Management s Discussion and Analysis of Financial Condition and Results of Operations Quarter ended June 30, 2015

Transcription

1 Management s Discussion and Analysis of Financial Condition and Results of Operations Quarter ended June 30, 2015 Todd Hofheins, Executive Vice President and Chief Financial Officer

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3 Introduction to Management s Discussion and Analysis Management s discussion and analysis provides additional narrative explanation of the financial condition, operational results and cash flow of Providence Health & Services (Providence) to increase understanding of the health system s combined financial statements. The discussion and analysis should be read in conjunction with the accompanying unaudited combined financial statements. Core strategy: Creating healthier communities, together As health care evolves, Providence is responding with a vision and core strategy to transform and innovate at scale. Across five states, Providence and its affiliates continue to pioneer how care is delivered by sharing one strategic plan designed to improve the health of entire populations by supporting the well-being of each person we serve. Our core strategy of Creating healthier communities, together is supported by five specific areas of focus in our strategic plan: Inspire: We must first inspire and develop our people. Know: To serve our communities effectively, we are building enduring relationships with consumers. Partner: Providing the best care requires new alignments with clinicians and care teams. Adapt: We ll develop and thrive under new care delivery and economic models. Adopt: To serve more people we will grow by optimizing expert-to-expert capabilities. This plan supports our vision, Together, we answer the call of every person we serve: Know me, care for me, ease my way, which is our promise to our patients, customers and communities. Through innovation, excellence, good stewardship and working together across Providence, we will continue to lead change to improve the health of our communities. Community benefit: investments to improve health and increase access In an environment of decreased reimbursement for government-sponsored medical care, community benefit spending related to the unpaid costs of Medicaid were $277 million in the first six months of A recent legislative decision in Montana and the use of executive power by the governor of Alaska means that every state served by Providence has chosen to broaden coverage for Medicaid. An estimated 70,000 Montanans and more than 40,000 Alaskans will have new eligibility to apply for this coverage. Providence continued to expand the number of patients served in the first half of 2015, for a total of 3.2 million people served in the past 12 months. Providence cares for everyone, regardless of their ability to pay. In the first half of 2015, we provided more than $67 million in free and discounted care. Many people who were previously uninsured now have access to health care through Medicaid expansion and the insurance exchanges. In the future, this coverage can help people access preventive care and address medical conditions before they are serious enough to need treatment in an emergency department. Providence s efforts to help people enroll in health insurance were so successful that we were invited to participate in panel presentations at the high-profile State of Enrollment conference in Washington, D.C., June 10-12, A case study featured how community leadership and Providence s strong outreach and commitment to train caregivers as certified application counselors helped reduce the uninsured rate Page 3

4 in the state of Montana from 20.7 percent in 2013 to 15.8 percent after the first year of enrollment under the Affordable Care Act. Commitment to quality: improving consumer experience and safety Providence named a 'Most Wired' health system Providence has been recognized as one of the Most Wired organizations in health care by the American Hospital Association s Health Forum and the College of Healthcare Information Management Executives. The survey examined how organizations are leveraging information technology to improve performance for value-based health care in the areas of infrastructure, business and administrative management, quality and safety and clinical integration. Providence's use of a single electronic health record across all patient care facilities was a primary factor in being chosen for this recognition. The Epic system has already shown results when it comes to improving the safety and care we provide our patients. High Quality and Reliability To become a high reliability organization with an internally driven safety focus, Providence has partnered with Healthcare Performance Improvement, a global organization with a successful track record of advancing safety and reliability across the health care industry. Together, we are building on Providence s strong foundation of high-quality care in a systematic way to spread evidence-based safety behaviors and practices even more broadly. Currently, all of our regions have undergone assessments and design sessions to address the most common causes of adverse safety events. This will lead to the development and use of a common set of tools and behaviors to guide our work, so that every caregiver will have the knowledge and support needed to consistently deliver safe, high-quality care, regardless of what role they serve in contributing to the health of our patients. Leadership training is in the beginning stages and we will launch the first caregiver training this summer. Ensuring we have an environment for the reliable delivery of safe care is critical to our efforts to improve the outcomes, experience and affordability of the care and services we provide to our communities across five states. Growth: collaborating with like-minded partners The Sisters of St. Joseph of Orange On July 31, 2015, Providence and St. Joseph Health signed a letter of intent to create a new, single organization. In addition to sharing common missions, St. Joseph Health and Providence share similar heritages. The Sisters of St. Joseph of Orange were called to meet the needs of Northern California 103 years ago and eventually grew to serve other parts of the state, as well as communities in Texas and New Mexico. Nearly 160 years ago, the Sisters of Providence voyaged from Montreal to Fort Vancouver, Wash., to build health care in the Northwest, eventually growing to serve Alaska, California, Montana, Oregon and Washington. Providence and St. Joseph Health complement one another; while we serve different communities, together we form a contiguous geography. Additionally, both systems maintain a strong tradition of Catholic health care and share a philosophy of inclusion and diversity. Both systems include non- Catholic health care affiliates that share a mission to care for everyone, especially those who are poor Page 4

