Tag Archives: Rural Health

CMS terminates Idaho hospital’s Medicare contract

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https://www.beckershospitalreview.com/finance/cms-terminates-idaho-hospital-s-medicare-contract-072718.html

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CMS ended its provider agreement with Blackfoot-based Idaho Doctors’ Hospital July 20.

Under rules enacted last September, a healthcare facility must average at least two inpatients per day and an at least two-night average length of stay to be considered an inpatient hospital for Medicare reimbursement. In April, CMS determined Doctors’ Hospital is not primarily engaged in providing care to inpatients and does not meet the new federal requirements for Medicare participation. The agency subsequently sent Doctors’ Hospital a Medicare termination notice.

“To go from being OK just 18 months ago, when we had our last survey, to now being told that we don’t meet the CMS conditions of participation because of new interpretations of the regulations is just difficult to comprehend,” Dave Lowry, administrative manager at Idaho Doctors’ Hospital, told KIFI earlier this month. “Like any business that is regulated by government agencies, we fully expect there to be changes to rules and their interpretations, but this drastic level of change just goes to show how much uncertainty there is in healthcare right now.”

After receiving the termination notice from CMS, Doctors’ Hospital sent letters to all patients affected by the contract termination, a spokesperson told Becker’s Hospital Review.

“We have worked with other area hospitals who provide the same services, and our staff provides this information for any patients who call with questions on where to go for care,” the Doctors’ Hospital spokesperson said.

 

Private equity’s next health care target

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https://www.axios.com/private-equity-firm-apollo-buying-lifepoint-health-1532121720-9e9a07eb-3090-4da3-9183-48144da93695.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

A patient sits in a hospital bed with machines nearby.

LifePoint Health owns hospitals in mostly rural areas.

For-profit hospital system LifePoint Health is nearing a deal to sell itself to private equity firm Apollo Global Management for $6 billion, including debt, Reuters reports. Apollo acquired a separate hospital chain — RegionalCare Hospital Partners, which is now known as RCCH HealthCare Partners — in 2015.

Why it matters: Private equity is craving health care deals right now, and this buyout would further consolidate the hospital industry, which is attempting to turn around a pattern of stagnant admissions.

Reuters reported Friday that private equity firm Apollo Global Management was considering buying LifePoint Health in a deal valued at $6 billion, which included debt. Axios’ Bob Herman breaks down the proposed deal…

Thought bubble, per Bob: Private equity has its hands all over the health care industry these days. But it’s a little surprising to hear such a large price tag for a company that owns mostly rural hospitals, which have struggled with fewer admissions and have relied more on the lower-paying Medicare and Medicaid programs.

The bottom line: Gary Taylor, an analyst with J.P. Morgan Securities, wrote this to hospital investors over the weekend, “We certainly do not expect another superior offer for a low-growth, challenged rural hospital company.”

Just how bleak is the financial outlook for rural hospitals?

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Nearly half are operating with negative margins, according to new research, which says a high rate of uninsured patients is among the reasons.

With healthcare services being concentrated more and more among major health systems and larger providers, rural hospitals are struggling.

A new study from Chartis Group and iVantage Health Analytics sheds light on the scope of the problem. About 41 percent of rural hospitals faced negative operating margins in 2016, the report found.

If those hospitals were located in a state that elected not to expand Medicaid under the Affordable Care Act, those margins were generally worse than those of their peers, suggesting that such expansion had a mitigating effect on financial pressures.

Due to those financial pressures, 80 rural hospitals closed from 2010 to 2016, indicating that the rural health safety net has seen better days.

One of the key factors behind this was a high rate of uninsured patients, and a payer mix heavy on public insurers with lower claims reimbursement rates. More patients are seeking care outside rural areas, which isn’t helping, and many areas see a dearth of employer-sponsored health coverage due to lower employment rates. Many markets are also besieged by a shortage of primary care providers, and tighter payer-negotiated reimbursement rates.

Demographics aren’t helping rural hospitals, either. Patients in rural markets are generally more socioeconomically disadvantaged, with many patients over 65 years old and suffering from multiple health disparities, which lead to higher general healthcare costs.

To make matters worse, there’s a shortage of physicians in rural communities as well, with only about 39.8 physicians per 100,000 people. By contrast, the ratio in non-rural areas is 53.3 physicians per 100,000 people.

