公立医院债务风险成因及化解策略探讨

在财政投入有限的情况下,医院为扩大规模,改善就医条件,提高综合实力,对外举债无疑是一条重要的筹资渠道,但是公立医院长期背负债务负重前行,在目前结余率极低的状况下,总体资产良好的局面会很快消失,取而代之的是沉重的债务负担,这既不利于维护公立医院的公益性质,也给医院的可持续发展带来了风险。文章通过对某地区18家公立医院的债务融资的现状进行分析,探讨其产生的根本原因,提出债务化解的方法和建议。     

Determinants of interest rates on tax-exempt hospital bonds

The aim of this paper is to examine the determinants of interest rates on tax-exempt hospital bonds. The results highlight the potential and actual roles of Federal and state policy in the determination of these rates. The shift to a Prospective Payment System under Medicare has subsidized the borrowing costs of some hospitals at the expense of others. The selection of underwriters by negotiation rather than by competitive bidding results in higher interest rates. The Federal tax act of 1986 raised the cost of hospital debt by encouraging bond issues to contain call features.     

The association of debt financing with not-for-profit hospitals' operational and capital-investment efficiency

Increased debt in companies can motivate both operational and capital-investment efficiency. This positive influence of debt is attributed to creditors' oversight of corporate behavior and the need to generate cash flows to service debt. Our study investigates whether debt has a similar relationship with efficiency in not-for-profit hospitals. Using statistical analysis of a database of audited financial statements of not-for-profit hospitals, we test whether debt is associated with six distinct measures of operational and capital-investment efficiency. We find that debt either has no association with efficiency or predicts decreased efficiency. Possible explanations are that creditors' oversight is less tight in the not-for-profit setting and that debt may at times motivate excessive capital investment because of a legal requirement to tie tax-exempt debt with a capital-investment project.     

Association of bond, market, operational, and financial factors with multi-hospital system bond issues.

Despite the growth of multi-hospital systems in the 1990s, their performance in the tax-exempt bond market has not been adequately evaluated. The purpose of this study is to compare bonds issued by multi-hospital systems to those issued by individual hospitals in terms of bond, market, operational, and financial characteristics. The study sample includes 2,078 newly issued, tax-exempt, revenue bonds between 1991 and 1997. The findings indicate that multi-hospital systems issued larger amounts of debt at a lower cost, were more likely to be insured, had higher debt service coverage and higher operating margins.     

An examination of contemporary financing practices and the global financial crisis on nonprofit multi-hospital health systems

This study examines the impact of the 2008 global financial crisis on large US nonprofit health systems. We proceed from an analysis of the contemporary capital financing practices of 25 of the nation's largest nonprofit hospitals and health systems. We find that these institutions relied on operating cash flows, public issues of insured variable rate debt, and accumulated investment to meet their capital financing needs. The combined use of these three financial instruments provided these organizations with $22.4 billion of long-term capital at favorable terms and the lowest interest rates. Our analysis further indicates that the extensive utilization of bond insurance, auction rate debt, and interest rate derivatives created significant risk exposures for these health systems. These risks were realized by the broader global financial crisis of 2008. Findings indicate these health systems incurred large losses from the early retirement of their variable rate debt. In addition, many organizations were forced to post nearly $1 billion of liquid collateral due to the falling values of their interest rate derivatives. Finally, the investment portfolios of these large nonprofit health systems suffered millions of dollars of unrealized capital losses, which may minimize their ability to finance future capital investment requirements.     

Mass. authority's bond sales set record

Fueled by low interest rates and competitive construction costs, the Massachusetts Health and Educational Facilities Authority recorded its heftiest fiscal year ever in new tax-exempt bond issues for hospitals and universities. The authority issued $1.25 billion in debt during its fiscal year ended June 30. Healthcare-related bonds accounted for two-thirds of the total.     

Improving financial performance: a study of 50 hospitals

This article provides an analysis of key differences between a small sample of high-performing and low-performing hospitals where performance was defined as return on equity. Some of the more significant findings were: (1) high-performing hospitals achieve their superior performance through cost control rather than higher prices; (2) high-performing hospitals minimize their investment in plant assets and accounts receivable. They are also likely to have a newer plant than low-performing hospitals; (3) high-performing hospitals are not afraid to use debt in their capital structure, but they use significantly less debt than low-performing hospitals; (4) high-performing hospitals have set aside greater reserves for future plant replacement, which helps them to keep their level of debt reasonable and generates significant amounts of investment income; and (5) high-performing hospitals have greater market share than low-performing hospitals.     

Why nonprofits? Hospitals and the future of American health care

The future of the nonprofit hospital depends on its relationship to the for-profit and governmental sectors of our economy. A decade ago, the primary challenge came from the growing investor-owned hospital companies. Nonprofit hospitals' responses--both competitive and imitative--led to new challenges from government regarding tax-exempt status. The reasons underlying this challenge include the growing commercialism of health care, the nation's failure to deal directly with the problem of the uninsured, and the lack of a coherent theory of tax exemption. Although hospitals are likely to retain exemptions from federal taxation, challenges to local tax exemptions are likely to continue. Strategies that hospitals pursue for competitive purposes may undercut their legitimacy as tax-exempt institutions, but several groups are working to address the issue.     