5 and vulnerable, and that have maintained their original faith tradition or secular status, as well as their brands and rich heritage traditions. Discussions are in the early stages and specific details about a partnership have not been finalized. St. Joseph Health and Providence expect discussions to take place during the next several months. Seattle Science Foundation The Seattle Science Foundation (SSF), a not-for-profit educational facility, is the newest member of the Providence family. SSF is a state-of-the art facility where physicians can learn how to use the newest instruments and train on the latest procedures. It includes a bioskills lab that simulates the operating room and offers the ability to train on cadaver specimens. It also features conference facilities and highspeed internet connectivity that makes it possible to broadcast courses to physicians worldwide. This partnership will bring more training opportunities to our specialists and provide a venue where clinicians can learn from one another and invent new techniques that will change health care. Providence Neurosciences Institute Across five states, Providence provides advanced and coordinated treatment for the full range of brain, spine and central nervous system conditions. Neurologists and neurosurgeons from across our system are actively engaged in system-wide clinical focus groups striving for clinical excellence, appropriate standardization and decreasing treatment and outcomes variations. In the past year within the neurosciences service line, system-wide collaborative groups were formed and successfully reduced our $67 million annual spinal implant expense by $12.1 million per year, built the nation s largest stroke registry; which holds over 52,000 records and adds over 7,000 new records each year, and developed standardized care pathways for the most prevalent forms of brain cancer. In the upcoming year these clinicians will continue to work on a list of 35 ongoing projects, while also adding new and impactful projects identified by physicians within our focus groups. Learning from the successes of our clinical performance groups, Providence has begun development of a virtual system-wide Neurosciences Institute. This Institute will unify a roster of world-class neurologists and neurosurgeons under a common, system-wide neurosciences brand. Patients receiving care from the Institute will experience the same exceptional quality supported by the same cutting-edge technology, regardless of whether they receive their neuro care in Los Angeles or Seattle. The Institute will be built on our proven ability to facilitate cross-regional clinical collaboration, as well as Providence s unique ability to gather disease-specific clinical data from one of the world s largest EHRs. Data from our EHR will be augmented by disease-specific registries for neurovascular care, brain tumors, spine outcomes and multiple sclerosis; each of which Providence already has a functioning pilot ready to be scaled system-wide. Data will be analyzed by a Healthcare Intelligence team staffed with biostatisticians and supported by clinical experts; these analytics will drive research and clinical improvement. When combined with a system-wide decision support system, the Institute will have the ability to quantify the financial impact of these improvements in quality, as well as identify new areas of opportunity to drive down costs, improve quality and increase access to those in need. Ultimately, building upon successes in clinical collaboration Providence s neuroscience institute will become a world leader in the treatment of brain, spine and nervous system conditions. Page 5