All this comes at a time when the shift from fee-for-service payment models to value-based reimbursement is in full swing, putting pressure on all hospitals to reduce costs — which is especially problematic for rural hospitals given that their demographic and staffing challenges have a tendency to drive costs up, not down.

The researchers pointed to the Graves-Loebsack Save Rural Hospital Act as a possible means of mitigating the problem. The bill, introduced by the House in 2015, would create a payment structure whereby 105 percent of “reasonable” costs would be reimbursed; 100 percent of bad debt would be reimbursed; and rural hospitals would be exempt from 2 percent of sequestration of payments.

The authors suggested revisiting the bill, which would also establish the Community Outpatient Hospital Program, a measure aimed at preserving emergency and outpatient care for rural markets. It would also recoup $5.4 billion in lost Medicare reimbursement among rural hospitals over 10 years.

 

 

Rising Uninsured Rate Expected to Stress Margins of Nonprofit Providers

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More than 4 million people have lost coverage in the past two years, including many lower-income adults. That could prove problematic for safety net hospitals in the near future.

The ongoing efforts to destabilize the Affordable Care Act will adversely affect the operating margins of not-for-profit healthcare providers, according to a new analysis from S&P Global.

S&P analyst Allison Bretz said that over time, “a growing uninsured population could be a credit negative for not-for-profit hospitals and health systems, as these facilities would likely see an uptick in self-pay patients, charity care and bad debt.”

Two years into the Trump administration’s efforts to roll back the ACA, the uninsured population has risen from about 12.7% in 2016 to 15.5% in 2018.

A study by The Commonwealth Fund estimates that 4 million people have lost health insurance since 2016, and that the uninsured rate among lower-income adults rose from 21% in 2016 to 25.7% this spring.

“This will be most acute at safety-net providers and other providers with a high concentration of Medicaid patients, as that population is most vulnerable to many of these changes,” Bretz said in remarks accompanying the report.

Beth Feldpush, senior vice president of policy and advocacy for America’s Essential Hospitals, said the report “underscores concerns we’ve had since last year’s attempts to repeal the ACA and, now, with piecemeal changes that have weakened the law.”

“Many of the people who lose coverage seek care at our hospitals, which adds to uncompensated costs and puts more pressure on our members’ already low operating margins,” Feldpush said. “Because essential hospitals, by their mission, turn no one away, this could prove financially unsustainable for some.

Although active efforts to repeal the ACA in Congress have slowed in the past year, it is facing one of its greatest threats, as a federal judge in Texas hears a lawsuit brought by 20 states that challenges the constitutionality of the sweeping healthcare law.

For-profit, Payer Outlook Stable

While the rising uninsured rate could prove challenging for not-for-profit providers, S&P analyst David Peknay said it should have little effect on for-profit providers.

“The for-profit companies we rate have been reporting some increase in uninsured patients, consistent with national trends, but the impact on ratings is also currently immaterial,” he said.

The losses in covered lives for health insurance companies is offset by other factors, said S&P analyst Joseph Marinucci.

“A key contributing factor is the sustained migration of the government-sponsored insurance segments toward coordinated care (Medicare Advantage and managed Medicaid), which is expanding the market opportunity for health insurers,” Marinucci said.

“We expect ratings in the insurance sector to remain relatively stable in the near term despite the growth in the number of working-age uninsured individuals,” he said.

 

 

 

 

 

A Long Road to Care for Rural Californians

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A Long Road to Care for Rural Californians

Cramped rural hospital in Happy Valley California

In the northeast corner of California, nearly kissing Nevada and Oregon, lies Surprise Valley. At approximately 70 miles long, the valley is home to 1,232 people, which works out to about two people per square mile. Services are sparse: The Chamber of Commerce website lists two grocery stores, one insurance agency, and one hospital with an emergency room to provide care to its residents.

Essential CoverageThat hospital, Surprise Valley Community Hospital, is a vital institution, but it is bankrupt. Barbara Feder Ostrov of Kaiser Health News reports that years of mismanagement caught up to the hospital in 2017. By the time state inspectors arrived that June, the hospital was in a state of disarray — crushed by debt, it had only one acute care bed and a chief administrator who was MIA. Residents of Surprise Valley were torn between keeping it open and shuttering it even though the nearest hospital with an emergency room is 25 miles away on the other side of a mountain pass. In the June 5 California election, county voters chose to sell the hospital to an out-of-state entrepreneur rather than risk the hospital’s closure.

