Outlook is negative for nonprofit hospital sector, Moody’s says

https://www.beckershospitalreview.com/finance/outlook-is-negative-for-nonprofit-hospital-sector-moody-s-says.html

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Moody’s Investors Service has issued a negative outlook on the nonprofit healthcare and hospital sector for 2019. The outlook reflects Moody’s expectation that operating cash flow in the sector will be flat or decline and bad debt will rise next year.

Moody’s said operating cash flow will either remain flat or decline by up to 1 percent in 2019. Performance will largely depend on how well hospitals manage expense growth, according to the credit rating agency.

Moody’s expects cost-cutting measures and lower increases in drug prices to cause expense growth to slow next year. However, the credit rating agency said expenses will still outpace revenues due to several factors, including the ongoing need for temporary nurses and continued recruitment of employed physicians.

Hospital bad debt is expected to grow 8 to 9 percent next year as health plans place greater financial burden on patients. An aging population will increase hospital reliance on Medicare, which will also constrain revenue growth, Moody’s said.

 

14 recent hospital, health system outlook and credit rating actions

https://www.beckershospitalreview.com/finance/14-recent-hospital-health-system-outlook-and-credit-rating-actions.html?origin=cfoe&utm_source=cfoe

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The following hospital and health system credit rating and outlook changes or affirmations occurred in the last week, beginning with the most recent:

1. Fitch affirms ‘AA-‘ rating for SSM Health

Fitch Ratings affirmed St. Louis-based SSM Health’s “AA-” issuer default rating and “AA-“/”F1+” rating where applicable on outstanding rated bonds.

2. Moody’s affirms Cook Children’s Medical Center’s ‘Aa2’ rating

Moody’s Investors Service affirmed its “Aa2” and “Aa2/VMIG 1” ratings for Fort Worth, Texas-based Cook Children’s Medical Center, affecting $356 million of outstanding revenue bonds.

3. Moody’s affirms ‘Baa2’ rating for Children’s Hospital Los Angeles

Moody’s Investors Service affirmed its “Baa2” rating for Children’s Hospital of Los Angeles, affecting $438 million of rated debt.

4. Moody’s affirms ‘A1’ rating for Lucile Packard Children’s Hospital

Moody’s Investors Service affirmed its “A1” revenue bond rating for Palo Alto, Calif.-based Lucile Packard Children’s Hospital.

5. Moody’s affirms ‘A2’ rating for Mary Greeley Medical Center

Moody’s Investors Service affirmed its “A2” rating for Ames, Ia.-based Mary Greeley Medical Center, affecting $64 million of outstanding revenue bonds.

6. Moody’s downgrades Marion County Health and Hospital to ‘Aa2’

Moody’s Investors Service downgraded Marion County (Ind.) Health and Hospital Corp.’s rating from “Aa1” to “Aa2.”

7. Moody’s assigns ‘A2’ rating to HonorHealth

Moody’s Investors Service assigned an “A2” rating to Scottsdale, Ariz.-based HonorHealth’s revenue bonds and affirmed its “A2” rating for the system’s outstanding parity debt.

8. Moody’s upgrades Gainesville Hospital District rating to ‘Ba1’

Moody’s Investors Service upgraded Gainesville (Texas) Hospital District issuer and general obligation limited tax debt ratings from “Ba2” to “Ba1.”

9. Moody’s downgrades Monroe County Health Care Authority rating to ‘Ba1’

Moody’s Investors Service downgraded Monroe County (Ala.) Health Care Authority’s rating from “A3” to “Ba1,” affecting $3.6 million in general obligation limited tax bonds.

10. Moody’s affirms ‘A2’ rating for MedStar Health

Moody’s Investors Service affirmed its “A2” rating on Columbia, Md.-based MedStar Health, affecting $1.4 billion of debt.

11. Moody’s assigns ‘A2’ rating to Mercy Health

Moody’s Investors Service assigned an “A2” rating to Cincinnati-based Mercy Health’s proposed taxable bond and also affirmed its “A2” and “A2/VMIG 1” ratings on the system’s outstanding bonds.

