes as the Trump administration looks for ways to weaken the ACA even if the health reform law is not repealed.

Nonprofit hospitals experienced declines in uncompensated care under the ACA because of an increase in healthcare coverage due to Medicaid expansion, rollout of healthcare exchanges and allowing children to stay on their parent’s health insurance plan until age 26.

While repeal efforts cause uncertainty for hospitals, current discussions regarding a bipartisan healthcare bill could be beneficial for nonprofit hospitals. A bipartisan effort could potentially reduce the insurance premium price hikes, according to Fitch.