ANNUAL REPORT [SEC RULE 15C2-12]

Transcription

1 ANNUAL REPORT [SEC RULE 15C2-12] $40,500,000 LOUISIANA PUBLIC FACILITIES AUTHORITY HOSPITAL REVENUE REFUNDING BONDS (TOURO INFIRMARY PROJECT) SERIES 2015 Touro Infirmary (the "Corporation") hereby submits this Annual Report pursuant to SEC Rule 15c2-12 with respect to the captioned bonds and Section 3 of the Continuing Disclosure Agreement dated April 24, 2015 (the "Disclosure Agreement"), by and between the Corporation and The Bank of New York Mellon Trust Company, N.A., as the trustee. Capitalized terms used herein and not otherwise defined have the meanings assigned thereto in the Official Statement dated May 15, Attached as Exhibit A is a copy of the audited financial statements for the Corporation for the fiscal year ended December 31, Reference is made to Note 1 for a description of the organizational structure of the Corporation and its subsidiaries and Note 7 for a description of the Corporation s 2015 acquisition of a 49% interest in Crescent City Surgical Center ( CCSC ). Set forth below is the updated operational data required by the Disclosure Agreement. General Description of Services Touro Infirmary ( Touro or the Hospital ) provides comprehensive services including 24-hour emergency services, general medicine, critical care, surgical, rehabilitation, and obstetrics/gynecology services. These services are complimented by a complete range of diagnostic and therapeutic services. The licensed bed composition is as follows: Bed Type Table Bed Type Rooms Licensed Beds Medical Surgical Intensive Care Obstetrics Rehabilitation Total Licensed Beds Additional Capacity Nursery NICU Total Bed Capacity Source: Hospital Licensure Reports 1

2 Medical Staff The Medical Staff of the Hospital represents a diverse physician population of both academic and community physicians. The Medical Staff had a net gain of 35 physicians for A majority of the physicians were associated with Louisiana State University ( LSU ). However, several community physicians also joined the staff. Physicians representing the surgical specialties of breast surgery, bariatric surgery, and colon and rectal surgery were among the additions. Touro Infirmary continues to have strong Medical Staff leadership and recruit new talent to the organization. Despite age, Touro also has a dedicated cohort of physicians who continue to practice. Of physicians age 66 and above, the percentage of total admissions increased from 17% for 2014 to 25% for /31/2015 Composition of Medical Staff Staff Category Number of Physicians Percent Active % Courtesy % House Physician 14 2% Total % Source: Hospital Medical Staff Office Over the past five years, the Hospital has experienced a net increase of 86 physicians in its Medical Staff and had a total of 600 physicians on staff as of December 31, The table below summarizes the additions and deletions to the Medical Staff of the Hospital during the past five years. Medical Staff Turnover Year Additions Deletions Net Increase/ (Decrease) (13) (2) Source: Hospital Medical Staff Office 2

3 2015 Admissions by Medical Staff by Age Group Percentage of Age Group Number of Physicians (had at least one inpatient admit) Total Admissions 35 and below 33 10% % % % 66 and above 38 25% Total % Source: Hospital Medical Staff Office Top Ten Admitting Physicians Physician Specialty Age Board Certified 2015 Admits % of Total Admits 1 Internal Medicine 67 Y % 2 Pediatrics 66 Y % 3 Pediatrics 70 N % 4 OB/GYN 46 Y % 5 Pediatrics 69 Y % 6 Internal Medicine 51 Y % 7 OB/GYN 45 Y % 8 OB/GYN 55 Y % 9 OB/GYN 50 Y % 10 Internal Medicine/ Cardiology 46 Y % % * Includes adults and nursery admits for the year ended December 31, Source: Hospital Medical Staff Office 3

4 Historic Utilization Admissions (excludes Nursery) Medical Surgical Rehabilitation NICU TOTAL Fiscal Year Ended December , ,837 10, ,747 10, ,456 Patient Days - (excludes Nursery) Medical Surgical Rehabilitation NICU TOTAL 49,486 14,418 6,108 70,012 50,733 15,088 5,553 71,374 48,985 14,940 5,339 69,264 Average Daily Census Emergency Department Visits Outpatient Surgeries Home Health Visits Deliveries ,083 4,633 20,913 3, ,441 4,423 22,171 3, ,002 5,054 22,165 3,516 Source: The Corporation Market Share The following table sets forth historical data regarding the Corporation and certain other hospitals within the service area of the Corporation. The hospitals included in this comparison have been selected by the Corporation due to their close physical proximity to the Corporation and because of their direct competition with the Corporation. Historical Data Regarding the Corporation and Certain Other Orleans Parish Hospitals Discharges Orleans Parish *Q1-Q Touro Infirmary 10,875 10,820 7,820 Ochsner Baptist Campus 1,908 3,706 3,261 Tulane University Hospital 6,049 6,081 4,710 LSU Interim Public Hospital/UMC 4,080 4,212 3,323 Patient Days Orleans Parish *Q1-Q Touro Infirmary 52,555 54,150 39,130 Ochsner Baptist Campus 7,257 14,610 11,663 Tulane University Hospital 29,605 28,584 22,486 LSU Interim Public Hospital/UMC 26,559 25,997 19,950 Source: Truven/Thomson Reuters Louisiana Health Information Network (LHIN), includes normal newborns *Q1-Q3 data time period = Jan 1, 2015 Sept 30, Data for Q not yet available. Ochsner Health System relocated services from its Jefferson Parish Hospital to Ochsner Baptist Campus in January