Surprise Valley isn’t alone in its lack of access to health care. Since 2010, 83 rural US hospitals have closed, Michael Graff writes in the Guardian. For residents of rural areas, the closure of the local hospital can cut off a lifeline. When Portia Gibbs of Belhaven, North Carolina, had a heart attack in 2014, her husband, Barry, had to choose between driving her 60 miles east to a hospital in Nags Head or 70 miles west to a hospital in the town of Washington. Portia never made it to a hospital.

It’s difficult to attract physicians and hospitals to rural areas, where wages and reimbursement rates tend to be lower. “What happens is if you’re a cardiologist you have a tendency to move to the East Coast where you can get paid more for the same procedure,” said US Senator Jerry Moran (R-Kansas) in a meeting with HHS Secretary Alex Azar, according to Modern Healthcare.

Solving the Rural Hospital Puzzle

There is no easy fix for the decline in the number of rural hospitals, but Moran and other senators have proposed fixing the Medicare wage index. The index, which factors into reimbursement of hospitals serving Medicare patients, is a formula that accounts for geographic differences in wages and the cost of living. Some lawmakers contend that the formula penalizes rural hospitals and exacerbates the hospital shortage. Updating the index to increase payments to Medicare providers in underserved areas could draw more physicians to rural hospitals, which could help prevent hospitals from going under.

Some rural hospitals have tried another solution: joining multihospital systems. In California, where 25% of rural hospitals have closed over the past two decades, 19 rural hospitals have combined forces in systems composed of at least two other hospitals. However, our analysis of six of these hospitals showed mixed results for this strategy: The financial status of one rural hospital improved substantially after joining a system, but two others saw lower net income.

Perhaps a more feasible solution to lack of access to care in rural areas can be found in expanding the health care workforce. A study published in Health Affairsfound a growing presence of nurse practitioners (NPs) among rural practices nationwide. From 2008 to 2016, the number of NPs in rural areas increased 43%. Not surprisingly, “states with restricted scopes of practice had lower NP presence and slower growth.” The authors conclude that “adding nurse practitioners is a useful way for practices to align themselves with contemporary efforts to improve access and performance.”

It seems fitting and bittersweet to end this edition of Essential Coverage with our tribute to the late Herrmann Spetzler, the visionary CEO and the heart of Open Door Community Health Centers in rural Humboldt and Del Norte Counties. To underscore his commitment to providing health care in remote locales, he often described himself in meetings and speeches as “Herrmann Spetzler, RURAL.” Spetzler’s unexpected death in March cut short his life’s work to provide health care to everyone, regardless of income or geography. His passing leaves a huge hole in the community he served.

 

Would Americans Accept Putting Health Care on a Budget?

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Would Americans Accept Putting Health Care on a Budget?

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If you wanted to get control of your household spending, you’d set a budget and spend no more than it allowed. You might wonder why we don’t just do the same for spending on American health care.

Though government budgets are different from household budgets, the idea of putting a firm limit on health care spending is far from unknown. Many countries, including Canada, Switzerland and Britain, pay hospitals entirely or partly this way.

Under such a capped system, called global budgeting, a hospital has an incentive to deliver less care — including reducing hospital admissions — and to increase the efficiency of the care it does deliver.

Capping hospital spending raises concerns about harming quality and access. On these grounds, hospital executives and patient advocates might strongly resist spending constraints in the United States.

And yet some American hospitals and health systems already operate this way, including Kaiser Permanente and the Veterans Health Administration. To address concerns about access and quality, these programs are usually paired with quality monitoring and improvement initiatives.

That brings us to Maryland’s experience with a capped system. The evidence from the state is far from conclusive, but this is a weighty and much-watched experiment for health researchers, so it’s worth diving into the details of the latest studies.

Starting in 2010 with eight rural hospitals, and expanding its plan in 2014 to the state’s other hospitals, Maryland set global budgets for hospital inpatient and outpatient services, as well as emergency department care. Each hospital’s budget is based on its past revenue and encompasses all payers for care, including Medicare, Medicaid and commercial market insurance. Budgets for hospitals are updated every year to ensure that their spending grows more slowly than the state’s economy.