Evaluating the underlying factors behind variable rate debt

BACKGROUND: Recent trends show a greater usage of variable rate debt among health care bond issues. In 2004, 63.4% of the total health care bonds issued were variable rate compared with 30.6% in 1995 (Fitch Ratings, 2005). PURPOSE: The purpose of this study is to gain a better understanding of the underlying factors, credit spread, issue characteristics, and issuer factors behind why hospitals and health system borrowers select variable rate debt compared with fixed rate debt. METHODOLOGY: From 2000 to 2004, this study sampled 230 newly issued tax-exempt bonds issued by acute care hospitals and health care systems that included both variable and fixed rate debt issues. Using a logistic regression model, hospitals with variable rate debt issues were assigned a value of 1, whereas hospitals with fixed rate debt issues were assigned a value of 0. FINDINGS: This study found a positive association between bond insurance and variable rate debt and a negative association between callable feature and variable rate debt. Facilities located in certificate-of-need states that possessed higher case mix acuity, earned higher profit margins, generated higher debt service coverage, and held less debt were more likely to issue variable rate debt. PRACTICE IMPLICATIONS: Overall, hospital managers and board members of hospitals possessing a strong financial performance have an interest in utilizing variable rate debt to lower their cost of capital. In addition, this outcome may also reflect that investment bankers are doing a better job in educating senior hospital management about the interest rate savings benefit of variable rate compared with fixed rate debt.     

Investing for the future

Financially savvy hospitals are getting aggressive with their investment management strategies, using healthy returns from wisely invested nonoperating dollars to finance construction projects, make acquisitions and expand services. Industry estimates show hospitals have a large nest egg to work with--some $400 billion in assets available for investment.     

Cash holdings of not-for-profit hospitals

Many not-for-profit (NFP) hospitals hold substantial cash reserves. Using a national sample of 608 NFP hospitals over the period 1996-1999, we related theories of cash holdings to NFP hospitals to develop a conceptual framework for understanding cash holdings. We tested whether these hospitals differentially managed operating and strategic cash with respect to establishing target balances and investigated motivations for holding cash. NFP hospitals actively targeted levels of operating cash, but did not target strategic cash balances. Strategic cash balances were positively related to profitability and growth in assets, but negatively associated with the use of debt.     

Capital structure strategy in health care systems

The capital structures (the relative use of debt and equity to support assets) of leading health care systems are viewed as a strategic component of their financial plans. While not-for-profit hospitals as a group have maintained nearly constant levels of debt over the past decade, investor-owned hospitals and a group of leading health care systems have reduced their relative use of debt. Chief financial officers indicated that in addition to reducing debt because of less favorable reimbursement incentives, there was a focus on maintaining high bond ratings. Debt levels have not been reduced as sharply in these health care systems as they have in investor-owned hospitals, in part due to the use of debt to support investments in financial markets. Because these health care systems do not have easy access to equity, high bond ratings and solid investment earnings are central to their capital structure policies of preserving access to debt markets.     

Income levels of bad-debt and free-care patients in Massachusetts hospitals.

This study disputes the common notion that many hospitalized patients whose expenses are written off to bad debt are able to pay their bills. By matching 1996 state tax returns to more than 350,000 bad-debt and free-care claims at seven Massachusetts hospitals, we found that most patients involved had incomes below the federal poverty level and thus were presumably eligible for either public programs or hospital-based free care. This suggests that hospitals and public officials need to investigate further why low-income, uninsured patients are not receiving benefits for which they are eligible. Our results also suggest that measurements of indigent care levels in hospitals for purposes of research or regulation should include some portion of bad debt.     

Can a violation of investor trust lead to financial contagion in the market for tax-exempt hospital bonds?

Not-for-profit hospitals rely heavily on tax-exempt debt. Investor confidence in such instruments was shaken by the 1998 bankruptcy of the Allegheny Health and Education Research Foundation (AHERF), which was the largest U.S. not-for-profit failure up to that date and whose default was accompanied by claims of accounting irregularities. Such shocks can result in contagion whereby all hospitals are viewed as riskier. We test for the significance and duration of resulting contagion using an industry-specific model of interest cost determinants. Empirical tests indicate that contagion does occur, resulting in higher interest on new debt issues from other hospitals.     

