Executive Summary Critical Access Hospital Financial Analyses

Transcription

1 xecutive ummary ritical ccess ospital inancial nalyses 2011 harles. wens xecutive irector atsy haley irector rittany. rown rogram pecialist nalysis erformed by: raffin and ucker, unded by the edicare unded by ural the ospital edicare lexibility ural ospital rant lexibility 7: rant 7: ,

2 able of ontents able 1: s haracteristics igure 2: perating argin igure 3: eturn on quity... 7 igure 4: ays ash on and... 8 igure 5: urrent atio... 9 igure 6: et ays evenue in ccounts eceivable igure 7: ong-erm ebt to apitalization igure 8: ebt ervice overage igure 9: atient ays ercentage by ayer igure 10: utpatient evenues to otal evenue igure 11: edicare cute ays as ercentage of otal ays igure 12: verage alaries per s igure 13: s per verage aily ensus igure 14: verage ge of lant igure 15: verage aily ensus igure 16: verage ength of tay (wing ed and cute eds) able 2: 2009 edian ndicator alues for eorgia and the nited tates ppendix lmanac of ospital inancial and perating ndicators published by ngenix a g e

3 ummary of indings he eorgia epartment of ommunity ealth (), tate ffice of ural ealth () contracted with raffin & ucker s to perform analyses on the fiscal sustainability of critical access hospitals (s) in eorgia. n on-site visit was made to each of the 32 participating s to assess their financial health. he latest (2007) audited financial statements, statistics, and edicare cost reports, as well as interviews with key management personnel, were analyzed. he data was collected and analyzed across six financial indicator dimensions. hese dimensions as suggested by the lex onitoring eam include: profitability, liquidity, capital structure, revenue, expenses, and utilization. 1 inancial data from each hospital was then compiled to present comparative financial information. he financial analyses were performed in three phases between leven hospitals were evaluated in 2007 and in 2008, and the remaining 10 in his report provides a summary of the comparative financial findings of the participating. s are identified in this report by a unique alpha character to maintain facility confidentiality. 2 ccording to eorge ink et al, ignificant differences in financial performance and condition exist among peer groups. 3 ariations exist in the types and number of services provided by s across the country. 1 his fact is believed to contribute to the variability in facility revenue and fiscal sustainability among s. eorgia s s mirror the operational trend of the s throughout the nation in that they do not conform to a universal operating model. he 32 eorgia s can be characterized by several factors, including but not limited to ownership and management type, system affiliation, and the diversification of services provided. esearch and data suggests that diversification of the services provides an additional source of revenue 1. hirty-one of the 32 eorgia s operated swing bed programs; however, the utilization of these programs varied greatly by hospital. ore than half (59 percent) of the 2 raffin & ucker, une 2010 ritical ccess ospital inancial nalyses ink,.., olmes,.., lpe,., trunk,.., cee,. and lifkin,.. (2006), inancial ndicators for ritical ccess ospitals. he ournal of ural ealth, 22: ink,.., olmes,.., hompson,.., lifkin,.. (2007) ariations in inancial erformance mong eer roups of ritical ccess ospitals. ournal of ural ealth, 23(4), a g e

4 hospitals also operated skilled nursing facilities and/or rural health clinics. ix of the 32 s operated mergency edical ervices () and 29 percent operated physician practices. he ownership and management types of the 32 s included those hospitals that are independent hospital authorities and able 1: s haracteristics those managed or owned by larger tertiary care facilities or private corporations. he classification of the 32 eorgia s are as follows: 50 percent (16/32) independent hospital authorities 38 percent (12/32) owned/leased 9 percent (3/32) affiliated 3 percent (1/32) other s wing ed ural ealth linic ndependent/uthority- 50% ffiliated - 10% 4 wned/eased a g e - 38% ther- 2% mergency edical ervices killed ursing acility hysician ractice acon ounty ospital ffingham ospital organ emorial ospital each egional edical enter utnam eneral ospital alhoun emorial ospital eff avis ospital onroe ounty ospital arms pring edical enter iller ounty ospital enkins emorial ospital andler ounty ospital iberty egional edical enter creven ounty ospital ills emorial ospital ower conee ommunity ospital hatuge egional ospital iggins eneral ospital hoebe orth edical enter leckley emorial ospital rooks ounty ospital harlton emorial ospital ptim edical enter of attnall asper emorial ospital arly emorial ospital itchell ounty ospital ountain akes edical enter t. oseph's at ast eorgia olk edical enter egional edical enter ouis mith emorial ospital linch emorial ospital ther