Because physician services are not part of the budgets, there is an incentive to provide more physician office visits, including primary care. According to some reports, Maryland hospitals are responding to this incentive by providing additional support outside their walls to patients who have chronic illnesses or who have recently been discharged from a hospital. Greater use of primary care by such patients, for example, could reduce the need for future hospital admissions.

In 2013, early results found, rural hospital admissions and readmissions were both down from their levels before the system was introduced.

In the first three years of the expanded program, revenue growth for Maryland’s hospitals stayed below the state-set cap of 3.58 percent, saving Medicare $586 million. Spending was lower on hospital outpatient services, including visits to the emergency department that do not lead to hospital admissions. In addition, preventable health conditions and mortality fell.

According to a new report from RTI, a nonprofit research organization, Maryland’s program did not reap savings for the privately insured population (even though inpatient admissions fell for that group). However, the study corroborated the impressive Medicare savings, driven by a drop in hospital admissions. In reaching these findings, the study compared Maryland’s hospitals with analogous ones in other states, which served as stand-ins for what would have happened to Maryland hospitals had global budgeting not been introduced.

But a recent study, published in JAMA Internal Medicine, was decidedly less encouraging.

Led by Eric Roberts, a health economist with the University of Pittsburgh, the study examined how Maryland achieved its Medicare savings, using data from 2009-2015. Like RTI’s report, it also compared Maryland hospitals’ experience with that of comparable hospitals elsewhere.

However, unlike the RTI report, Mr. Roberts’s study did not find consistent evidence that changes in hospital use in Maryland could be attributed to global budgeting. His study also examined primary care use. Here, too, it did not find consistent evidence that Maryland differed from elsewhere. Because of the challenges of matching Maryland hospitals to others outside of the state for comparison, the authors took several statistical approaches in reaching their findings. With some approaches, the changes observed in Maryland were comparable to those in other states, raising uncertainty about their cause.

A separate study by the same authors published in Health Affairs analyzed the earlier global budget program for Maryland’s rural hospitals. They were able to use other Maryland hospitals as controls. Still, after three years, they did not find an impact of the program on hospital use or spending.

Changes brought about by the Affordable Care Act, which also passed in 2010, coincide with Maryland’s hospital payment reforms. The A.C.A. included many provisions aimed at reducing spending, and those changes could have led to hospital use and spending in other states on par with those seen in Maryland.

A limitation of Maryland’s approach is that payments to physicians are not included in its global budgets. “Maryland didn’t put the state’s health system on a budget — it only put hospitals on a budget,” said Ateev Mehrotra, the study’s senior author and an associate professor of health care policy and medicine at Harvard Medical School. “Slowing health care spending and fostering better coordination requires including physicians who make the day-to-day decisions about how care is delivered.”

A broader global budget program for Maryland is in the works. The U.S. Centers for Medicare and Medicaid Services is reviewing a state application that commits to global budgets for Medicare physician and hospital spending. An editorial that accompanied the JAMA Internal Medicine study noted that a few years may be insufficient time to detect changes. It suggests that five to 10 years may be more appropriate.

“Maryland hospitals are only beginning to capitalize on the model’s incentives to transform care in their communities,” said Joshua Sharfstein, a co-author of the editorial and a professor at the Johns Hopkins Bloomberg School of Public Health. “This means that as Maryland moves forward with new stages of innovation, there is a great deal more potential upside.” As former secretary of health and mental hygiene in Maryland, he helped institute the Maryland hospital payment approach.

Global budgets are unusual in the United States, but their intuitive appeal is growing. A California bill is calling for a commission that would set a global budget for the state. And soon Maryland won’t be the only state using such a system. Pennsylvania is planning a similar program for its rural hospitals.

Can this system work across America?

How much spending control is ceded to the government is the major battle line in health care politics. An approach like Maryland’s doesn’t just poke a toe over that line, it leaps miles beyond it.

But the United States has been trying to get a handle on health care costs for decades, spending far more than other advanced nations without necessarily getting better outcomes. A successful Maryland experiment could open an avenue to cut costs through the states, perhaps one state at a time, bypassing the steep political hurdle of selling a national plan.

 

Rural health care is expensive, and Washington isn’t helping

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https://www.axios.com/rural-areas-aca-unaffordable-d45599c2-3823-4041-ad8c-696cf7c15d8f.html

Image result for Rural health care is expensive, and Washington isn't helping

 

Some of the Affordable Care Act’s biggest problems — rising premiums and lackluster competition among insurers — are most severe in rural areas. And those areas tend to be conservative, but there’s little serious effort among Republicans to address these problems.

