U.S. Not-For-Profit Health Care Sector Medians, 2017-2018 Perspective The focus turns back to operations Copyright 2017 by S&P Global. All rights reserved.
Agenda 1. 2016 Medians Highlights: Stand-alones and 2. Comparative Statistics: 2015 vs. 2016 3. 2016 Medians Highlights: Small Hospitals and Speculative Grade 4. 2017 Update 5. Sector Overview 6. Q&A 2
Not-for-Profit Health Care Rating Distribution Three-Year Glance 60% 50% 40% 30% 20% 10% 0% AAA AA A BBB BB B CCC 2015 2016 2017 YTD Ratings as of 9/11/2017; Source: S&P Global Ratings 3
Highlights of the 2016 Median Reports Operating performance, cash flow, and non-operating income generally down - As a result, MADS coverage also lower - Masked issues around industry trends/pressures beginning to emerge post ACA Medicaid expansion Balance sheets remain largely stable - Some declines in 2016 due to investment markets, although recovery through year-to-date 2017 - Continued higher capital spending relative to depreciation, mainly among stronger credits/institutions Rating distributions remain similar year to year among standalone and systems - continue to have higher rating distributions due generally to their stronger enterprise profiles Upgrades and downgrades through 2017 are generally balanced - However, downgrades more concentrated among standalones - Bigger isn t always better Trend to more negative outlooks than positive outlooks - Slightly higher percentage of negative outlooks within standalones Consolidation continues to impact number of standalone hospitals within portfolio (303 from 409 in 2012) while system portfolio generally stable (156). 4
Not-For-Profit Health Care System vs. Stand-Alone Rating Distribution 60% 50% 40% 30% 20% 10% 0% AAA AA A BBB BB B CCC System Stand-Alone 5
2016 Medians Income Statement Highlights (continued) EBIDA margins reflect slowing operations and weak nonoperating returns 14.0 12.0 10.0 8.0 6.0 EBIDA Margin (%) 12.2 12.2 11.2 10.5 11.5 9.9 4.0 2.0 - Stand-Alones & Health Stand-Alones 2015 2016 MADS Coverage (x) MADS coverage weaker across the board 6.0 5.0 4.0 3.0 4.3 3.9 4.0 3.8 5.0 4.3 2.0 1.0 Ratings as of 9/11/2017; Source: S&P Global Ratings - Stand-Alones & Health Stand-Alones Private & Confidential 8
2016 Medians Income Statement Highlights NPR Growth (%) Reimbursement/ volume pressures hurting revenue growth 25.0 20.0 15.0 10.0 5.0 22.5 8.4 14.2 9.0 7.4 7.9 0.0 Stand-Alones & Health Stand-Alones 2015 2016 Operating margins weaken due to softer revenues and growing expenses Ratings as of 9/11/2017; Source: S&P Global Ratings; NPR Net patient revenue 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5-3.4 3.4 Stand-Alones & Health Operating Margin (%) 3.6 2.4 2.4 2.4 Stand-Alones Private & Confidential 9
2016 Medians Balance Sheet Highlights 25.0 Unrestricted Reserves Growth (%) 21.7 Despite weak cash flow, balance sheet strength is stable 20.0 15.0 10.0 5.0 7.1 13.3 6.2 9.7 1.9 - Stand-Alones & Health Stand-Alones 2015 2016 Days Cash on Hand Days cash on hand unable to keep pace with expense growth Ratings as of 9/11/2017; Source: S&P Global Ratings 225.0 220.0 215.0 210.0 205.0 200.0 195.0 190.0 185.0 217.0 210.3 Stand-Alones & Health 221.7 216.6 Stand-Alones 205.5 197.6 Private & Confidential 10
2016 Medians: Credit Supporting Factors Enterprise profiles of stronger standalone and systems continue to support the stable outlook in 2017 Industry consolidation expected to continue, leading to further cost savings over time and support for broadening the base for the shift from volume to value Management s cost reduction plans are on-going and are now a yearly initiative for many as revenue pressures are likely to continue General stability of unrestricted reserves and year-to-date improvement helps to offset some noise, for the short-term, around financial performance challenges Debt metrics remained steady or improved due to low interest rates and associated debt re-financings (particularly in 2016) 5
2016 Medians: Ongoing Challenges Reimbursement continues to pressure revenues - Shifts in payor mix: Medicare, higher deductible plans - Focus on value based contracts for both commercial plans and federal reimbursement - Some state challenges could impact future of Medicaid and related funding Federal executive and legislative direction creates uncertainty around ACA and some of its components Still some difficulty obtaining next level cost reductions while expenses continue to increase - Often results in M&A as markets continue to consolidate Preparation for population health and consumer demand will help usher in evidence based medicine & higher quality but these investments (new IT platforms, MD and ambulatory investments, new payor products) likely to pressure to operating margins and even unrestricted liquidity depending on capital spending for these efforts 6