5 lthough edicare reimburses qualified s at 101 percent of allowable cost, the majority of these designated facilities are struggling to breakeven. n order to determine eorgia s profitability, otal argin, perating argin and eturn on quity were analyzed. ccording to the lmanac of ospital inancial & perating ndicators, otal argin defines the percentage of total revenue that has been realized in the form of net income, or excess revenues over expenses. 4 he perating argin measures the revenue and costs that are solely related to patient-care activities. f the 32 hospitals included in the analyses only 10 had a positive otal argin, while only 5 had a positive perating argin. ixty-nine percent (22/32) of eorgia s are operating with a negative otal argin. eorgia s median otal argin, -1.6 percent, is significantly below the national median, 2.4 percent. eorgia s otal argin ratios ranged from a percent to a 9.0 percent, with the mean otal argin of -3.6 percent. igure 1: otal argin -41.9% -0.3% -0.5% -0.6% -0.8% -1.3% -1.4% -1.8% -2.2% -3.8% -4.2% -4.8% -6.1% -6.9% -7.2% -7.6% -9.1% -11.0% -12.1% -13.7% -14.9% -16.7% -3.6% -1.6% 9.0% 8.8% 7.5% 6.7% 6.0% 4.9% 4.3% 2.5% 1.9% 0.1% 2.4% edian at'l ean 4 enter for ealthcare ndustry erformance tudies (), lmanac of ospital inancials and perating ndicators, 2009 ed. (ngenix ublishing roup, 2000). 5 a g e (xcess evenues over xpenses/ otal evenue) 100

6 ighty-four percent (27/32) of s are operating with a negative perating argin. perating argins ranged from percent to 7.9 percent with a median perating argin of -6.7 percent compared to the national median perating argin of 2.4 percent. hese negative margins greatly affect the ability of s to generate the financial return required to replace assets, meet increases in service demands, and compensate investors. negative perating argin is usually an early sign of financial difficulties. igure 2: perating argin -35.6% -24.3% -6.7% -6.2% -18.4% -15.6% -15.3% -13.8% -13.2% -12.3% -11.8% -9.4% -9.1% -7.3% -6.9% -6.9% -6.5% -6.4% -5.9% -4.7% -4.3% -3.2% -2.7% -2.2% -1.4% -1.3% -1.1% -1.1% -0.9% 2.4% 1.8% 4.3% 6.7% 7.0% 7.9% at'l ean edian ((perating evenue-otal perating xpenses)/ perating evenue) a g e

7 he eturn on quity ratio was used to determine eorgia s ability to add new investments in plant and equipment without adding excessive levels of new debt. nly 24 percent (8/32) of the participants experience a positive return on equity, while 75 percent (24/32) of the participants experienced a negative return. f those with a negative eturn on quity, 22 also experienced net losses for the fiscal year. eturn on quity ratios ranged from a low of -2, percent to a high of percent. n increasing trend is viewed positively. igure 3: eturn on quity eturn on quity , (xcess evenues over xpenses/ et ssets) 100 iquidity indicators: ays ash on and, urrent atio, and ays in ccounts eceivable were analyzed to measure the ability of the 32 participating s to meet cash obligations in a timely manner and to pay off debts on a short-term basis. edians for two of the three indicators of liquidity (ays ash on and hort-erm, 7 a g e

8 and urrent atio) were lower than the median values for the national s; while the et verage ays in ccounts eceivable was greater than the national median. he median ays ash on and for eorgia s was days compared to the national median of days. edian ays ash on and ranged from days to days. n average s in eorgia could operate for approximately days if no cash was collected or received. n increasing trend in ays ash on and is desired in all health care organizations. igure 4: ays ash on and at'l ean edian (ash + hort-term nvestments)/ ((otal xpenses-epreciation xpenses)/365) urrent atio measures the number of times short-term obligations can be paid using short-term assets. his is the most widely used measure of liquidity. 8 a g e