Why it matters: Rising premiums put health care further out of reach for middle-class people in these areas. At some point, they’re going to want to hear workable solutions from their elected representatives.

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The problem: By definition, rural areas are sparsely populated. So there’s not much competition among hospitals and other providers, which means insurers don’t have much leverage to negotiate lower prices. And with fewer customers overall, one very expensive patient can have a disproportionate impact on a plan’s bottom line.

  • “Conservative approaches to dealing with health costs tend to revolve around a competitive market, but the challenge with rural areas is you don’t have the ingredients for a competitive market,” said Larry Levitt of the Kaiser Family Foundation.

What they’re saying: Broadly, Republicans have focused on proposals that would make it easier for healthy people to extricate themselves from the ACA’s insurance markets. Those consumers would likely pay less, but costs and competition would only get worse for the people who need the coverage guarantees the ACA provides.

“This boils down to money for services. One way or another you have to come up with the money, find a way to get the price of the services down, or find a way to not use all of the services.”
— Joe Antos of the American Enterprise Institute

The other side: There was some bipartisan support earlier this year for a new reinsurance program, which would offset the costs of insurers’ most expensive customers. Experts said it would have helped, including in rural areas. But it fell apart.

  • Democrats have proposed a slew of ideas they say could help ease the burden in sparsely populated regions, mostly at taxpayers’ expense — including a public option, an expansion of the ACA’s premium subsidies, or new caps on payments. But none of those ideas have any real chance of actually happening, at least any time soon.

The bottom line: Reinsurance is by far the most bipartisan solution to the rural problem. Even that couldn’t get through this Congress, and lawmakers aren’t expected to return to health care policy before the midterms. This problem will likely get worse before it gets better.

The driving force of health care fear

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https://www.axios.com/driving-force-health-care-fear-c90adaf6-e5f8-4c11-816d-d3893b5d1374.html

Stethoscope

Insurers are afraid of a deteriorating market for individual coverage, fueled by the repeal of the Affordable Care Act’s individual mandate as well as regulatory changes from the Trump administration.

What to watch: Over the course of the spring, they’ll be deciding whether it makes sense to simply quit offering ACA coverage in some parts of the country. Rural areas will likely be the first to see insurers leave.

Pharma fears Washington after a couple of surprising defeats on Capitol Hill have shown the industry may not be as bulletproof as it seems.

  • What to watch: The Trump administration is eager to show progress on drug prices, and its early efforts have largely steered clear of drug companies themselves. But Health and Human Services secretary Alex Azar is open to reining in some of the industry’s patent tricks — a move that could cost drugmakers billions of dollars.

Everyone fears Amazon. Just the possibility that it might enter the pharmacy business has accelerated a trend of health care mega-mergers, as the old guard looks to lock in as much market power as it can.

And the public fears the cost of health care. That’s part of the reason the industry, which profits from those costs, is right to worry about what’s ahead.

 

Beating Amazon to the punch: Zipline launches drone to deliver medical supplies at 79 mph

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https://www.beckershospitalreview.com/supply-chain/beating-amazon-to-the-punch-zipline-launches-drone-to-deliver-medical-supplies-at-79-mph.html

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Zipline, a startup based in California that focuses on delivering medical supplies via drone, created a new drone that can travel up to 79 mph and carry 3.85 pounds of cargo, reports CNBC.

Established in 2011, the California-based startup beat Amazon, Fed-Ex and UPS to the punch when it established drone-based logistics for delivering medical supplies in 2016.

The startup initially focused on delivering life-saving medical supplies, such as blood, to rural areas in Rwanda. However, Zipline plans to expand into more markets this year — including the U.S.

Zipline investor and former aerodynamics engineer Paul Willard told CNBC the startup’s new drone — dubbed Zip 2 — can be scaled globally because of its speed and battery life.

Zipline will begin making medical supply deliveries in the U.S. later this year as part of a Federal Aviation Administration pilot program. Once the company establishes a service area in the U.S. for its drones, it would be able to make deliveries within 30 minutes to people in its service area.

A service area would be 99 miles in diameter and would encompass a population of around 10 million people, according to CNBC.