12. S&P revises Spartanburg Regional Health’s outlook to negative

S&P Global Ratings revised its outlook for Spartanburg (S.C.) Regional Healthcare System from stable to negative.

13. S&P affirms ‘A+’ rating for Rush University Medical Center

S&P Global Ratings affirmed its “A+” long-term rating for Chicago-based Rush University Medical Center’s outstanding revenue bonds.

14. S&P raises rating for Columbus Regional Healthcare to ‘A+’

S&P Global Ratings raised its rating for Whiteville, N.C.-based Columbus Regional Healthcare System from “BBB-” to “A+.”

 

 

 

9 hospitals with strong finances

https://www.beckershospitalreview.com/finance/9-hospitals-with-strong-finances-110818.html

Here are nine hospitals and health systems with strong operational metrics and solid financial positions, according to recent reports from Moody’s Investors Service, Fitch Ratings and S&P Global Ratings.

1. Wausau, Wis.-based Aspirus has an “AA-” rating and stable outlook with S&P. The health system has solid debt and liquidity metrics, according to S&P.

2. Charlotte, N.C.-based Atrium Health has an “AA-” rating and stable outlook with S&P. The health system has a strong operating profile, favorable payer mix, healthy financial performance and sustained volume growth, according to S&P.

3. St. Louis-based Mercy Health has an “Aa3” rating and stable outlook with Moody’s. The health system has favorable cash flow metrics, a solid strategic growth plan, a broad service area and improving operating margins, according to Moody’s.

4. Traverse City, Mich.-based Munson Healthcare has an “AA-” rating and positive outlook with Fitch. The health system has a leading market share in a favorable demographic area and a healthy net leverage position, according to Fitch.

5. Parkview Regional Medical Center in Fort Wayne, Ind., has an “AA-” rating and stable outlook with S&P. The hospital is executing on its strategic plan, and S&P expects it to maintain its balance sheet metrics.

6. Vancouver, Wash.-based PeaceHealth has an “AA-” rating and stable outlook with Fitch. The health system has a leading market position, robust reserves and strong cash flow, according to Fitch.

7. Baltimore-based Johns Hopkins Health System has an “Aa2” rating and stable outlook with Moody’s. The health system has favorable liquidity metrics, strong fundraising capabilities, a healthy market position and regional brand recognition, according to Moody’s.

8. Madison-based University of Wisconsin Hospital and Clinics has an “Aa3” rating and stable outlook with Moody’s. The hospital has an integral relationship with the University of Wisconsin-Madison and is a major academic medical center and quaternary referral center for the region and state, according to Moody’s.

9. Willis-Knighton Medical Center in Shreveport, La., has an “AA-” rating and positive outlook with Fitch. The hospital has a leading inpatient market share, favorable payer mix and healthy operating margins, according to Fitch.

 

15 health systems with strong finances

https://www.beckershospitalreview.com/finance/15-health-systems-with-strong-finances-100418.html

Here are 15 health systems with strong operational metrics and solid financial positions, according to recent reports from Moody’s Investors Service and Fitch Ratings.

Note: This is not an exhaustive list. Health system names were compiled from recent credit rating reports and are listed in alphabetical order.

1. St. Louis-based Ascension has an “Aa2” senior debt rating and stable outlook with Moody’s. The health system has a large diversified portfolio of sizable hospitals and strong liquidity. Moody’s expects Ascension’s margins to improve in fiscal year 2019.

2. Morristown, N.J.-based Atlantic Health System has an “Aa3” rating and stable outlook with Moody’s. The system has a strong market position, favorable balance sheet ratios and strong operating performance, according to Moody’s.

3. Atrium Health has an “Aa3” rating and stable outlook with Moody’s. The Charlotte, N.C.-based health system has historically stable operating performance and solid cash-flow metrics, according to Moody’s.

4. Prince Frederick, Md.-based Calvert Health System has an “AA-” rating and stable outlook with Fitch. The system has a leading market share, a favorable payer mix and stable cash flow, according to Fitch.