9 higher value for the urrent atio implies that a hospital is in a good position to pay short-term obligations; their assets are greater than their liabilities. he median urrent atio for eorgia s was 1.75 compared to the median national urrent atio of here were significant variances in urrent atio among participants. urrent ratios for eorgia s ranged from 0.4 to 5.5. igure 5: urrent atio at ean e urrent ssets/urrent iabilities et ays in ccounts eceivable is based on the latest audited fiscal year end and the accounts outstanding at the time of the on-site visit. 9 a g e

10 he number of days required for eorgia s to collect receivables ranged from days to days, with a median of days. he national median et ays in ccounts eceivable was he report suggests that variability in et ays in ccounts eceivable may be attributable to varying bad debt policies. reater days in accounts receivable places hospitals at higher risk by decreasing their ability to meet shortterm obligations. igure 6: et ays evenue in ccounts eceivable ean at'l ed (ccounts receivable - llow for uncollectible) / (otal operating revenue / 365) apital tructure was evaluated to determine the extent of debt and equity financing. ong-erm ebt to apitalization and ebt ervice overage were used to access capital structure. ong-erm ebt to apitalization measures the percentage of total capital that is debt. his ratio is used to identify the amount of long-term funds supplied by creditors to access financial leverage utilized by the. his is used to quantify and analyze risk exposure. igher values indicate a greater 10 a g e

11 percentage of capital is shown as debt as opposed to equity. ebt allows not-forprofit organizations to provide more services than it could if it were financed only by contributed capital and retained earnings. 5 ospitals that have a leverage ratio greater than 50 percent are generally considered a greater risk than those with lower ong-erm ebt to apitalization igure 7: ong-erm ebt to apitalization ratios. his is generalized because the ratio implies the s ability to carry debt is lowered. declining trend is positive. n the other hand, s with very low ratios may indicate opportunities for debt financing. he ong-term ebt to apitalization ratio for the participating s ranged from percent to percent. he national median ong-term to ebt apitalization ratio is 20.7 percent. he median for the 32 s is percent % % % % 26.23% 14.91% % % % 97.40% 96.18% 88.50% 69.34% 67.80% 62.90% 54.80% 43.39% 33.00% 29.83% 23.10% 16.11% 13.70% 12.70% 8.90% 6.60% 5.30% 3.93% 3.70% 2.73% 0.88% 0.00% 0.00% 0.00% % at'l edian edian s,, and did not indicate long-term debt on their financials. ospitals,,, and indicated long-term debt is comprised of intercompany payables. 5 nland,.; onton, ; ot-or-rofit ospitals ace ew hallenges ccessing apital,arch 3, 2003<accessed> 09/31/ a g e ong-erm ebt / (ong-erm ebt + et ssets) 100

12 ebt ervice overage measures the ability to meet debt service payments from cash flow. he measure does not take into account positive or negative cash flow associated with balance sheet changes. higher ratio is favorable and an increasing trend is desirable. 4 igher values are viewed positively by creditors. he ebt ervice overage ratio for the hospitals ranged from to ospitals,,,, and had no long-term debt principal payments. ospital s long-term debt is due to intercompany expenses with no fixed principal payments. 1 igure 8: ebt ervice overage ((xcess-7.4 evenue / xpenses + nterest xpense) + epreciation & mortization xpenses))/ (ebt rincipal ayments + nterest xpenses) raffin & ucker, une 2010 ritical ccess ospital inancial nalyses enter for ealthcare ndustry erformance tudies (), lmanac of ospital inancials and perating ndicators, 2009 ed. (ngenix ublishing roup, 2000). 12 a g e

13 nalyses were performed to evaluate and compare revenue and costs among the participating s. evenue indicators measure the amount and mix of different sources of revenue. he atient ays ercentage by ayer, utpatient evenues to otal evenues atio and edicare ays as a ercentage of otal igure 9: atient ays ercentage by ayer ays measures were used to analyze the revenue of the participating s. xpense/cost indicators measure the amount and mix of different types of costs. he expense/cost indicators that were measured were verage alaries per s, s per verage aily ensus, and ge of lant atient ays ercentage by ayer edicare atient ays ercentage by ayer ther atient ays ercentage by ayer edicaid 13 a g e