 

 

Hospital Distress to Grow If Congress Closes Door to Muni Market

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https://www.bloomberg.com/news/articles/2017-12-08/hospital-distress-to-grow-if-congress-closes-door-to-muni-market

  • Small, lower-rated facilites could see costs rise 1-2 percent
  • At least 26 non-profit hospitals already in default, distress

As Congress moves to assemble the final version of its tax plan, projects like Spooner, Wisconsin’s 20-bed hospital hang in the balance.

The rural community, about 110 miles (177 kilometers) northeast of Minneapolis, sold tax-exempt bonds to build the $26 million facility it opened last May. The hospital’s chief executive officer said that if its access to such low cost financing had been cut off it would have paid over $6 million more in interest.

That may soon be an expense that other hospitals across the country will have to shoulder. The House’s tax legislation revokes non-profit hospitals’ ability to raise money in the municipal market, where investors are willing to accept lower interest rates because the income is exempt from federal taxes. That’s threatening to saddle health-care providers with higher borrowing costs at a time when their finances are already under pressure.

“Should tax-exempt financing not be available in the future, it may really harm our ability to build affordable senior housing and assisting living facilities,” said Michael Schafer, Spooner Health’s CEO.

For small, rural hospitals across the country, labor, drug, and technology costs are increasing faster than the revenue and patients’ unpaid debts are on the rise. Higher financing costs would be one more challenge.

David Hammer, head of municipal bond portfolio management for Pacific Investment Management Co., said the loss of the tax-exemption could raise borrowing costs by 1 to 2 percentage points at small facilities with a BBB rating or below. That “could have a meaningful impact on their balance sheets,” he said.

At least 26 non-profit hospitals are already either in default or distress, meaning they’ve notified bondholders of financial troubles that make bankruptcy more likely, according to data compiled by Bloomberg. That includes falling short of financial terms set by their debt agreements and having too little cash on hand.

Many of them are based in rural communities where the populations tend to be “older, poorer and sicker,” according to Margaret Elehwany, the vice president of government affairs and policy at the National Rural Health Association. She estimates that about 44 percent of rural hospitals operate at a loss. There have been at least seven municipal bankruptcy filings by hospitals since last year, the most of any municipal sector excluding Puerto Rico.

The risk that Congress will prevent hospitals from accessing the municipal market worries Dennis Reilly, the executive director of the Wisconsin Health & Educational Facilities Authority, an agency that issues debt for non-profits such as Spooner Health.

“All of us in the industry were completely blindsided by the House proposal,” Reilly said in an interview from Washington, where he was meeting with members of Congress about the proposed bill.

“Without tax-exempt financing, not-for-profits across the country will have increased borrowing costs of 25 to 35 percent because they’ll have to access the taxable market,” he said. “For many of the rural providers like Spooner, much of their project they would not have been able to do with the higher cost of capital.”

A Rush to Beat the Clock

Hospitals are among those rushing to issue tax-exempt debt while they still can. Mercy Health, a Catholic health-care system that operates in Ohio and Kentucky, is scheduled to sell $585 million tax-exempt bonds next week. The deal, originally planned for early next year, was moved up after the release of the House proposal.

Spending more on debt would cut into the funds available for facilities, equipment and charitable outreach, like programs for opioid addiction, according to Jerome Judd, Mercy’s senior vice president and treasurer. “Things like that are impacted,” he said.

At least some members of Congress share the hospital executives’ concerns. Last month, some Republican lawmakers sent a letter to leadership pushing for the final plan to preserve the ability of hospitals and other entities, like affordable housing agencies and universities, to issue tax-exempt bonds.

“Private activity bonds finance exactly the sort of private public partnerships of which we need more of, not less,” they wrote. “These changes are incompatible with President Trump’s priority for infrastructure investment in the United States.”

It’s Tough to be Small

Some hospitals already opt to sell their bonds in the taxable municipal market to avoid disclosures and restrictions over how the proceeds are used, though they are typically larger entities that can secure advantageous rates because of the size of their deals. Patrick Luby, a municipal analyst at CreditSights, said smaller clinics with only a few million of bonds to sell would have a hard time accessing that market, which attracts corporate debt investors accustomed to big issues.

“Even what we would consider a large deal in the muni market is almost an odd lot in corporate bonds,” he said. “Very large hospital chains, large household name universities — global investors will buy those names, but they’re not going to buy a $15, $25, $50 million local hospital.”

If the House plan is enacted, hospitals “will have a really difficult time accessing the market,” he said.