5. Children’s Healthcare of Atlanta has an “Aa2” rating and stable outlook with Moody’s. The health system has a dominant market position, strong margins and ample liquidity, according to Moody’s.

6. Cleveland Clinic has an “Aa2” rating and stable outlook with Moody’s. Cleveland Clinic has strong brand recognition, exceptional fundraising ability and healthy cash flow, according to Moody’s.

7. Inova Health System has an “Aa2” rating and stable outlook with Moody’s. The Falls Church, Va.-based health system has consistently strong cash-flow margins, a leading market position and a good investment position, according to Moody’s.

8. Philadelphia-based Main Line Health has an “Aa3” rating and stable outlook with Moody’s. The system has a strong market position, healthy balance sheet metrics and a light debt burden, according to Moody’s.

9. Rochester, Minn.-based Mayo Clinic has an “Aa2” rating and stable outlook with Moody’s. Mayo has a strong clinical reputation, favorable fundraising capabilities and a robust balance sheet, according to Moody’s.

10. Dallas-based Methodist Health System has an “Aa3” rating and stable outlook with Moody’s. The health system has a favorable liquidity position, consistent operating results and a growing market population, according to Moody’s.

11. Omaha-based Nebraska Medicine has an “AA-” rating and stable outlook with Fitch. The system has strong operating margins and a light debt burden, according to Fitch.

12. Fort Wayne, Ind.-based Parkview Health System has an “Aa3” rating and stable outlook with Moody’s. The system has healthy debt service coverage, manageable capital spending and improving liquidity metrics, according to Moody’s.

13. Sisters of Charity of Leavenworth (Kan.) Health System, which does business as SCL Health, has an “Aa3” rating and stable outlook with Moody’s. The system has a good market position in a favorable service area, strong operating margins and limited capital spending, according to Moody’s.

14. Hollywood, Fla.-based South Broward Hospital District has an “Aa3” rating and positive outlook with Moody’s. The health system has a dominant market position, robust debt coverage and improving operating margins, according to Moody’s.

15. Chapel Hill-based University of North Carolina Hospitals has an “Aa3” rating and stable outlook with Moody’s. The health system has an excellent market position, strong patient demand and healthy financial performance, according to Moody’s.

 

 

 

Nonprofit hospitals ‘on an unsustainable path,’ Moody’s says

https://www.healthcaredive.com/news/nonprofit-hospitals-on-an-unsustainable-path-moodys-says/531245/

Dive Brief:

  • Not-for-profit and public hospitals spent more than they gained in revenues for the second consecutive year in fiscal 2017, according to Moody’s Investors Service.
  • Moody’s said the widening gap leaves facilities “on an unsustainable path” and will remain the largest strain on nonprofits through next year.
  • Median annual expense growth decreased to 5.7% in 2017 from 7.1%. That’s compared to annual revenue growth, which declined to 4.6% from 6.1%, according to Moody’s analyst Rita Sverdlik.

Dive Insight:

Hospitals, especially nonprofit facilities, are facing difficult times. Morgan Stanley recently reported that about 18% of more than 6,000 hospitals studied were at a risk of closure or are performing weakly. About 8% of studied hospitals were at risk of closing and 10% were called “weak,” according to that report. 

For perspective, just 2.5% of hospitals closed over the past five years.

What’s in store for hospitals in the near term depends on the specific outlook. Moody’s this year revised its outlook for the sector from stable to negative. That move followed nonprofit hospitals seeing more credit downgrades in 2017.  

On the other hand, Fitch Ratings recently called off its “Rating Watch” for U.S. nonprofit hospitals and health systems after the organizations showed improved or stable results this year.

So, there are signs of improvement in the sector, but challenges with revenues, sagging reimbursements and lower admissions will continue to plague hospitals.

The reasons Moody’s gave for lower revenue growth came from lower reimbursements, the shift to outpatient care, increased M&A activity and additional ambulatory competition. It said the move away from inpatient to outpatient moved into its fifth year.

Reversing sluggish volume trends and growing profitable service lines will be critical to improving the sector’s financial trajectory over the near-term as most hospitals continue to operate in a fee-for-service environment,” Sverdlik said.