5 Summary of Consolidated Revenues and Expenses of Unrestricted Funds Consolidated Summary of Revenues and Expenses of Unrestricted Funds Fiscal year Ended December 31, (000's omitted) Net Patient Service Revenues $ 341,754 $ 281,831 $ 324,302 Provision for Uncollectible Accounts 7,261 9,921 11,767 Net Patient Service Revenues Less Provision 334, , ,535 Other Operating Revenues 14,466 19,360 22,277 Total Operating Revenues 348, , ,812 Operating Expenses Salary and Employee Benefits 136, , ,095 Purchased Services, Supplies & Other 115, , ,228 Depreciation and Amortization 17,794 19,601 19,834 Impairment Interest 2,028 2, Total Operating Expenses 271, , ,135 Income from Operations 77,139 5,440 29,677 Non-Operating Gains and (Losses) Investment Income (Loss) 3,752 3,202 (353) Other Non-Operating Gains and (Losses) (4,849) (985) (1,875) Total Non-Operating Gains and (Losses) (1,097) 2,217 (2,228) Increase in Unrestricted Net Assets before adjustments noted below: 76,042 7,657 27,449 Net Assets Released from Restriction 525 1, Increase in Unrestricted Net Assets 76,567 9,453 28,340 Non-controlling Interests in Income of Consolidated Subsidiaries (51) (120) (122) Increase in Unrestricted Net Assets Before Other Changes 76,516 9,333 28,218 Adjustment to Pension Liability 5,385 (4,416) 1,270 Increase in Unrestricted Net Assets $ 81,901 $ 4,917 $ 29,488 Source: Audited Financial Statements of the Corporation 5

6 Sources of Patient Service Revenues The Corporation receives payment for services from commercial insurers and other private payors, the State of Louisiana under the Medicaid program, Health Maintenance Organizations ("HMO's"), other managed care entities including Medicaid managed care, the federal government under the Medicare program and directly from patients. Historical Payor Mix by Gross Revenue Medicare Managed Medicare Medicaid (includes Medicaid Mgd Care) Managed Care Other Worker's Compensation Private Pay & Charity % 24.6% 24.1% 23.2% 24.4% 24.9% 21.2% 19.1% 19.4% 24.7% 3.0% 0.7% 2.5% 25.6% 3.3% 0.5% 2.5% 26.2% 3.0% 0.7% 1.7% Source: The Corporation Selected Audited Balance Sheet Items Fiscal year Ended December 31, (000's omitted) Cash and Cash Equivalents 77,469 52,333 31,396 Funds internally designated by Board for: Capital projects and Specific Programs 46,254 47,921 47,217 Restricted by Bond Indenture, Debt Service Reserve 9,571 9,571 3,219 Other Restricted Purpose funds 1, Donor-restricted long-term investments 11,560 11,890 11,582 Total Cash Available 146, ,322 93,446 Long Term Bonds Payable 70,514 68,320 60,332 Unrestricted Net Assets 191, , ,614 Total Assets 336, ,661* 356,865 *Amount restated for consistency with 2015 classifications Source: Audited Financial Statements of the Corporation 6