Distinguishing community benefits: tax exemption versus organizational legitimacy

US policymakers continue to call into question the tax-exempt status of hospitals. As nonprofit tax-exempt entities, hospitals are required by the Internal Revenue Service (IRS) to report the type and cost of community benefits they provide. Institutional theory indicates that organizations derive organizational legitimacy from conforming to the expectations of their environment. Expectations from the state and federal regulators (the IRS, state and local taxing authorities in particular) and the community require hospitals to provide community benefits to achieve legitimacy. This article examines community benefit through an institutional theory framework, which includes regulative (laws and regulation), normative (certification and accreditation), and cultural-cognitive (relationship with the community including the provision of community benefits) pillars. Considering a review of the results of a 2006 IRS study of tax-exempt hospitals, the authors propose a model of hospital community benefit behaviors that distinguishes community benefits between cost-quantifiable activities appropriate for justifying tax exemption and unquantifiable activities that only contribute to hospitals' legitimacy.     

Under the gun

This year Congress will consider proposals to significantly restrict the access of not-for-profit healthcare organizations to affordable capital and other federal benefits of their tax-exempt status. The federal benefits of tax-exempt status are (1) exemption from federal tax on net income, (2) eligibility for tax-deductible charitable contributions, and (3) access to tax-exempt financing. Of these, the last is probably most important because hospitals' capital needs are substantial and almost always met through the issuance of tax-exempt bonds. In recent years, budget pressures have prompted many state and local governments to challenge the tax-exempt status of not-for-profit organizations. At the federal level, tax-exempt bonds have been under sustained attack for the past 10 years, and tax-exempt organizations have been under scrutiny for the past 4 years. In 1989 several bills were introduced in Congress that would limit some of the benefits of tax exemption. This year the signs are particularly ominous: Budget pressures are severe, no one seems willing to call for "new taxes," and tax-exempt organizations are considered fair game. To preserve their tax-exempt status, not-for-profits must act now to convince congressional decision makers that they deserve their tax exemptions and need them to continue to provide community service.     

New arrangements, new scrutiny. The IRS reconsiders hospital-physician relationships at tax-exempt facilities

The pressure to maintain adequate operating margins has forced many not-for-profit hospitals to adopt more overtly competitive behavior than they have in the past. However, in struggling to remain economically viable, these facilities should carefully avoid actions that would threaten their tax-exempt status. Not-for-profit facilities should be particularly careful that their arrangements with physicians, which often appear designed to increase referrals, do not violate the criteria according to which the Internal Revenue Code extends tax exemption to charitable organizations. Section 501(c)(3) of the code exempts organizations "no part of the net earnings of which inures to the benefit of any private shareholder or individual." According to this provision, "insiders" (i.e., those with a personal interest in or opportunity to influence organization activities from the inside) are entitled to no more than reasonable payment for their goods or services. The Internal Revenue Service (IRS) takes the position that, as employees or individuals having a close professional working relationship with a hospital, physicians are insiders. Thus a hospital that pays physicians what the IRS judges to be more than fair market value for services (or charges physicians less than fair market value for office rental) may find its exemption in jeopardy. If not-for-profit hospitals want to maintain their tax-exempt status, they must be certain the arrangements they enter into with physicians truly further their exempt purpose: to promote the health of the community.     

The economics of for-profit and not-for-profit hospitals

This paper examines the economics of for-profit and not-for-profit hospitals through the prism of capital acquisitions. The exercise suggests that of two hospitals that are equally efficient in producing health care, the for-profit hospital would have to charge higher prices than the not-for-profit hospital would, to break even on capital acquisitions. The reasons for this divergence are (1) the typically higher cost of equity capital that for-profit hospitals face; and (2) the income taxes they must pay. The paper recommends holding tax-exempt hospitals more formally accountable for the social obligation they shoulder, in return for their tax preference.     

The hospital bond market and the AHERF bankruptcy

An analysis of hospital, tax-exempt bonds issued before and after the Allegheny Health, Education, and Research Foundation (AHERF) bankruptcy demonstrated that despite the decline in market rates for tax-exempt securities in the post period, bonds issued by hospitals and systems carried higher coupon rates than they did in the pre period. There was a significant decline in the proportion of hospital/system bonds that were insured from the pre to the post period. Bond insurance firms tightened their credit criteria after the bankruptcy, which may explain, in part, why the proportion of insured bonds declined. We conclude that hospital bonds are now viewed as riskier instruments than they were prior to the AHERF bankruptcy. This is reflected in higher coupon rates for both insured and uninsured bonds and fewer insured bond issues. This decline in hospital creditworthiness comes at a time when many hospitals need to replace aging assets and acquire new technologies in response to increased inpatient utilization.     

Health care providers under pressure: making the most of challenging times

Whether the slowing economic recovery, tight credit markets, increasing costs, or the uncertainty surrounding health care reform, the health care industry faces some sizeable challenges. These factors have put considerable strain on the industry's traditional financing options that the industry has relied on in the past--bonds, banks, finance companies, private equity, venture capital, real estate investment trusts, private philanthropy, and grants. At the same time, providers are dealing with rising costs, lower reimbursement rates, shrinking demand for elective procedures, higher levels of charitable care and bad debt, and increased scrutiny of tax-exempt hospitals. Providers face these challenges against a back ground of uncertainty created by health care reform.