6 Innovation: leading dynamic change Finding better solutions faster We are developing an innovation ecosystem in which technology companies that solve important problems in health care work with Providence to deliver higher quality health care at a lower cost, with a better customer experience for consumers, patients and clinicians. To achieve this, we ve established three innovation groups that are working together to lead dynamic change across Providence. Since the inception of Providence Ventures fund 10 months ago, we have reviewed a significant number of investment opportunities focusing on six core areas: online primary care access, care coordination and patient engagement, chronic disease management, clinician experience, data analytics and consumer health and wellness services. Sqord, one of the first wearables designed specifically with kids in mind, has received $2.3 million in seed-round funding from Providence to expand the program to seven sites. A successful pilot program in several northwest Washington communities has showed that 5th grade students increased their activity by percent by using Sqord. The Digital Innovation Group has moved its headquarters to Seattle, Washington, where it can continue to grow and attract top talent for development, product and commercial expertise. This work is complemented by the Consumer Innovation Group, which is working on making care delivery more customer-focused. Rewarding quality, not quantity Several areas within Providence have been doing amazing work to advance our population health strategies, including our physician networks, Providence-Swedish Health Alliance and other accountable care teams, contracting services and our health plan. As of June 30, 2015, Providence serves 606,000 members in these types of arrangements aimed at partnering with patients to improve their overall health. We continue to invest in the infrastructure, including care management, data analytics, clinical design and network formation needed to support our transition to alternative payment methods and increased accountability for clinical outcomes, member experience and predictable costs. As we work to serve more people through value-based models of care, we welcome one of the nation s most respected experts in the field who joins Providence as the new executive vice president of population health. Rhonda Medows, M.D., began her role with Providence in May She comes to us by way of UnitedHealth Group, one of the largest health insurance and population health management organizations in the country. She served as executive VP and chief medical officer for United for the last five years. Financial performance Operating income was $216 million with a 3.0 percent operating margin for the six months ended June 30, 2015, which was $102 million ahead of budget. Net income for the same period was $283 million, which was $28 million ahead of budget. Operations benefited from strong revenues that grew 21.7 percent over the prior year compared with expense growth of 20.8 percent. Operations have generated Page 6

7 $679.4 million of EBIDA (earnings before depreciation, interest and amortization). Cash reserves of $6.2 billion as of June 2015 represented 176 days cash on hand, compared to 175 days as of March Financial performance was impacted by Medicaid provider tax programs in several states in which we operate. These states continue to face budgetary challenges due to the slow economic recovery and other factors that have resulted in reduced Medicaid funding levels to health care providers. As an alternative means of funding provider payments, many of the states we serve have adopted broad-based provider taxes to fund the non-federal share of Medicaid programs. Providence recorded net operating income of approximately $60 million during the first six months of 2015 related to these programs. Net income also includes $31 million in revenue related to the Hospital Transformation Performance Program, an incentive pool established by the Oregon legislature for diagnosis-related group hospitals that implement and report on health care delivery reform initiatives. The table below presents consolidated key financial indicators. Key Financial Indicators YTD June 2015 Actual Budget Organic Growth Actual* 2014 Net Operating Income $216.2m $113.9m $187.0m $133.1m Operating Margin % 3.0% 1.7% 2.7% 2.2% Net Income $283.2m $255.5m $250.6m $719.7m EBIDA $679.4m $680.0m $622.4m $655.0m Total Community Benefit $431.5m $417.5m $411.1m $371.9m Accounts Receivable Days Days of Cash on Hand Long-term Debt to Total 32.9% 30.6% 32.4% 33.8% Capitalization Cash to Debt 137.9% 131.4% 148.1% 121.9% *Excludes results for any affiliated entities not included in the 2014 comparative results due to affiliation date. Volume Year-to-date acute care admissions of 180,213 were 3.2 percent ahead of budget and 11.6 percent higher than prior year. The increase was partially driven by 8,538 admissions at facilities that affiliated with Providence in Observation visits of 27,368 were 5.5 percent behind budget on a year-to-date basis and 6.0 percent lower than prior year. Surgeries of 118,756 were higher than budget by 3.3 percent. Inpatient surgeries were higher than budget by 1.7 percent, as well as outpatient surgeries were above budget by 4.8 percent, demonstrating the transition of care from acute to ambulatory settings. Outpatient emergency visits were 9.7 percent ahead of budget, with 637,843 visits compared with 547,133 in the prior year. The increase was partially driven by 39,286 outpatient emergency visits at facilities that affiliated with Providence in Physician visits of 3.8 million were 588,525, or 18.1 percent greater than prior year. The increase was partially driven by 298,922 physician visits at facilities that affiliated with Providence in Continuum services, which include long-term care, hospice, supportive housing, assisted living and home health, Page 7