7 Management's Discussion and Analysis of Recent Financial Performance Total operating revenues, consisting of both net patient service revenues and other operating revenues, were $334.8 million in fiscal year 2015, a decrease of $14.1 million (4.1%) from The decrease is attributed to a reduction in the Medicaid Supplemental Revenues ( MSR ) received from the State. In 2013, 2014 and 2015 the Corporation recorded MSR of $80.1 million, $21.7 million and $48.7 million, respectively. The $31.4 million reduction in MSR from 2013 was partially offset by a growth in the Corporation s net patient service revenue of $9.5 million (3.7%) during the same periods. In addition, from 2013 to 2015, other operating revenues grew by $7.8 million (54%). Overall inpatient volumes (excluding nursery) declined from 2013 to 2015; inpatient admissions were down 3.2% while inpatient days were down 1.1%. In spite of these inpatient declines the Hospital s net patient service revenues (excluding MSR) increased $8.7 million (4.0%) due to some favorable changes in patient service mix (i.e. Rehabilitation growth), generalized outpatient services growth (particularly infusion therapy, surgery and imaging services), negotiated/inflationary reimbursement rate increases and implementation of the strategic revenue cycle improvements recommended by Huron Consulting. Deliveries increased 5% from 2013 to Touro s delivery volumes were ranked as third largest in the State during 2013 and second in the State in 2014 and Emergency department (ED) visits decreased by 3.2% (2013 to 2015). The decrease is attributed to the openings of the new University Medical Center facility in August 2015 and the new New Orleans East Hospital ( NOEH ) in July 2014, both of which has syphoned off some ED volumes (primarily self-pay and Medicaid patients) into those facilities. During 2015, NOEH transferred 149 inpatients to Touro for services NOEH does not provide. The Corporation s employed physician network CCPI has increased from 50 physicians in 2013 to 55 in 2015; net revenues have remained relatively unchanged with an increase of $.3 million (1.2%) from 2013 to Woldenberg increased its net patient service revenue by $.5 million (3.4%) from 2013 to The improvements in recent years (including ) have been achieved by increasing independent unit occupancy by approximately 10.0% and an improvement in the nursing home payor mix. The Corporation has invested during the past several years in upgrades to modernize the aesthetics and amenities of the independent living units. For the Corporation, other non-patient operating revenues increased by $7.8 million (54%) from 2013 to 2015 primarily as a result of the new incoming CCSC earnings of $3.7 million (representing the Corporation s share of that facility s earnings), the increase in 340B retail pharmacy program revenue of $3.1 million and $1.1 million in new management related income for the Corporation s management of the NOEH facility. Electronic Health Record ( EHR ) Incentive Payments decreased in 2015 compared to prior years as the incentive payment program nears completion. The Corporation received EHR payments of $2.6 million, $1.5 million and $0.3 million in 2013, 2014 and 2015, respectively. These payments to the Corporation are funded by the programs established by the American Recovery and Reinvestment Act of 2009 for professionals and hospitals that adopt a meaningfully use certified EHR technology. Total operating expenses were $305.1 million in fiscal year 2015, an increase of $33.3 million (12.3%) from The Corporation has continued to provide its workforce market competitive merit increases while simultaneously focusing on the improvement of the efficiency of the workforce and the infrastructure of management positions. Salary and Employee Benefits have increased $13.6 million (10%) between 2013 and An increase of $2.7 million occurred in the Corporation's employed physician network as physicians were hired to expand existing services into new service areas and physician benefit packages were enhanced to remain 7

8 competitive. The remaining $10.9 million of the Salary and Benefit increase was due to market and merit wage adjustments and one hundred four (104) FTE increase from 2013 to 2015 in the Corporation s operations to align with the changes in service patterns, new initiatives and revised staffing targets during this period. There was a $4.4 million increase in the self-funded 2015 health insurance expense due to a higher incidence of individually large claims, the high cost of newly-released specialty drugs and overall increased utilization of plan benefits that took place in The efficiency of the labor force within the Hospital as measured by FTE s per Adjusted Occupied Bed which remained stable between 2014 and 2015 but were increased from the 2013 level; the measurements were 4.25 in 2013, 4.38 in 2014 and 4.39 in Purchased Services, Supplies and Other Expenses (composed primarily of Purchased Services, Supplies and Professional Fees, each discussed separately below) increased $18.7 million from 2013 to 2015 (16.2%). Purchased services increased by $11.5 million from 2013 to 2015 mostly due to a $9.5 million increase in the LCMC management fees. Much of the management fee increase is associated with the LCMC system-wide engagement of the Huron Consulting Group for a strategic performance improvement review and change management implementations for the revenue cycle and other shared service models, including supply chain, human resources and talent management, information systems and information technology, resulting in programmed and monitored financial/resource consumption improvements to the functions impacted. The performance improvement consulting fees will not repeat after Supply expense increased $4.7 million from 2013 to Aside from an inflationary increase of approximately $1 million, the remainder of the increase is associated with the increases in service mix to many more costly and complicated procedures (e.g., spine cases generated $1.5 million in new implant expenses in 2015). In addition, $1.1 million of the increase in supply cost since 2013 is associated with the 340B retail pharmacy program implemented in late 2013 (see increase in related 340B revenues included in non-patient operating revenues described above). Professional Fees increased by $2.4 million from 2013 to 2015 for two primary reasons: 1) the 2014 implementation of on-call payments for specialty physicians to provide emergency room coverage, which has equated to approximately $1 million per year, and 2) a $1 million increase in consulting fees primarily related to a major system conversion. Depreciation expense increased by $2.0 million (11.5%) from 2013 to 2015 due to the continued strategic investment in the Corporation s plant, equipment and information technology. Interest expense decreased by $1.0 million (51.8%) from 2013 to 2015 due to the effective rate savings achieved with the restructuring of the outstanding Bond Debt and associated interest rate swap agreements ( Swaps ); additionally, there was an early redemption of approximately $6 million of outstanding bonds in April and May of Income From Operations was $77.1 million, $5.4 million, and $29.7 million in fiscal years 2013, 2014 and 2015, respectively. The income translates into operating margins of 22.1%, 1.9% and 8.9% in the same fiscal years, respectively. Non-Operating Gains/(Losses) were $1.1 million Loss in 2013, $2.2 million Gain in 2014 and $2.2 million Loss in Non-Operating Gains/(Losses) include Investment Income/(Losses), which include dividend and interest income and realized and unrealized gains/(losses) on securities and unrealized gains/(losses) on interest rate swap agreements ( Swaps ). Investment Income/(Losses) were $3.8 million, $3.2 million and $-0.4 million, in fiscal years 2013, 2014 and 2015, respectively. Unrealized Investment Gains/(Losses) on investments, excluding Swaps, account for $2.1 million, $-2.6 million and $-1.8 million of Investment Income/(Losses) for fiscal years 2013, 2014 and Unrealized market value changes on the Swaps were $-1.0 8