Moody’s added that more hospitals reported operating deficits in 2017. That coincided with lower absolute operating cash flow. It said 28.4% of nonprofit hospital experienced operating losses, an increase from 16.5% in 2016. Also, 59% of providers reported lower absolute operating cash flow, which was more than double the 24% noted in 2015. The 2017 figure was the highest percentage in five years.

Don’t expect times to get better any time soon. Moody’s said nonprofit hospital margins will continue to remain thin through this year. Margins have fallen to an all-time low of 1.6% operating and 8.1% of operating cash flow.

“Margin pressures led to softened debt coverage ratios, though the median growth rate of total debt has been negative over the last five years,” Sverdlik said. “Ongoing operating pressures will constrain the ability to reverse these trends, especially if providers turn to debt to fund capital needs.”

However, it’s not all bad news. Moody’s said the medians have shown positive signs. For instance, median unrestricted cash and investments growth rate improved to 8.9% thanks to strong market returns and steady capital spending. Also, absolute cash growth exceeded expenses growth, which caused improved median cash on hand. That trend isn’t expected to continue if hospitals spend more cash flow on capital or if equity markets fall.

 

 

15 recent hospital, health system outlook and credit rating actions

https://www.beckershospitalreview.com/finance/15-recent-hospital-health-system-outlook-and-credit-rating-actions-8-3-18.html

The following hospital and health system credit rating and outlook changes and affirmations occurred in the last week, beginning with the most recent.

1. S&P downgrades Westchester County Health Care to ‘BBB-‘
S&P Global Ratings downgraded Valhalla, N.Y.-based Westchester County Health Care’s revenue and refunding bonds to “BBB-” from “BBB.”

2. S&P revises UAB Medicine’s outlook to negative over weaker operations
S&P Global Ratings revised Birmingham, Ala.-based UAB Medicine’s outlook to negative from stable.

3. S&P upgrades Torrance Memorial Medical Center’s rating to ‘A’
S&P Global Ratings upgraded its long-term and underlying rating on Torrance (Calif.) Memorial Medical Center’s outstanding debt to “A” from “BBB.”

4. Moody’s affirms ‘A1’ rating on ProHealth Care
Moody’s Investors Service affirmed its “A1” rating on Waukesha, Wis.-based ProHealth Care, affecting $181 million of outstanding debt.

5. Moody’s assigns ‘Baa1’ to Baptist Healthcare System’s bonds
Moody’s Investors Service assigned its “Baa1” rating to Louisville-based Baptist Healthcare System’s proposed $130 million series 2018A revenue refunding bonds. At the same time, Moody’s upgraded the health system’s parity debt to “Baa1” from “Baa2,” affecting $442 million of debt.

6. S&P assigns ‘BBB+’ rating to CHI’s bonds
S&P Global Ratings assigned its “BBB+” long-term rating on Englewood, Colo.-based Catholic Health Initiatives’ proposed $275 million series 2018A bonds.

7. S&P places Essentia Health on credit watch negative
S&P Global Ratings placed its “A” underlying rating on Duluth, Minn.-based Essentia Health on credit watch with negative implications.

8. S&P revises Halifax Hospital Medical Center’s outlook to negative over litigation risks
S&P Global Ratings affirmed its “A-” long-term rating on Daytona Beach, Fla.-based Halifax Hospital Medical Center’s revenue bonds and revised the outlook to negative from stable.

9. Fitch assigns ‘AA’ IDR to Advocate Aurora Health
Fitch Ratings assigned an issuer default rating of “AA” to Advocate Aurora Health — the entity formed by the recent merger of Downers Grove, Ill.-based Advocate Health Care and Milwaukee-based Aurora Health.

10. Fitch affirms Nebraska Medicine’s ‘AA-‘ rating
Fitch Ratings affirmed its “AA-” rating on Omaha-based Nebraska Medicine’s outstanding bonds. Concurrently, Fitch assigned its “AA-” issuer default rating to the academic healthcare provider.