8 providedd 1,157,632 visits and were 3.0 percent higher thann prior year. The net impact of the volumes above resulted in gross revenues that were $781 million above budget. Inpatient gross revenuee was above budget by $322 million. The following table presents consolidated key volume indicators. Key Volume Indicators YTD June 2015 Organic Actual Budget Growth 2014 Actual* Inpatientt Activity Inpatient Admissions Outpatient Activity Outpatient Revenuee Non-Acute Patient Visits Physician Care Visitss Connected Lives - Member Months CMI Adjusted Length of Stay (Days) Rate - Net Service Revenue/CMAA Observations 180,213 $5,693m 1,157, 632 3,838, 187 2,995, $12,322 27, ,544 $5, 489m 1,132,900 3,796,748 2,741, $11,953 28, ,675 $5,320m 1,157,632 3,539,265 2,995, $12,332 27, ,497 $5,153m 1,123, 518 3,249, 662 2,536, $11,562 29,108 *Excludes results for any affiliated entities not included in the 2014 comparative results due to affiliation date. The following charts show comparisons of the source of YTD gross revenue for June 2015 and June % 9% 32% % 2015 YTD Gross Revenue 55% Total Ac cute Care - Inpatient Total Acute Care - Outpatient Total Primary Care Non-Acute Care % 2014 YTD Gross Revenue 7% 4% 34% 55% Total Acute Care - Inpatient Total Acute Care - Outpatient Total Primary Care Non-Acute Care Revenue Year-to-datee operating revenue was $97.6 million ahead of budget and 18.5 percent greater than prior year. Net service revenue accounted for $595 million of the favorable variance. Capitated and premium revenue of $924 million was $35 million behind budget and $ 123 million greater than prior year. Capitated and premium revenue represented 13 percent of Providence s total operating revenue through the second quarter. Meaningful use funding of $5.6 million was recognized in other operating revenue. Page 8

9 The following table presents the components of operating revenue. December Operating Revenuee Month to Date Year to Date Prior Year (in millions) Actual Budget IP Net Service Revenue OP Net Service Revenue Medical Group Continuum Services Bad Debt Capitated & Premiumm Revenuee Other Revenue Total Operating Revenue $ ( 16.9) $1,228.2 $ (24.6) $1,130.6 Actual $3, , (89.0) $7,316.7 Budget $2,852.4 $2, , , (142.7) (70.1) Actual $6,723.0 $6,009.7 The following tables show comparisons of the source of actual and budgeted payer mix based on gross revenue through June % 2% Actual 4% 3% Budget 19% 33% Self-pay Commercial Medicaree 18% 32% Self-pay Commercial Medicaree 43% Medicaidd Other 43% Medicaidd Other Operating Expenses Year-to-datee operating expenses were $491 million unfavorable to budget,, driven in part by purchased medical services related to capitated and premiumm contracts. These claims and medical expenses representing medical services purchased outside of the healthh system were $102 million greater than budget due to growth in enrollment and capitated revenue, as discussed above. Operating expenses, excluding purchased medical expenses and healthcare taxes, were $1588 million unfavorable to budget. Supply expenses were $ 82 million, or 8.9 percent behind budget through June. The unfavorable supply expenses are largely due to increased pharmaceutical expenses, which were 18.8 percent unfavorable to budget and 37.2 percent higher than the same six month period in Pharmaceutical price increases averaged 35.2 percent over the prior year, with particularly high inflation among sole-source generic drugs and specialty pharmaceuticals. Most of the price inflation on sole-source generic drugs was concentrated to a few particular treatments where six particular drugs accounted for 14 percent of the total year-over-year Page 9

