Financing
Q&A: Financial Restructuring and Healthcare Providers
Any casual reader of healthcare news in recent years has taken note of the upheaval and financial uncertainty facing healthcare providers. Take for example a recent Bloomberg story detailing the closure of Hahnemann University Hospital in Philadelphia – “Philadelphia Hospital Collapse Highlights Healthcare ‘Anarchy’”. Anarchy or not, closures, consolidations, and financial restructuring are all too common for healthcare providers across the care continuum. To get a better sense of how financial restructuring is impacting healthcare providers and what options a provider facing a restructuring may have, Kristen Barlow, a Dorsey Health Strategies consultant, recently spoke to Annette Jarvis, a Partner with Dorsey’s Finance & Restructuring Group. Annette is a national expert in insolvency and one of the nation’s leading bankruptcy and restructuring lawyers. Kristen: Annette, are there particular segments of the healthcare industry that you think are especially vulnerable to financial restructuring – and if so, why? Annette: While all healthcare providers face financial challenges, some providers face particular challenges. For example, hospitals in rural areas have lower profit margins and may serve more uninsured patients than their urban counterparts. These rural hospitals are more at risk for closure – the Government Accountability Office recently reported that in the five years through 2017, 64 rural hospitals closed compared to 49 hospitals located in urban areas. Another segment of the healthcare industry particularly vulnerable to financial restructuring is post-acute and long-term care providers. Recent years have seen the bankruptcies of a number of large skilled nursing facility providers and many long-term acute care hospitals. Expensive overhead, reductions in Medicare reimbursement rates, and pressure to invest in care quality improvements all help create an environment that puts post-acute and long-term care providers at particular risk for financial restructuring. Annette: Kristen, from your perspective, how have you seen providers change and adapt their strategic plans to respond to these financial pressures? Kristen: Annette, providers are absolutely trying to change and adapt their strategic plans to succeed in a more financially constrained environment. One strategic response providers may pursue is to find financial security through increased scale. The rise of M&A activity for healthcare providers is well documented – a recent Commonwealth Fund report found that the vast majority of provider markets (~90%) are either highly concentrated or super concentrated. Providers may find that consolidation permits them to gain negotiating leverage with insurers and realize efficiencies through economies of scale – all considerations that make consolidation an attractive strategy in the face of a financially worrisome outlook. Kristen: Annette, consolidation is just one strategic response providers may have to financial pressures – what other strategies have you seen providers pursue? Annette: Other strategies I have seen implemented include the reduction of services in rural hospitals or the roll up of certain services into larger hospital systems. This can occur through distressed acquisitions in or out of receiverships or bankruptcies or through less traditional combinations allowing sharing of services and patient care. Kristen: Annette, how would you advise a company that may be worried about their financial outlook to think about their options? Annette: Providers may want to remember that hospitals and other facilities are, by their nature, capital intensive. Often, by deferring capital investments (and unless their loan documents have covenants that are tripped by early substandard performance), the company can put off facing financial problems by deferring capital investments until a cash crisis hits. Then the options for saving the business are more limited. Facing financial problems early and getting professional help are essential for restructuring. Kristen: Annette, are there common mistakes that companies facing a financial restructuring should avoid? Annette: Facing financial problems early means providers must often come to terms with a scary and uncertain future. The most common mistake I see is avoiding facing problems, including changes that are necessary for long term financial viability, as soon as they arise. Early intervention is important for maximizing all potential solutions. By working with counsel and financial advisors experienced in restructuring, the company may be able to take care of a number of problematic issues outside of bankruptcy. The company will quite frankly be better off for approaching financial issues early with a proactive mindset and the appropriate legal and financial advice. If you would like additional information on how Dorsey can assist healthcare organizations facing financial restructuring, please contact the authors directly at jarvis.annette@dorsey.com or barlow.kristen@dorsey.com or your regular attorney at Dorsey & Whitney.
August 7, 2019
by Annette Jarvis
Financing
Advance Refunding Bond Legislation of Interest to Non-Profit Hospitals and Senior Living Organizations
On February 13, in a matter of special note to non-profit hospitals and senior living organizations across the country, legislation was introduced in the United States House of Representatives that would restore tax exemption for interest on advance refunding bonds. The Tax Cuts and Jobs Act of 2017 eliminated tax exemption for interest on such advance refundings when President Trump signed the act into law on December 22. Non-profit health care organizations have used advanced refundings for years as a way to take advantage of lower interest rates and to refinance debt in advance of the call date. That financing tool was taken away by the new tax law as of December 31, 2017. Representative Randy Hultgren (R-IL), joined by five co-sponsors representing both parties (two Republicans and three Democrats), introduced H.R. 5003 seeking to fully reinstate tax exemption for interest on advance refunding bonds. The legislation, which has been referred to the House Committee on Ways and Means, enjoys not only bipartisan support but also the backing of national organizations such as the American Hospital Association and the Bond Dealers of America. The text of the legislation can be found here https://www.congress.gov/115/bills/hr5003/BILLS-115hr5003ih.pdf. Among the numerous legislative responses to the new tax law introduced this session, tax-exempt health care organizations should pay particular attention to the progress of H.R. 5003.
February 26, 2018
by Neal N. Peterson