11. Fitch affirms ‘AA’ rating on Presbyterian Healthcare
Fitch Ratings affirmed its “AA” rating of Albuquerque, N.M.-based Presbyterian Healthcare Services’ outstanding bonds, affecting $850 billion of debt. At the same time, Fitch assigned its “AA” issuer default rating to the health system.

12. Moody’s affirms ‘Aa3’ rating on Main Line Health
Moody’s Investors Service affirmed its “Aa3” rating on Philadelphia-based Main Line Health’s outstanding bonds, affecting $219.5 million of debt.

13. Moody’s downgrades Lafayette General Medical Center
Moody’s Investors Service downgraded its rating on Lafayette (La.) General Medical Center to “Baa2” from “Baa1,” affecting $147 million of rated debt.

14. Moody’s affirms SCL Health’s ‘Aa3’ rating
Moody’s Investors Service affirmed its “Aa3” long-term rating on Sisters of Charity of Leavenworth (Kan.) Health System, which does business as SCL Health. The rating affects about $1.2 billion of debt.

15. S&P ratings on ProMedica debt unchanged after HCR ManorCare acquisition
ProMedica’s acquisition of Toledo-based nursing home chain HCR ManorCare will not immediately affect its “A+” long-term ratings on the Ohio-based health system’s debt, according to S&P Global Ratings.

 

 

Can A Community Hospital Stick To Its Mission When It Goes For-Profit?

http://radio.wpsu.org/post/can-community-hospital-stick-its-mission-when-it-goes-profit

Proponents of hospital mergers say the change can help struggling nonprofit hospitals "thrive," with an infusion of cash to invest in updated technology and top clinical staff. But research shows the price of care, especially for low-income patients, usually rises when a hospital joins a for-profit corporation.

Mission Health, the largest hospital system in western North Carolina, provided $100 million in free charity care last year. This year, it has partnered with 17 civic organizations to deliver care for substance abuse by people who are low-income.

Based in bucolic Asheville, the six-hospital system also screens residents for food insecurity; provides free dental care to children in rural areas via the “ToothBus” mobile clinic; helps the homeless find permanent housing and encourages its 12,000 employees to volunteer at schools, churches and nonprofit groups.

Asheville residents say the hospital is an essential resource.

“Mission Health helped saved my life,” says Susan ReMine, a 68-year-old Asheville resident for 30 years who now lives in nearby Fletcher, N.C. She was in Mission Health’s main hospital in Asheville for three weeks last fall with kidney failure. And, from 2006 to 2008, a Mission Health-supported program called Project Access provided ReMine with free care after she lost her job because of illness.

After 130 years as a nonprofit with deep roots in the community, Mission Health announced in March that it was seeking to be bought by HCA Healthcare, the nation’s largest for-profit hospital chain. HCA owns 178 hospitals in 20 states and the United Kingdom.

The pending sale reflects a controversial national trend in the U.S. as hospitals consolidate at an accelerating pace and the cost of health care continues to rise.

“We understand the business reasons [for the deal], but our overwhelming concern is the price of health care,” says Ron Freeman, chief financial officer at Ingles Markets, a supermarket chain headquartered in Asheville with 200 stores in six states.

“Will HCA after a few years start to press the hospital to make more profit by raising prices? We don’t know,” Freeman says.

And the local newspaper, the Citizen Timeseditorialized in March: “How does it help to join a corporation where nearly $3 billion that could have gone to health care instead was recorded as profit? … We would feel better were Western North Carolina’s leading health-care provider to remain master of its own fate.”

Across the U.S., the acquisition of nonprofit hospitals by corporations is raising concern among some advocates for patients and communities.

“The main motivation of for-profit companies is to grow so they can cut costs, get paid more and maximize profits,” says Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led health care think tank and advocacy group. “They are not as focused on improving access to care or the community’s overall health.”

Merger mania across the U.S.

From 2013 to 2017, nearly 1 in 5 of the nation’s 5,500-plus hospitals were acquired or merged with another hospital, according to Irving Levin Associates, a health care analytics firm in Norwalk, Conn. Industry analysts say for-profit hospital companies are poised to grow more rapidly as they buy up both for-profits and nonprofits — potentially altering the character and role of public health-oriented nonprofits.