10 price increases, with inflation on some drugs these drugs increasing as much as 7,700 percent over the prior year. Similarly, specialty pharmaceutical prices increased 23 percent during the same period, along with an increase in prescribing rates. Providence is actively growing our specialty pharmacy in order to counteract price increases and make specialty medication accessible and affordable. Labor, employee benefits, and purchased services combined were $57 million unfavorable to budget. The unfavorable variance was primarily due to higher than budgeted use of agency contract labor to staff open positions during the first six months of the quarter. Full-time equivalents (FTEs) of 68,706 were 0.3 percent, or 207 FTEs, favorable to budget, while employee benefits were $21 million favorable to budget year-todate. Per member per month (PMPM) employee medical costs in 2015 are projected to be 5.8 percent higher over the prior year, despite the significant increases in pharmaceutical expenses discussed above. The table below presents consolidated key efficiency indicators. Key Efficiency Indicators YTD June 2015 Actual Budget Organic Growth 2014 Actual* FTEs 68,706 68,914 65,471 64,443 Productivity Labor % Net Service 48.1% 52.3% 48.3% 50.8% Revenue Supplies % Net Service Revenue 16.7% 17.0% 16.6% 16.8% Efficiency - Expense per CMAA $11,898 $11,720 $11,945 $11,269 *Excludes results for any affiliated entities not included in the 2014 comparative results due to affiliation date. Non-Operating Gain (Loss) Year-to-date investment income was $85 million. The investment portfolio is up 1.70 percent through June, compared to the benchmark return of 1.69 percent. This outperformance was a result of a diversified investment approach. Providence s broad mix of investment classes provides a higher degree of diversification which can lead to more consistent performance regardless of current market conditions. The portfolio s current asset allocation is shown below in comparison to the average healthcare portfolio allocations in 2012, the most recent year for which data was available. Investment Asset Providence Asset Pool Allocation Average Healthcare Allocation Cash 5.3% 3% Public Equities 38.5% 36% MLP Unit 2.7% 0% Risk parity 5.6% 0% Hedged Strategies 14.1% 21% Fixed Income 24.1% 32% Liability Driven Investing (LDI) 6.5% 0% TIPs 1.6% 0% Other Short-term Securities 0% 8% Commodities 1.6% 0% Total % % Page 10

11 The performance of small capitalization, growth, relative value, tactical trading hedge funds, and commodities allocations in the first six months of the year preserved higher year-to-date gains than the more traditional portfolio would have provided over the same time period. Specifically, year-to-date performance of the portfolio s growth-oriented investments was 3.62 percent through June 30, 2015 outperforming the global equity benchmark return of 3.13 percent. This half a percent outperformance is specifically attributable to the performance of global public equities and hedged strategies in the portfolio. Income assets have returned 1.37 percent year-to-date, outperforming the Barclays Aggregate Benchmark of percent. Conversely, the portfolio's allocation to diversifying asset classes such as treasury inflation-protected securities (TIPS) and long treasuries hurt overall performance through June, returning percent, compared to the benchmark at 1.00 percent. The strategically broad diversification of investments within the operating assets portfolio continues to work as intended; dampen volatility and reduce risk within the portfolio. This strategy becomes ever more important during times of market uncertainty and turmoil, which the global markets are currently experiencing. Credit Agency Ratings Providence received affirmation on the following ratings from the three national credit rating agencies during the latest round of review. Fitch: "AA" Standard and Poor's: "AA-" Moody's Investors Services: "Aa3" Additionally, all three agencies have issued a stable outlook based on improved year-over-year operating performance and stable balance sheet measures. The report issued in July by Fitch showed high confidence in Providence s business practices, stating Fitch believes management is proactively transitioning the organization to maintain its leadership positions as key markets move to population health management payment models. Providence's excellent management practices are reflected in a robust IT platform and continued centralization of shared services that allows for detailed operational reporting. Agency reports also cited Providence's large footprint, good diversification of cash flows, leadership position in most markets, and overall commanding revenue base. Page 11

