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Managing Hospital Credit Relationships

Understanding the Capital Formation Process

By Calvin W. Wiese; CPA MBA

www.HealthcareFinancials.com

Every hospital needs to manage their credit relationships. Rating agencies and credit providers need to be targeted by hospitals for development and maintenance of credit relationships. Credit relationships are an ongoing process. They need to be fed and nurtured. Hospitals should make sure that they cultivate their relationships with credit analysts even during times when they are not seeking credit.

Capital Financing

Too often, hospitals work on credit relationships only when they need capital financing. That’s the wrong time. Relationships need to be in place before they need financing. Credit relationships should not be transaction based; rather formed and nurtured on an ongoing basis, resulting in better, more optimal transaction results. Credit relationships are fed and nurtured through communication. Communication strategies need to be multi-faceted: quarterly reporting, annual face-to-face reviews, and ad-hoc telephone conversations. Reporting needs to go beyond just what is required by the covenants. Covenanted reporting should be viewed as the minimum.

[picapp align=”none” wrap=”false” link=”term=hospital&iid=246735″ src=”http://view1.picapp.com/pictures.photo/image/246735/woman-hospital-recovery/woman-hospital-recovery.jpg?size=500&imageId=246735″ width=”320″ height=”480″ /]

Annual Meetings

Perhaps the most important component of nurturing credit relationships is the annual meeting. Annual meetings should be set up and conducted at the offices of the credit analysts. The meeting should review the past year and describe the plans for the future. An important component of the annual review is the financial forecast. Credibility is established by presenting a three- to five-year financial forecast each year. Variances from the forecast should be discussed and whether they are favorable or unfavorable should be explained. Candor about the good and especially the bad creates understanding and trust, which are critical components in credibility.

Uncertain Forecasts

Financial forecasts are inherently uncertain. The future is unknown, and in most cases unknowable. A financial forecast is not so much a prediction of the future, but a description of a management team’s view of the future. That view encompasses both external factors that are largely out of the control of management, and internal factors that are controllable. The forecast describes management’s strategies of dealing with that environment. As such, the financial forecast creates the context for a very profitable discussion between management and analysts. The view of the external environment can be compared and contrasted and challenged by the analysts. It is important for them to develop a comfort level with management’s view of the external environment. Given that environment, analysts can then evaluate management’s strategies for successfully leading the hospital through that environment.

Assessment

Presenting updated forecasts each year provides additional dimensions for useful dialogue. Changes in environmental views can be highlighted and discussed. Implications to hospital strategy can then be usefully identified and debated. Failures and successes in meeting the assumptions presented in prior forecasts highlight strengths and weaknesses of management in dealing with the uncertainties of its environment.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Are the credit relationships at your healthcare institution proactive or retro-active? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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About Tax-Exempt Hospital Debt

Understanding the Capital Formation Process

By Calvin W. Wiese CPA MBA

www.HealthcareFinancials.com

Tax exempt debt has become an important means of external financing for hospitals, primarily because its cost is very attractive. Interest rates on tax-exempt financing are lower than interest rates on financing that is not tax-exempt because the interest income earned by the holders is exempt from federal income tax. In some states, it is also exempt from state income tax and in some cities; it is also exempt from city income tax. Accordingly, the holders of these debt instruments (usually bonds) are willing to accept lower rates of interest.

State and Local Governments Issue Hospital Debt

Hospitals themselves are not capable of issuing tax-exempt debt. Only state and local governments are. A state or local government issues tax-exempt debt for hospitals and then loans the proceeds to hospitals. This is called “conduit” financing: the state or local government acts as a conduit through which hospitals can access tax-exempt debt markets. State and local governments are authorized to loan proceeds of their bond issues to hospitals through state statutes, and each state statute is different. Some states authorize any state or local government to issue bonds to loan to hospitals. Other states restrict such power to special purpose governmental entities only. And some states restrict this power to a single governmental entity that is specially formed for the sole purpose of issuing tax-exempt bonds on behalf of hospitals.

[picapp align=”none” wrap=”false” link=”term=medical+clinic&iid=252095″ src=”http://view2.picapp.com/pictures.photo/image/252095/clinical-waiting-room/clinical-waiting-room.jpg?size=500&imageId=252095″ width=”324″ height=”480″ /]

The IRS and Tax Exempt Financing

The Internal Revenue Service (IRS) regulates the issuance of tax-exempt financing. While the IRS code nominally provides that debt instruments issued by state and local governments are exempt from federal income tax, it imposes special rules on conduit issues. Therefore, tax-exempt issues whose proceeds are loaned to hospitals must comply with special IRS rules. Although very complex, these rules primarily regulate the use of proceeds, restricting the use of tax-exempt proceeds to the acquisition of property, plant components and equipment. Given state statutes, IRS code and applicable security laws (both state and federal), issuing tax-exempt bonds is legally complex. Many lawyers get paid handsome fees every time tax-exempt debt is issued. The quarterback of the legal team is the bond counsel who represents the interests of the bondholders; the bond counsel issues the critical tax opinion that investors rely upon to claim tax-exemption on the interest from these instruments. Everything revolves around getting this opinion. Given its’ critical nature, only highly qualified lawyers are accepted by the market to provide this opinion. Underwriter’s counsel represents the interests of the investment bankers; their primary concern is compliance with security laws. Issuer’s counsel represents the interests of the state or local government, and hospital counsel represents the interests of the hospital; both have relatively minor roles. In the event credit enhancement is involved, credit enhancement counsel represents their interests and has significant influence on the process.