9 million, $1.4 million and $-0.3 million for fiscal years 2013, 2014 and 2015, respectively. In 2015 the Swaps also realized a $0.7 million gain due to early termination prompted by a restructuring of the underlying Bond debt. While the restructuring will produce a financial saving to the Corporation in the future, the GAAP accounting for the transaction resulted in the Hospital having to record a $1.1 million Loss on the Extinguishment of Debt primarily due to the write down of balance sheet issuance cost and discount that were being amortized annually over the life of the bonds outstanding. Increases in Unrestricted Net Assets Before Other Changes were $76.5 million, $9.3 million and $28.2 million in fiscal years 2013, 2014 and 2015, respectively. These gains translate into excess margins of 21.9%, 3.2% and 8.4% in fiscal years 2013, 2014 and 2015, respectively. The significant fluctuations are primarily due to the varying amounts of MSR that the Corporation received in those given years as discussed above. The Corporation s liquidity represented by cash and cash equivalents and board designated funds has declined from $123.7 million in 2013, or days cash on hand, to $78.6 million in 2015, or days cash on hand, representing a $45.1 million decline. As described in Note 7 to the audited financial statements, in 2015 the Corporation exchanged consideration of $44.1 million for a 49% interest in CCSC. Long-term debt capitalization decreased from 26.9% in 2013 to 21.1% in Long-term debt decreased from $70.5 million in 2013 to $60.3 million in 2015 as a result of routine principal payments on the outstanding debt, in addition to $6 million in early redemptions when the debt was restructured in early Unrestricted Net Assets have grown from $191.2 million in 2013 to $225.6 million in 2015, an increase of $34.4 million an 18% improvement. Employees The Corporation, including Touro, Woldenberg Village, LLC and Crescent City Physicians, Inc. has 2,267 employees (2,003 Total FTE s) with competitive compensation and benefit programs. Total Employees FTE s* December 31, ,212 1,898 December 31, ,394 1,987 December 31, ,267 2,003 *2013 and 2014 data has been restated to be consistent with industry standard calculations,to include total manhours paid (employed and nonemployed). Annual Hospital Turnover Rate Annual Hospital Vacancy Rate December 31, % 4.89% December 31, % 5.09% December 31, % 5.74% Source: Corporation s Human Resource Office 9

10 Reference is made to Note 9 to the audited financial statements for a description of the Corporation s employee retirement plans, including the Corporation s decision to freeze the defined benefit plan as of December 31, Other Louisiana Children s Medical Center ( LCMC ) Affiliation LCMC is a Louisiana non-stock, not-for-profit corporation that was incorporated in 2009, with its founding member being Children s Hospital (Children s). Through a Health Care System Agreement between LCMC, Children s, Touro Infirmary and its subsidiaries, and Cooperative Endeavor Agreements ( CEA ) with University Medical Center Management Corporation (UMCMC) and West Jefferson Holdings, LLC, these parties have determined that together they can provide a multi-hospital, not-for-profit community-based system that will provide a continuum of care to the families of the Gulf South region. LCMC functions as the System Parent with reserve powers to be exercised to promote the best interest of the System and its affiliates. In addition, effective April 1, 2014, LCMC and Touro entered into a CEA with the Parish Hospital Service District for the Parish of Orleans to manage the daily operations of a new 80 bed public hospital located in eastern New Orleans, which is known as the New Orleans East Hospital ( NOEH ). NOEH, which opened in July 2014, is a managed affiliate of the LCMC Health System. Reference is made to Notes 17 and 20 to the audited financial statements for descriptions of transactions with LCMC and Affiliates. 10

11 Exhibit A Audited Consolidated Financial Statements of the Corporation and its Affiliates 11