12 PROVIDENCE HEALTH & SERVICES Unaudited Consolidated Balance Sheets (In thousands of dollars) June 30, December 31, Assets Current assets: Cash and cash equivalents $ 1,177,347 $ 1,237,337 Short-term management-designated investments 203, ,338 Accounts receivable, less allowance for bad debts of $261,463 and $289,908, respectively 1,465,121 1,419,495 Other receivables 367, ,185 Supplies inventory 181, ,821 Other current assets 142, ,337 Current portion of funds held by trustee 75,710 76,365 Total current assets 3,613,626 3,696,878 Assets whose use is limited: Management-designated cash and investments 4,805,083 4,601,153 Gift annuities, trusts, and other 56,088 53,954 Funds held by trustee 222, ,473 Assets whose use is limited, net of current portion 5,084,051 4,834,580 Property, plant and equipment, net 6,526,250 6,622,566 Other long-term assets 565, ,884 Total assets $ 15,789,572 $ 15,722,908 Page 12

13 PROVIDENCE HEALTH & SERVICES Unaudited Consolidated Balance Sheets (In thousands of dollars) June 30, December 31, Liabilities and Net Assets Current liabilities: Accounts payable 459, ,942 Accrued compensation 757, ,075 Payable to contractual agencies 129, ,778 Retirement plan obligations 91, ,517 Current portion of self-insurance liability 108, ,943 Other current liabilities 351, ,865 Short-term debt 13,245 12,500 Current portion of long-term debt 192, ,287 Total current liabilities 2,103,966 2,386,907 Long-term debt, net of current portion 3,827,412 3,844,262 Other long-term liabilities: Self-insurance trusts 289, ,541 Pension benefit obligation 1,027,464 1,040,939 Other long-term liabilities 299, ,099 Total other long-term liabilities 1,616,375 1,542,579 Total liabilities 7,547,753 7,773,748 Net assets: Unrestricted Controlling interest 7,778,560 7,492,324 Noncontrolling interest 45,302 45,302 Temporarily restricted 310, ,277 Permanently restricted 107, ,257 Total net assets 8,241,819 7,949,160 Total liabilities and net assets $ 15,789,572 $ 15,722,908 Page 13

14 PROVIDENCE HEALTH & SERVICES Unaudited Consolidated Statement of Operations (In thousands of dollars) Six months ending June Operating revenues: Net patient service revenues $ 6,102,034 $ 4,968,332 Provision for bad debts (88,969) (70,063) Net patient service revenues less provision for bad debts 6,013,065 4,898,269 Premium and capitation revenues 923, ,277 Other revenues 380, ,182 Total operating revenues 7,316,728 6,009,728 Operating expenses (including charity and unsponsored community benefit expenses of $431,532 and $371,925, respectively): Salaries and wages 2,892,333 2,487,219 Employee benefits 675, ,501 Puchased healthcare 653, ,450 Professional fees 278, ,249 Supplies 1,003, ,340 Purchased services 541, ,627 Depreciation 313, ,856 Interest 79,581 73,639 Amortization 388 3,312 Other 662, ,411 Total operating expenses 7,100,520 5,876,604 Excess of revenues over expenses from operations 216, ,124 Net nonoperating gains: Contribution from affiliation (2,593) 469,426 Other nonoperating gains 69, ,117 Total net nonoperating gains 67, ,543 Excess of revenues over expenses 283, ,667 Net assets released from restriction and other 3,019 9,146 Change in noncontrolling interests in consolidated joint ventures - 30 Increase in unrestricted net assets $ 286,236 $ 728,843 Page 14