14 ore than half of acute patient days for 28 of the 32 s in eorgia are attributed to edicare patients. his payer percentage is significantly higher than that experienced in prospective payment system () hospitals. edicare patient days ranged from days to days. he second largest payer group was classified as ther. his group is comprised of the commercial, self-pay and other payers. ccording to the latest audited financial statements, the largest component of this group was self-pay. edicaid patients were the smallest percentage of payers amongst all of the participants. utpatient services comprise the majority of many hospitals revenue base. utpatient evenues to otal evenues measures the percentage of total revenues that are for outpatient services. utpatient revenues for the participating hospitals ranged from 28 percent to 89 percent. he median outpatient revenue to total revenue for the 32 eorgia ritical igure 10: utpatient evenues to otal evenue % 89.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 28.00% 30.00% 20.00% 10.00% 0.00% otal utpatient evenue/ otal atient evenue 14 a g e

15 edian ean ccess ospitals was 56 percent compared to the national median of 70 percent. he higher the edicare utilization, the more difficult it is for a to generate a profit. edicare will reimburse 101 percent of its share of allowable cost; therefore profits must come from other payer sources. ospital had the lowest combined percentage of edicare days for acute and swing bed at 14.6 percent, while ospital had the highest combined percentage at percent. he median edicare cute ays as ercentage of otal ays for participating s was percent. igure 11: edicare cute ays as ercentage of otal ays 90.00% 80.00% 83.90% 70.00% 60.00% 58.70% 50.00% 40.00% 30.00% 20.00% 10.00% 14.60% 0.00% ncludes cute and wing ed 15 a g e

16 he majority of s administrators would agree that staff retention is consistently of major concern. study conducted as a part of the / ational racking roject in 2003 suggested that competitive salaries was the third most important factor in recruitment and retention. 6 verage alaries per ull ime quivalent () ranged from a low of $17, to a high of $60, he median of the average salary per s was $35, igure 12: verage alaries per s ean edian $35, $37, $17, $19, $21, $23, $24, $26, $27, $29, $29, $31, $31, $33, $33, $34, $36, $37, $37, $38, $38, $38, $38, $39, $40, $40, $40, $40, $41, $41, $42, $43, $50, $60, xcludes on-ospital omponents he use of shared staffing in hospitals with killed ursing acilities () components may distort the average salary comparisons. se of contract services, rather than employed staff will also affect comparability. he omponent and contract staff were excluded from the average salaries calculations. 1 6 / ational racking roject, indings from the ield olume 3, umber 6 ovember 18, a g e

17 s per verage aily ensus measures the number of full-time employees per each average occupied patient bed. ery high values may indicate low volume and a potential opportunity to evaluate staff productivity. ery low values may indicate high volume or a high level of staff productivity. s per verage aily ensus ranged from a high of 5.82 s to a low of 2.37 s. he median s per verage aily ensus for the 32 participates was 3.98 s. igure 13: s per verage aily ensus any participants use contract services, rather than employed staff to perform certain functions. he use of contract staff will affect the comparisons. here are also participants that, as a component of a hospital system, benefit from consolidated billing functions a g e

18 he verage ge of lant ratio provides a rough estimate of the age of eorgia s s fixed assets. his includes the average age of property, plant and equipment owned by the hospital. he average age of plant ratio for the 32 s spans from 1.0 years to 34.5 years. he average age is directly affected by ongoing renovations to the facility. ower values indicate new facilities and equipment, whereas higher values indicate greater amounts of older assets. ery high values may indicate a need for fixed-asset replacement. igure 14: verage ge of lant ecent purchase or lease ecent purchase or lease ccumulated epreciation/ (epreciation + mortization xpense) raffin & ucker analyzed the verage aily ensus (swing beds and acute beds) and the verage ength of tay (swing beds and acute beds) for the a g e

19 participating s. hese utilization indicators measure the extent to which fixed assets are fully occupied. nder federal legislation, s are limited to 25 beds. onsistent with their bed size, s historically have a low average daily census; the verage aily ensus for the 32 s acute beds is 5.63 patients. hen swing patients are included in the calculation, the average daily census increased by 12 percent to 6.3 patients per day. verage aily ensus for acute beds ranged from 16.3 patients to 1.1 patients a day. verage aily ensus for swing bed patients ranged from a low of 0 to a high of patients. igure 15: verage aily ensus ed ver verage aily ensus verage aily ensus- cute / wing ed ays/ ays in eriod = verage aily ensus / cute are ed ays/ ays in eriod = verage aily ensus cute 19 a g e