Bond Trustees

Another unique party to most tax-exempt bond issues is the bond trustee. The bond trustee is usually a bank who performs a fiduciary duty on behalf of the bond holders throughout the life of the bonds. The face of the faceless bond holders, they act on their behalf. And they, too, are represented by counsel in the bond issuance process. State or local government typically appoints bond counsel. In many cases, they work with only a single firm. Not unusually, these relationships are quite cozy, and often result in fees being paid that are well in excess of what otherwise would be paid.

The Indenture

An excess of documents is involved in most tax-exempt financings. The heart of the documents is the indenture, which is the agreement between the bond trustee (on behalf of the bond holders) and the state or local government issuer. It contains the promises made to the bond holders, and it describes the work of the bond trustee. The bond trustee will only perform actions on behalf of bond holders that are explicitly set forth in the bond indenture. The bond indenture is the security given to the bond holders, describing all their recourses.

Assessment

The bond indenture is typically supported by the loan agreement between the state or local government that issues the bonds and the hospital to which the proceeds are loaned. Its terms complement the terms of the bond indenture, which together, form the conduit.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Hospital Credit Analysis

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Understanding the Definition of “Essentiality”

[By Calvin W. Wiese CPA MBA]

An important component of hospital credit analysis is essentiality. Hospitals are unusual businesses that many times possess some form of essentiality to their communities. Healthcare is important to the economic vitality of every community. Many hospitals have served their communities for many years; it is not uncommon to find hospitals that have been continuously operating for more than 100 years in the same community.

Not for Profit Entities

Most hospitals are not-for-profit. In not-for-profit hospitals, no private party actually “owns” the hospital; control is vested in various boards, but no one explicitly “owns” a not-for-profit hospital. In a broad sense, communities own not-for-profit hospitals. They are considered “charities” with a “charitable purpose.” Though a not-for profit hospital may not have owners, it has many” stakeholders,” parties that have vested interests in the continuing success of the hospital.

Stakeholder Webs

Many hospitals have broad and vast webs of stakeholders. Stakeholders are why hospitals rarely close or are shut down. Too many stakeholders have interests in the continuing successful operation of hospitals.

Hospital stakeholder relationships need to be considered in the analysis of essentiality. How strong are these relations? How many are there? How important is the continuing success of this hospital to these stakeholders?

Service Analysis

Another dimension of the essentiality analysis is service analysis. How significant are the hospital’s services? If the hospital shuts down, what population segments would suffer? How significant is the population that would suffer? How much would they suffer?

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Assessment

Analysis of hospital’s stakeholders and services should provide a credible view of the degree of essentiality associated with a hospital. Higher degrees of essentiality suggest higher likelihoods that hospitals, one way or another, will meet their commitments, particularly their payment commitments.

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Conclusion

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Join the ME-P “Thought-Leader” Pipeline

Modern Finance and e-Health Culture Devotees Wanted

By Ann Miller RN, MHA

[Executive-Director]

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Doctors are not always totally hip and do not always know what’s going on in popular culture.  Actually, many have no idea what is going on outside of the walls of the hospital; but we’d really like to know.

Health 2.0 

Thus, the “thought-leader” pipeline concept was born. The Pipeline is a team of elite individuals that actually are hip and in the know when it comes to the financial advisory and business sides of medical practice.  These super cool technical individuals are known as ME-P “thought-leaders” and help keep us up to date about Health 2.0 collaboration. Think you’re up for the task?

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Medical Endowment Fund Manager Selection

Are External Financial Consultants Necessary?

[By Dr. David E. Marcinko MBA]

http://www.CertifiedMedicalPlanner.org

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http://www.CertifiedMedicalPlanner.org

John English, of the Ford Foundation, once observed that:

[T]he thing that is most interesting to me is that every one of the managers is able to give me a chart that shows me he was in the first quartile or the first decile. I have never had a prospective manager come in and say, ‘We’re in the fourth quartile or bottom decile’.

According to Wayne Firebaugh CPA, CFP® CMP™ most medical endowment funds today, even those with internal investment staff, rely heavily upon consultants and external managers.

In fact, the 2006 Commonfund Benchmarks Healthcare Study revealed that 85% of all surveyed institutions relied upon consultants with an even greater percentage of larger endowments relying upon consultants.  The common reasons given by endowments for such reliance are augmenting staff and oddly enough, cost containment.  In essence, the endowment staff’s job becomes one of managing the managers.