15 PROVIDENCE HEALTH & SERVICES Unaudited Consolidated Statement of Cash Flows (In thousands of dollars) Six months ending June Operating Activities: Change in net assets $ 292,659 $ 803,252 Adjustments to reconcile change in net assets to net cash provided by operating activities: Contribution from affiliation 2,593 (534,816) Depreciation and amortization 314, ,168 Provision for bad debt 88,969 70,063 Loss (gain) on sale of property, plant, and equipment (4,194) 304 Equity income on joint ventures (19,239) (17,842) Changes in certain current assets and current liabilities (294,152) (452,286) Change in other long-term liabilities and other 72, ,670 Restricted contributions and investment income received (34,379) (37,286) Net realized and unrealized losses on investments (84,310) (153,899) Net cash provided by operating activities 334, ,328 Investing activities: Property, plant, and equipment additions (257,748) (260,041) Proceeds on the disposal of property, plant and equipment 2, Purchases of investments (3,220,135) (1,787,875) Proceeds from sales of investments 3,094,171 1,844,400 Change in securities lending collateral - 9,386 Changes in other long-term assets and other 10,710 (127,804) Change in funds held by trustee, net (42,752) (61,319) Cash paid for affiliations, net of cash acquired - (98,958) Net cash used in investing activities (412,798) (481,701) Financing activities: Proceeds from restricted contributions and restricted net income 34,379 37,286 Debt borrowings ,490 Debt payments (28,464) (275,860) Change in securities lending payable - (11,307) Change in deferred financing costs and other 11,979 69,421 Net cash provided by financing activities 17, ,030 Increase (decrease) in cash and cash equivalents (59,990) 109,615 Cash and cash equivalents, beginning of period 1,237, ,965 Cash and cash equivalents, end of period $ 1,177,347 $ 962,580 Supplemental disclosure of cash flow information: Cash paid for interest (net of amounts capitalized) $ 94,108 $ 73,310 Page 15

16 Debt Supported by Self-Liquidity PH&S has authorized $200 million in taxable commercial paper that is supported by self-liquidity. As of June 30, 2015, none of the commercial paper was outstanding. The System reports monthly on its cash and investment balances available to retire maturing shortterm debt in the event notes cannot be remarketed. The table below summarizes the information provided to the rating agencies at the end of the second quarter describing cash and investments that could be available for liquidation. Liquidity Assessment Provider Name: Portfolio As of Date: Providence Health & Services June 30, 2015 Asset Allocation (Security Type) Assets ($ millions) with Assets ($ millions) with next Assets ($ millions) with > same $ in Millions same day liquidity (T+0) day liquidity (T+1) day liquidity (T+2, T+3, T+n) Discount Factor Discounted Assets Cash & Cash Equivalents * $ $ - $ - $ $ S&P rated money market funds (> Am) $ $ - $ - $ $ Highly rated (A-1 or A-1+) dedicated bank line $ - $ - $ - $ $ - Highly rated (A-1 or A-1+) money market instruments (< 1yr) $ - $ 4.76 $ - $ $ 4.33 U.S. Treasury Debt Obligations (> 1 year) $ - $ $ - $ $ U.S. TIPs $ - $ $ - $ $ U.S. Agencies (> 1 year) $ - $ $ - $ $ Investment Grade Debt (that is not included above) $ - $ - $ $ $ Equities** $ - $ - $ $ $ Non-Investment Grade Debt $ - $ - $ $ $ Total $ 1, $ $ $ 2, $ 2, Discounted Total $ 1, $ $ Discounted Total Enter amount of Self Liquidity Backed Debt with: Same Day Notice Next Day Notice > Next Day Notice Commercial Paper $ $ Variable Rate Demand Note or Obligation $ - $ - Fixed Rate Debt Other Securities Total $ - $ $ Remaining Discounted Assets $ 1, $ 1, $ 1, Same Day +/- Next Day +/- > Next Day +/- Sufficient Sufficient Sufficient TOTAL DEBT SUPPORTED BY SELF LIQUIDITY TOTAL REMAINING DISCOUNTED ASSETS $ $ 1, Page 16