20 s must maintain an annual average length of stay of 96 hours or less for their acute care patients. here is no length of stay limit for swing bed patients. he average length of stay acute days for the 32 participating s ranged from a low of 0 days to a high of 22.2 days. he median average length of stay for acute care was 3.25 days. he average length of stay swing bed ranged from 2.1 days to 3.8 days. here were significant differences in both average daily census () and average length of stay () among the participants. wing beds are highly utilized by eorgia s; however, their models of utilization greatly differ. ospitals,, and provided high volumes of therapy services to the patients, which would indicate that a majority of the patients were admitted for rehabilitative services. ome s are providing post-orthopedic and stroke aftercare to the patients, while others are using the swing beds as an interim level of care between the acute and killed ursing acility () settings igure 16: verage ength of tay (wing ed and cute eds) verage ength of tay 20 a g e otal npatient ays, wing ed / otal ischarges, wing ed = verage aily ensus otal npatient ays, cute are / otal ischarges, cute are = verage ength of tay cute

21 ationally, ritical ccess ospitals vary substainally from one another in organizational structure, ownership and management type, the diversification of services provided, and the method of delivery of services. hese key differences have a large impact on the variances in the financial health of these hospitals. here is also evidence to justify that geographical location may also contribute to financial variances amongst s. hose located in the western and id- estern regions of the are less impacted by the external forces that cause a greater concern for those located in the outheastern region. xternal forces as recognized by the outheastern states include proverty rates, payer mix, health status and provider availability. hese and other forces weigh heavily on the financial outcomes of s. comparision of the overall financial health of eorgia s and the ational s standards can be seen in able 2. has been suggested that diversification of services will provide additional revenue sources; this is necessary to offset shrinking inpatient volumes. roverty levels are higher in areas where some s are located, greatly contributing to decreased profitability. he second largest payer group consisted of self-pay and commercial insurance, with self-pay comprising the majority of this group. his greatly impacts the amount of bad debt and charity care write-offs. ritical ccess ospitals in eorgia are heavily influenced by the external force of edicare. ore than 50 percent of inpatients seen by eorgia s are edicare patients. s a result, the slightest change in edicare regulations has the potential to greatly alter the bottom line of eorgia s s. ollowing the trend of financial variability among s in the nited tates, eorgia s showed great variations in many of the financial indicators that were accessed through this review. ach was found to be unique. hey differ in ownership and management type, the amount of financial support given by the community, and the sevices provided. t 21 a g e

22 able 2: 2009 edian ndicator alues 2009 edian ndicator alues for eorgia and the nited tates inancial ndicators eport ssue 8 ndicator otal argin ash low argin eturn on quity perating argin urrent atio ays ash on and et ays evenue in ccounts eceivable quity inancing ebt ervice overage ong-erm ebt to apitalization utpatient evenues to otal evenues atient eductions edicare npatient ayer ix edicare utpatient ayer ix edicare utpatient ost to harge edicare evenue per ay alaries to et atient evenue verage ge of lant s per djusted ccupied ed verage aily ensus wing- eds verage aily ensus cute eds umber of ncluded s ource: lex onitoring eam ata ummary eport o. 6. (ctober 2009) inancial ndicators eport: ummary of ndicator edians by tate. etrieved from 22 a g e

23 ppendix nless otherwise note, data used in the raffin& ucker, ritical ccess ospital inancial nalyses was taken from the hospitals latest audited financial statements and/or the latest filed edicare cost reports. iscal ear nd iscal ear nd ational averages included in various charts were obtained from the 2009 lmanac of ospital inancial and perating ndicators published by ngenix. 23 a g e

24 he 2009 lmanac of ospital inancial and perating ndicators was used to analyze the desired trend of the key financial indicators used to assess eorgia ritical ccess ospital s financial health. he chart summarizes the desired position of a hospital in terms of trends and medians. esired osition rend edian perating argin p bove otal argin p bove eturn on quity p bove esired osition rend edian urrent atio p bove ays ccounts eceivable own elow ays ash n and p bove esired osition rend edian ebt to ervice p bove ong-erm ebt to apitalization own elow 2009 lmanac of ospital inancial and perating ndicators published by ngenix 24 a g e