Nonprofit hospitals are exempt from state and local taxes. In return, they must provide community services and care to poor and uninsured patients — a commitment that is honored to varying degrees nationwide.

Of the nation’s 4,840 general hospitals that aren’t run by the federal government, 2,849 are nonprofit, 1,035 are for-profit and 956 are owned by state or local governments, according to the American Hospital Association.

In 2017, 29 for-profit companies bought 18 for-profit hospitals and 11 not-for-profits, according to an analysis for Kaiser Health News by Irving Levin Associates.

Sales can go the other way, too: 53 nonprofit hospital companies bought 18 for-profits as well as 35 nonprofits in 2017.

A recent report by Moody’s Investors Service predicted stable growth for for-profit hospital companies, saying they are well-positioned to demand higher rates from insurers and have less exposure to the lower rates paid by government insurance programs such as Medicare and Medicaid. In contrast, a second Moody’s report downgraded — from stable to negative — its 2018 forecast for the not-for-profit hospital sector.

‘We wanted to thrive, and not just survive’

Ron Paulus, Mission Health’s president and CEO, says he and the hospital’s 19-member board concluded last year that the future of Mission Health was iffy at best without a merger.

HCA declined to make anyone available for an interview but provided this written statement: “We are excited about the prospect of a transaction that would allow us to support the caliber of care they [Mission Health hospitals] have been providing.”

Driving Mission Health’s decision, Paulus says, were strained finances and the board’s strong feeling that the hospital needed to invest in new technology, modern data management tools and top clinical talent.

“We wanted to thrive and not just survive,” he says. “I had a healthy dose of skepticism about HCA at first. But I think we made the right decision.”

During the past four years, Paulus says, the company has had to cut costs — from between $50 million and $80 million a year — to preserve an “acceptable operating margin.” The forecast for 2019 and 2020, he says, saw the gap between revenue and expenses rising to $150 million a year.

Miriam Schwarz, executive director of the Western Carolina Medical Society, says many physicians in the area were surprised by the move and “are trying to grapple with the shift.”

“There’s concern about the community benefits, but also job loss,” Schwarz says. Still, she adds, the doctors in her region “do recognize that the hospital must become more financially secure.”

Weighed against community concerns is the prospect of a large nonprofit foundation created by the deal. Depending on the final price, the foundation could have close to $2 billion in assets.

Creation of such foundations is common when for-profit companies buy nonprofit hospitals or insurance companies. Paulus says the foundation created from Mission Health could generate $50 million or more a year to — among other initiatives — “test new care models such as home-based care … and address the causes of poor health in the community in the first place.”

In addition, HCA will have to pay upward of $10 million in state and local taxes.

Mixed results

Industry analysts say the hospital merger and consolidation trend nationwide is inevitable given the powerful forces afoot in health care.

That includes pressure to lower prices and costs and improve quality, safety and efficiency; to modernize information technology systems and equipment; and to do more to improve overall health.

But academics and consumer advocates say hospital consolidation yields mixed results. While mergers — especially purchases by for-profit companies — provide much-needed capital and financial stability, competition is stifled, and that’s often led to higher prices.

Martin Gaynor, a professor of economics and health policy at Carnegie Mellon University, and colleagues examined 366 hospital mergers from 2007 to 2011 and found that prices were, on average, 12 percent higher in areas where one hospital dominated the market versus areas with at least four rivals. Another recent study found that 90 percent of U.S. cities today have a “highly concentrated” hospital market. Asheville is one, and Mission Health is dominant there.

“The evidence is overwhelming at this point,” Gaynor says. “Mergers solve some problems for hospitals, but they don’t make health care less expensive or better. In fact, prices usually go up.”

Mission Health CEO Paulus says he believes HCA is committed to restraining price increases and the growth in costs.

If no obstacles arise, Paulus says, HCA’s purchase of Mission Health would be formalized in August and finalized in November or December, pending state regulatory approval.