17 Performance Metrics Year-To-Date Actual June 30, 2015 Year-to-Date Year-To-Date Budget Year-To-Date Last Year Volume: Acute Adjusted Admissions 325, , ,661 Total Acute Admissions 180, , ,497 Total Acute Patient Days 807, , ,659 Acute Outpatient Visits 4,274,526 4,192,374 3,901,588 Observations 27,368 28,968 29,108 Primary Care Visits 3,838,187 3,796,748 3,249,662 Long-Term Care Patient Days 202, , ,561 Home Health Visits 349, , ,883 Hospice Days 324, , ,477 Housing and Assisted Living Days 281, , ,597 Health Plan Members 505, , ,866 Total Occupancy % 64.8% 62.4% 59.6% Total Average Daily Census 4,459 4,280 4,004 Surgeries: Inpatient 56,697 55,740 50,948 Outpatient 62,059 59,194 57,419 Total Surgeries 118, , ,367 Emergency Room Visits: Inpatient 98,468 94,193 86,473 Outpatient 637, , ,133 Total Emergency visits 736, , ,606 Outpatient Visits: Outpatient Surgery 62,059 59,194 57,419 Emergency Visits 637, , ,133 Primary Care 3,838,187 3,796,748 3,249,662 Homecare Visits 349, , ,883 Observations 27,368 28,968 29,108 All Other 3,547,256 3,522,730 3,267,928 Total Outpatient Visits 8,462,272 8,327,051 7,478,133 Page 17

18 Performance Metrics Year-To-Date Actual June 30, 2015 Year-to-Date Year-To-Date Budget Year-To-Date Last Year Efficiency: FTE's 68,706 68,914 64,443 YTD Overall Case-Mix Index YTD Case-Mix Adj Admissions (CMAA) 509, , ,590 YTD Acute Care LOS (case-mix adj) YTD Net Svc Rev/CMAA 12,322 11,953 11,562 YTD Net Expense/CMAA 11,898 11,720 11,269 YTD Paid Hours/CMAA YTD Productive Hours/CMAA FTE's Per Adjusted Occupied Bed Financial Performance: Operating Margin 3.0% 1.7% 2.2% Total Margin 3.8% 3.7% 10.9% EBIDA ('000) 679, , ,007 EBIDA Margin 9.3% 10.1% 18.7% R12 Days of Total Cash on Hand Net Patient AR Days (3 mo rolling ave) Ave Yearly Salary/FTE (w/o benefits) 84,892 82,894 81,569 Employee Benefits as a % of Salaries 23.4% 24.6% 24.4% Salary Wages as a % of Net Op Rev 39.5% 42.1% 41.4% Supplies as a % of Net Op Revenue 13.7% 13.7% 13.7% YTD Supplies Expense/CMAA 1,970 1,890 1,813 YTD Med Supplies Exp/CMAA 1,058 1,040 1,040 Debt to Total Net Asset Ratio Cash to Debt Ratio Current Ratio Bad Debt & Charity % Gross Svc Rev 1.8% 3.0% 3.0% Community Benefit: ('000) Cost of Charity Care Provided $ 67,971 $ 106,668 $ 114,921 Medicaid Charity 277, , ,112 Education and Research Programs 37,965 39,252 36,426 Unpaid Cost of Other Govt Programs ,055 Negative Margin Services and Other 32,087 30,309 29,838 Non-Billed Services 16,299 12,915 13,573 Total Community Benefit $ 431,532 $ 417,495 $ 371,925 Page 18