Everything comes to pass and nothing comes to stay. This is the message, usually comforting and reassuring, delivered in sermons, therapy sessions, or along with a bear hug from grandma. Covid-19 has already been an abhorrent presence for too long, and it cannot pass quickly enough for any of us, especially for its principal victims: those with serious underlying medical conditions and those over 65. Medicare is the federal health insurance program for those of us in this age group or with certain disabilities. More than 62 million Americans, nearly 19% of our population, now fall into one of these categories. In data released on Monday, the Centers for Medicare and Medicaid Services reported that, between January 1 and May 16, there were 326,674 Medicare recipients diagnosed with Covid-19, with peak counts coming between mid-April and early May. The percentage of men and women affected was nearly equal, as was the percentage of the aged and disabled, but the agency found disproportionately higher counts in those over 85 as well as in Black enrollees, those in lower income brackets, and those from urban areas. Of all diagnosed, 109,607 or 33% required hospitalization at an average cost of $23,100 per patient. Twenty-seven percent of those admitted were successfully treated and went home, 23% were discharged to a skilled nursing or assisted living facility, 5% went to hospice care, and 28% died in the hospital.
There are 6,146 hospitals here in the United States and, at last count by the American Hospital Association (“AHA”), they have an average occupancy of 60%. Altogether they have 924,107 staffed beds or 2.8 beds available for every 1,000 people. And, every second of every hour of every day, at least one patient is being checked in. Hospital staff began preparing for chaos early this year, they opened satellites in gyms and convention centers, rationed masks and ventilators, and saw pandemic-related spikes in admissions mid-Spring. Many now face new surges and wonder, what comes next? The paradox is that hospitals are the only place where the word “positive” is a bad thing.
On an annual basis, for one reason or another, 34.2 million of us will be admitted to what is known as a community hospital. The AHA defines such facilities as non-federal hospitals serving the general public with average lengths of stay under 30 days; others define them as hospitals with fewer than 550 beds and minimal teaching programs, typically located in a smaller town and locally governed. Fifty-eight percent of us live less than five miles away from a community hospital but–even if the closest one is 25 or more miles away–we can all immediately call to mind the one nearest us where our babies were born, the place we rushed to at 3 am when an alarming symptom appeared, where we celebrated a miracle cure or lost someone we love, where we can count on facts and empathy from doctors and nurses because they are also neighbors and friends. These hospitals are among our largest local employers and serve as a central resource not only for acute care but also for counseling, housing, shelter, job training, and long-term care placement. Some are actually designated as “safety nets” when in fact they all are. In every sense, our community hospitals are not only essential service providers but the true lifelines of our communities.
At HJ Sims, we remain big believers in not-for-profit community hospitals and are investors in the bonds that they issue. Our traders and analysts take a close look at individual credits which vary widely by location, size, level of care, specialization, ownership, management quality and function. We like many critical access hospitals–those with 25 or fewer inpatient beds located more than 35 miles from another hospital. We consider inpatient and outpatient revenue, operational challenges such as nursing shortages, operational efficiencies such as sponsored or acquired health plans, competitors with major market share, government payor mixes, area demographics, charity care, and the emergence of nontraditional disruptors like Amazon. Since the pandemic hit, we have been monitoring the amount of federal assistance received, the increased use of telemedicine, the resumption of elective surgeries, the levels of hazard pay wage increases, and the likelihood of consolidations, particularly for rural hospitals under the most financial stress.
On April 10, the U.S. Department of Health and Human Services began distributing the first of $175 billion of relief funds to hospitals and health care providers. Although federal aid has offset some of the increased expenses and revenue losses attributed to the pandemic, many hospitals have nevertheless had to delay capital projects, furlough staff, and make pay cuts. Some entered the crisis with strong cash positions and are in locations that have been less severely impacted. Others have been slammed and, lacking further aid, may soon breach their bond covenants. Although it is unlikely that debt service payments will be missed, each situation varies depending on the depth and extent of the pandemic, its spread in the community, and the timing of successful treatments and vaccines. Financial challenges posed by dwindling patient volumes, increased competition, rising costs, and reduced reimbursements have already led to the closure or bankruptcy of at least 42 hospitals so far this year.
Our day to day inventory of hospital bonds varies but we have access to a wide array in different rating, geographic and functional categories. At this writing, we own and offer, for example, New Jersey bonds issued for AA- rated RWJ Barnabas Health, the largest academic healthcare system in the state by virtue of its affiliation with Rutgers University and one of the state’s largest private employers with 11 acute care hospitals, 4 children’s hospitals, and the state’s largest behavioral health network. At the time of its last financial report on March 31, the system had 274 days cash on hand and covered its debt service by 3.9 times. These bonds will likely be sold by the time of this publication, but we welcome inquiries for this or similar credits. The primary calendar has recently been heavy with health care deals as institutions look to refinance or bolster liquidity. In the market last week for example, Spartanburg Regional Medical Center in South Carolina, a tertiary care hospital with the first regional heart center and in-patient hospice unit in the two Carolinas, sold $125 million of insured A3/A rated revenue bonds that included a 20 year tax-exempt term maturity priced at 3.00% to yield 3.02% and taxable muni bonds due in 2050 at par to yield 3.553%. The Seattle Cancer Care Alliance, the top cancer treatment and research center in Washington state, issued $232.9 million of A2 rated revenue bonds; the maximum yield bonds in 2055 came with a coupon of 5.00% to yield 2.66%.
This week’s calendar includes tax-exempt and taxable bond issues totaling $350 million for Aa1 rated Intermountain Healthcare, a system of 24 hospitals based in Salt Lake City. On the forward calendar is a $32.1 million deal for BBB- rated White River Medical Center and Stone County Medical Center which together serve 10 counties in North Central Arkansas. The California Health Facilities Financing Authority also plans to bring a $145 million issue for AA rated Stanford Health Care in Palo Alto, the principal teaching affiliate of Stanford University School of Medicine.
The AAA general obligation bond benchmark yields are significantly below where they began the year and where they stood one year ago. The 2-year at 0.27% is 77 basis points below the yield on January 2, the 10-year at 0.88% is 56 basis points lower, and the 30-year at 1.66% has dropped by 43 basis points. One year ago, these benchmark yields were at 1.27%, 1.63% and 2.32%, respectively. So far this year, hospital bonds as measured by the ICE Bank of America Merrill Lynch Hospital Index, have returned 1.42%. The ICE BoAML main gauge of municipal bond performance is up 1.78% and its taxable municipal bond index is up 7.31%.