Manager Selection 

Even those endowments that use consultants to assist in selecting outside managers remain involved in the selection and monitoring process.  Interestingly, performance should generally not be the overriding criterion for selecting a manager.  Selecting a manager could be viewed as a two-step process in which the endowment first establishes its initial allocation and determines what classes will require an external manager.  The second part of the process is to select a manager that due diligence has indicated to have two primary characteristics: integrity and a repeatable and sustainable systematic process.  These characteristics are interrelated, as a manager who embodies integrity will also strive to follow the established investment selection process.

Of Medical-Managers

In medicine, obtaining the best care often means consulting a specialist.  As a manager of managers, the average endowment should seek specialist managers within a given asset class. Just as physicians and healthcare institutions gain additional insight and skill in their area of specialty, investment managers may be able to gain informational or system advantages within a given concentrated area of investments.

Assessment

Since most plan managers are seeking positive alpha by actively managing certain asset classes, many successful endowments will use a greater number of external managers in the concentrated segments than they will in the larger, more efficient markets.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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About My House Call MD.com

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A New Health Education Project

By Joshua T. Goldman, MD, MBA

Resident Physician | UCLA Department of Family Medicine

Editor-in-Chief & Founder | House Call, MD | www.myhousecallmd.com

P: 760.409.4531 

Dear ME-P  Readers,

As many of you know, I have been working on a health education project called House Call, MD (www.myhousecallmd.com) for the past year and a half.  The idea was born out of the numerous questions people have about their bodies and illness but are unable to have them answered. Knowledge is incredibly powerful when dealing with one’s health but is not emphasized enough in the current health care system.  Doctors are spread increasingly thin and, unfortunately, aren’t given the time to answer the many questions patients have about their conditions and treatment. 

Enter House Call MD

That’s where House Call, MD comes in.  I have recruited an outstanding team of medical professionals that are skilled with the pen (or keyboard) to translate medical knowledge and research into articles for general population. Sounds a lot like WebMD, right?  After you take a look, we hope you will think otherwise.  We’ve taken a unique approach at House Call, MD specifically because we don’t think that the WebMD’s of the world are doing the trick. What’s different about House Call, MD?

The Difference

  • Real Doctor, Real Medicine: Our articles are written by medical professionals (not reporters) and supported by published scientific research.  When we publish it, you know it’s been proven.
  • Medicine that Matters:   WebMD is great when you’ve developed a strange rash that you are attempting to self-diagnose but it’s not the best place to find riveting medical information that you’ll enjoy reading.  We bring you medicine in context.  Our articles are based on things taking place in society today.  We translate that information into straightforward take home messages you can apply to your everyday life.  Medicine you want to know about delivered in a usable way.    
  • Enjoyable Reading: It’s hard to relate to medical professionals.  They speak in a foreign language.  They not around long enough for all your questions.  Our medical professionals are different.  They listen.  They’re funny (most of the time).  They’ve been patients just like you. Most importantly, they speak in a language you can understand and will enjoy reading.
  • Multi-Disciplinary Medicine: Health is complex and multi-factorial.  As such, we’ve taken a team approach at House Call, MD, including pharmacists, dietitians, physical therapists and nurses on our staff, all of whom share their unique expertise.     

I would love your support in trying to share our unique approach to health and wellness with the world.  How can you help support House Call, MD? 

Support 

Ten great ways to show your support:

  1. Sign up for our Healthy Dose Newsletter: http://www.myhousecallmd.com/subscribe
  2. Send it to your friends and family (and forward this e-mail…especially to people in different states, countries, industries)
  3. Tweet it out: http://twitter.com/HouseCallMD 
  4. ‘Like’ it on Facebook: http://www.facebook.com/HouseCallMD
  5. Tell your Doctor (we have a newsletter for primary care doctor’s practices)
  6. Tell your Corporate Wellness Program/College Health Center (we also have a wellness newsletter for corporate & college health programs)
  7. Make it your Facebook status update/GChat status/Linkedin Update
  8. Send it to press you know (We call it cost-efficient health care reform, Mr. President)
  9. Send it around the office
  10. Oh yeah, read the articles!

Twitter: http://twitter.com/HouseCallMD

Facebook: http://www.facebook.com/HouseCallMD

Assessment 

Most importantly, we are always looking for new ways to improve our articles and share our message with a broader audience.  Don’t hesitate to let me know if you have any brilliant ideas.  I can’t thank you enough for your support. Hoping to make the world a healthier place, one article at a time

-Josh Goldman MD MBA

Editor’s Note: We are also pleased to introduce Dr. Goldman as our newest ME-P “thought-leader” and look ahead to his comments and posts. 

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Give www.myhousecallmd.com a click, and tell us what you think? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

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What Does Health Reform Mean to You?

A Health Reform Pamphlet from the NCPA

By Staff Reporters

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The new health care legislation will impact every American. The National Center for Policy Analysis [NCPA] has created a new pamphlet, “What Does Health Reform Mean for You? It explains the new legislation’s major points in a succinct and unbiased way.

Content Overview

The contents of the pamphlet are reviewed below:

http://www.ncpa.org/healthreform/

Full Report

The full report is available here.

Link: What-Does-Health-Reform-Mean-for-You-A-Consumers-Guide

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

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