Small Stand-Alone Hospital Medians Hospitals with net patient revenue (NPR) below $125 million. - Mostly in the BBB and speculative grade category. - Potentially increasing threshold to $150 million of total operating revenue under proposed not-for-profit acute-care criteria, with possible periodic adjustments. Overall, 42 rated providers met this definition in 2016, down from 54 in 2015. Acquisitions, refundings, and growing net patient revenue continue to shrink this subcategory. - Five credits had NPR surpass $125 million for the first time in fiscal 2016. In general, small hospital medians are stronger at each rating level than the corresponding median financial ratios for all-stand alone hospitals. - Given inherent weaknesses on the enterprise profile (such as small service area populations, limited medical staffs, and usually more constrained payor mixes), financial profile assessments generally must provide the appropriate cushion to offset these risks. - This includes higher margins and debt service coverage, more robust measures of unrestricted reserves, and a lighter debt load. 11
Small Hospital Medians vs. Stand-Alone Medians 8 Small hospitals Stand-alone hospitals Operating margin (%) 6 4 2 0-2 A* BBB+ BBB BBB- S.G. 600 Days cash on hand 400 200 Long-term debt/ capitalization (%) 0 50 40 30 20 10 0 A* BBB+ BBB BBB- S.G. A* BBB+ BBB BBB- S.G. Ratings as of 6/30/2017; Source: S&P Global Ratings; *Includes hospitals rated 'A-' through 'A+ ; S.G.--speculative grade. 12
Speculative Grade Medians Includes both stand-alone hospitals and health care systems rated BB+ or below. - No 2015 speculative grade credits were upgraded to investment grade this past year, whereas three previously investment grade credits were downgraded to BB+. Overall, 28 acute-care credits carry speculative grade ratings, including 25 stand-alone hospitals and three health care systems. - This is down from 31 speculative grade credits in 2015 due to acquisitions and refundings, such as: Good Shepherd Medical Center (TX) acquired by CHRISTUS Health Metropolitan Health Corporation (MI) acquired by University of Michigan Health Mission Regional Medical Center (TX) acquired by Prime Healthcare Foundation In general, performance for speculative grade credits showed continued deterioration in 2016, with some improvement in balance sheet metrics likely driven by weaker credits being removed from the sample. 13
BB+ Medians vs. Stand-Alone Hospital BBB- Medians When looking at the border between investment and speculative grade 2016 medians, we observe BBB- credits have incrementally better performance with significantly more balance sheet cushion. 1 0.75 0.5 0.25 0 2.5 2 1.5 1 0.5 0 0.3 BBB- Ratings as of 6/30/2017; Source: S&P Global Ratings 0.1 Operating margin (%) 2.3 1.8 MADS coverage (x) BB+ 140 120 100 80 60 40 20 0 120 100 80 60 40 20 0 50 40 30 20 10 0 129.1 91.3 Days' cash on hand 100.3 61.1 Unrestricted reserves/long-term debt (%) 48.2 41.6 Long-term debt/capitalization 14
2017 Rating Actions Reflect Stability Overall, credits remain quite stable Upgrades/Downgrades (count) Upgrade 2016 44 2017 YTD 26 263 total affirmations for the health care sector Downgrade Upgrades/Downgrades (%) 38 2016 29 2017 YTD Upgrade 54% 47% Downgrade 46% 53% Ratings as of 9/11/2017; Source: S&P Global Ratings 15
Not-for-Profit Health Care Outlook Distribution 2016 2017 YTD 12% 8% 7% 11% 80% 82% Stable Positive Negative Stable Positive Negative Ratings as of 9/11/2017; Source: S&P Global Ratings 16
Sector Stability As Seen Through 2016 Medians and 2017 Year-To-Date Rating Actions Stable outlook supported by 2016 medians and 2017 y-t-d rating actions Overall balance sheets remain strong, stable and robust Non-operating performance recovers in 2017 suggesting cash flow coverage improvements for 2017 ratios Mergers & acquisitions continue to boost enterprise profiles for many. upgrades exceed downgrades. Overall rating changes balanced, but slightly more downgrades than upgrades Number of stable outlooks remains constant Despite stable outlook, operating margins pressures re-emerge, driving more negative outlooks & drop in positive outlooks appear better equipped to handle the current environment as seen by upgrades to downgrades comparing systems to stand alones ACA expansion benefits waning as they are now baselined into operations/ payor mix Value orientation & acceptance of more risk-based contracts continues to reduce use rates Aging population driving up Medicare at the expense of employer based commercial payors Surgical/ Medical mix hurting performance for some Growing labor shortages 17
Recent Trends That Temper Out Stable Outlook Recent fiscal 2016 audits that show notable declines in operating income levels Growing labor shortages, Weaker inpatient volumes from 2015 highs, and Unfavorable payor mix shifts Expectation of longer-term revenue pressures--particularly as the recent improvement in volume and in the level on insurance coverage from Medicaid expansion wanes; The potential impact of legislative changes on state and federal health care policy under a new federal administration, including the potential for a sharp rise in the number of people without health insurance; and Continued uncertainty, including the pace of change toward value models and potentially significant legislative changes which could also alter the movement to value-based reimbursement models, and the growing role of consumerism and price consciousness among buyers of health care. 18
Q&A 19
Thank you Martin Arrick Managing Director T: 415.371.5078 Martin.Arrick@spglobal.com Ken Gacka Senior Director & Analytical Manager T: 303.721.4829 Kenneth.Gacka@spglobal.com Suzie Desai Director T: 312.233.7046 Suzie.Desai@spglobal.com Patrick Zagar Associate T: 214.765.5883 Patrick.Zagar@spglobal.com 20
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