2010 Nonprofit Hospitals and Healthcare Systems Outlook. Presenters Jeff Schaub and Anthony Houston

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1 2010 Nonprofit Hospitals and Healthcare Systems Outlook Presenters Jeff Schaub and Anthony Houston

2 Nonprofit Healthcare Group Analytical Team Location Telephone Jeff Schaub Sector Head New York Michael Burger New York Jonathan Mandel New York Gary Sokolow New York Eva Thein New York Anthony A. Houston Chicago James LeBuhn Chicago Emily Wadhwani Chicago Michael Borgani San Francisco Carolyn Tain San Francisco Business Development Lead James Mitchell Tampa

3 Agenda Outlook Summary 2010 Major Credit Themes > Health Reform > Operating Profile > Risk Assessment and Mitigation > Bedrock of Support Additional Points of Interest Conclusion and Q&A 2

4 2010 Nonprofit Hospital and Healthcare Systems Outlook > Negative - (revised from Stable Dec. 2008) Fitch anticipates rating downgrades will moderately outpace upgrades during the coming year, but with affirmations constituting the bulk of 2010 rating actions. For the most part, 2009 operating profitability remained stable. Margin and coverage erosion more likely in 2010 than in Negative rating pressure will continue to be disproportionately felt by lower rated entities. 3

5 Health Reform > Uninsured The burden of the uninsured remains a pressure within the sector and will likely demand continued attention within the broader reform debate. > Payment Reform CMS is poised to continue its efforts to reduce or slow the rate of growth in overall reimbursement. > Reduced increases > Paying for value (high quality-low cost) > Emphasis on coordination of care Broad shifts of economic incentives will be a catalyst driving further alignment across the care continuum. Highly aligned organizations are most likely to take advantage of value-based payment incentives. 4

6 Operating Profile 12.0 Operating EBITDA Margin > Key credit determinant Fundamental operating performance is a primary indicator of overall credit quality. > Matching costs with revenues Responses by hospital managers in 2009 helped buoy performance. Many providers will be challenged to maintain the cost-cutting initiatives implemented in Most providers will undergo strategic service offering and scale reviews could lead to accelerated consolidation in certain markets Current Operating EBITDA - Debt Service Coverage Current AA A BBB AA A BBB

7 Risk Assessment & Mitigation > Active management of both sides of the balance sheet continues to be viewed as a best practice by Fitch. > Fitch expects a continued shift to issuance of fixed-rate debt in lieu of variable-rate debt. Ensuing increased annual debt service could bring rating pressure on those organizations with already thin financial cushions. However, for most borrowers, debt service is only a small portion of their expense base, therefore Fitch expects most organizations to absorb these higher expenses without credit deterioration. > The much-discussed credit gap between higher and lower rated providers could continue to grow. > Close scrutiny will continue for those organizations with large put debt relative to their unrestricted cash, significant bank commitment risk, or those with significant amounts of alternative investments. 6

8 Bedrock of Support > Most hospitals serve a unique and essential role in their community The endorsement of this essentiality manifests itself in many ways, including tax exemption, political influence, community support, and philanthropic benefits. The concept of essentiality of service that can temper the most onerous effects of industry restructuring and proposed reimbursement cuts. > Most hospitals and health systems are major economic drivers within their communities. > Although not wholly subject to income or property taxation, the economic stability and viability of nonprofit hospitals does lend a great deal of support to a stable tax base. 7

9 Additional Points of Interest for 2010 > Pension Funding Emphasis placed on the ability of an organization to meet and/or mitigate the cash funding requirements and less on the overall ratio impact. > Fiscal Stress on U.S. States Medicaid programs likely to be stressed if the recession continues; pressuring reimbursement levels for providers that serve a large portion of Medicaid enrollees. The general weakness in the tax base may drive a resurgence of scrutiny focused on justifying providers charity status. 8

10 Additional Points of Interest for 2010, continued > Demand for Greater Transparency Nonprofit providers will continue to be pressed to increase transparency. > Scrutiny of Off-Balance Sheet Transactions Many providers have increased their use of off-balance sheet, or nondebt, transactions. Fitch will continue to evaluate the effect on financial ratios but expects the underlying credit quality for most providers to be largely unaffected. 9

11 Conclusion and Q&A 10

12 Fitch Ratings New York One State Street Plaza New York, NY FITCH Chicago 70 West Madison Chicago, IL FITCH London 101 Finsbury Pavement London EC2A 1RS UK Singapore 7 Temasek Blvd. Singapore The Fitch Group Fitch Ratings Algorithmics Fitch Training

Insurance Roadshow London, October 2008. Solvency 2 Update

Insurance Roadshow London, October 2008 Solvency 2 Update Agenda Progress to date Overview of key component of Solvency 2 Further issues for discussion Impact on ratings Solvency 2 - What s new? Progress