KOHALA HOSPITAL
1. Target Overview & Investment Thesis
KOHALA HOSPITAL is a 25-bed safety-net/medicaid heavy in HAWAII, HI with $19.7M in net patient revenue and a 10.2% operating margin. The hospital serves a payer mix of 7.5% Medicare, 70.5% Medicaid, and 22.0% commercial.
Thesis: Turnaround. Our ML models identify $1.4M in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from 10.2% to 17.5% (+736bps).
| Net Revenue HCRIS | $19.7M |
| Current EBITDA COMPUTED | $2.0M |
| Operating Margin COMPUTED | 10.2% |
| Occupancy HCRIS | 79.8% |
| Revenue / Bed COMPUTED | $787K |
| Net-to-Gross HCRIS | 78.9% |
| Distress Probability ML | 62.5% |
2. Market Context & Competitive Position
HI has 26 Medicare-certified hospitals with a median operating margin of -14.7%. The target's margin of 10.2% places it above the state median. Among 2513 size-comparable peers (12-50 beds), the median margin is -6.3%. The target performs in line with or above peers.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (12-50), prioritizing same-state peers. 2513 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| KOHALA HOSPITAL (Target) | HI | 25 | $19.7M | 10.2% |
| DANA-FARBER CANCER INSTITUTE | MA | 30 | $1.88B | -35.1% |
| FRED HUTCHINSON CANCER CENTER | WA | 20 | $1.17B | -50.0% |
| MERCY WALWORTH HOSPITAL | WI | 25 | $616.4M | 4.4% |
| MOUNTAIN VIEW HOSPITAL | ID | 43 | $382.5M | 8.7% |
| WISE HEALTH SYSTEM - PARKWAY | TX | 36 | $361.0M | -15.5% |
| CORYELL MEMORIAL HOSPITAL | TX | 25 | $305.9M | -1.5% |
| VALLEY VIEW HOSPITAL | CO | 31 | $285.3M | -3.1% |
| TAHOE FOREST HOSPITAL | CA | 25 | $264.3M | 13.0% |
4. Predicted Improvement Opportunities
Improvement targets set at P75 of comparable peers with 60% gap closure assumption. Coefficients calibrated to published research bands. Total EBITDA uplift: $1.4M (736bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $413K | +210bp | 18mo |
| Cost to Collect | 4.5% | 2.5% | $393K | +200bp | 12mo |
| Denial Rate Reduction | 12.0% | 6.5% | $389K | +198bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $239K | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $13K | +6bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $2.0M |
| + RCM Uplift | +$1.4M |
| Pro Forma EBITDA | $3.4M |
| Current Margin | 10.2% |
| Pro Forma Margin | 17.5% |
| WC Released (1x) | $755K |
6. Returns Analysis — Scenario Matrix
5-year hold, 5.5x leverage, 3% organic growth, 10%/yr debt paydown. Base case uses 100% of predicted RCM uplift. Bull case: 130% uplift at lower entry. Bear case: 50% uplift at higher entry.
| Scenario | Entry | Exit | Equity In | Equity Out | MOIC | IRR |
|---|---|---|---|---|---|---|
| Base Case | 10.0x | 10.0x | $3.1M | $27.7M | 9.00x | 55.2% |
| Base (11x exit) | 10.0x | 11.0x | $3.1M | $31.4M | 10.22x | 59.2% |
| Bull Case | 9.0x | 11.0x | $2.8M | $37.2M | 13.45x | 68.2% |
| Bull (12x exit) | 9.0x | 12.0x | $2.8M | $41.4M | 14.97x | 71.8% |
| Bear Case | 11.0x | 10.0x | $3.4M | $19.4M | 5.74x | 41.9% |
| Bear (11x exit) | 11.0x | 11.0x | $3.4M | $22.5M | 6.64x | 46.0% |
7. Key Risks & Mitigants
| Severity | Risk Factor | Mitigant |
|---|---|---|
| Medium | Elevated Medicaid exposure (70.5%) | Medicaid reimburses below cost in most states. Mitigant: denial reduction lever has highest impact on Medicaid claims |
| High | Elevated distress probability | Model estimates 62.5% probability of financial distress. Mitigant: distressed entry pricing (7-9x) compensates for risk |
8. Data Sources & Methodology Appendix
Data Sources
- CMS HCRIS Cost Reports (Medicare-certified hospitals)
- CMS Medicare Utilization (DRG-level volumes)
- CMS Chronic Conditions (county-level disease prevalence)
- HCRIS multi-year trend data (financial time series)
Comparable Selection
- 2513 hospitals with 12-50 beds
- Same-state prioritization (n=7)
- Comp margins: P25=-18.7% / P50=-6.3% / P75=4.4%
Bridge Methodology
- Targets: P75 of comparable peers (60% gap closure)
- Denial: avoidable share = 35% of delta × NPR
- AR: bad debt coefficient = $0.65 per day per $1K NPR
- NCR: 60% coefficient on collection rate improvement
- CDI: 0.75% of Medicare revenue per 0.01 CMI point
Returns Assumptions
- Leverage: 5.5x entry (84.6% debt / 15.4% equity)
- Organic growth: 3% annual EBITDA growth
- Debt paydown: 10% of principal per year
- Hold period: 5 years
Generated by SeekingChartis on April 26, 2026. All predictions use public data only. Confidence intervals calibrated via split conformal prediction (90% coverage target). This memo is for informational purposes and does not constitute investment advice.