KOOTENAI HOSPITAL DISTRICT
1. Target Overview & Investment Thesis
KOOTENAI HOSPITAL DISTRICT is a 324-bed suburban community hospital in KOOTENAI, ID with $656.5M in net patient revenue and a -24.6% operating margin. The hospital serves a payer mix of 31.4% Medicare, 19.7% Medicaid, and 48.9% commercial.
Thesis: Undervalued. Our ML models identify $48.3M in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from -24.6% to -17.2% (+736bps).
| Net Revenue HCRIS | $656.5M |
| Current EBITDA COMPUTED | $-161.4M |
| Operating Margin COMPUTED | -24.6% |
| Occupancy HCRIS | 72.9% |
| Revenue / Bed COMPUTED | $2.0M |
| Net-to-Gross HCRIS | 37.8% |
| Distress Probability ML | 47.3% |
2. Market Context & Competitive Position
ID has 51 Medicare-certified hospitals with a median operating margin of -3.5%. The target's margin of -24.6% places it below the state median. Among 1423 size-comparable peers (162-648 beds), the median margin is -3.6%. The target's below-peer margin suggests operational improvement opportunity.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (162-648), prioritizing same-state peers. 1423 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| KOOTENAI HOSPITAL DISTRICT (Target) | ID | 324 | $656.5M | -24.6% |
| ST. LUKES HOSPITAL | PA | 633 | $8.94B | 87.9% |
| MEMORIAL HOSPITAL FOR CANCER A | NY | 514 | $4.34B | -32.5% |
| U OF U HOSPITALS & CLINICS | UT | 616 | $2.72B | -1.8% |
| UNIVERSITY OF WI HOSPITALS & C | WI | 644 | $2.68B | 3.2% |
| RONALD REAGAN UCLA | CA | 446 | $2.62B | -6.8% |
| OHSU HOSPITAL AND CLINICS | OR | 549 | $2.57B | -6.3% |
| LUCILE PACKARD CHILDRENS HOSPI | CA | 394 | $2.39B | -0.8% |
| UNIVERSITY OF MIAMI HOSP & CLI | FL | 532 | $2.36B | 0.9% |
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: $48.3M (736bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $13.8M | +210bp | 18mo |
| Cost to Collect | 4.5% | 2.5% | $13.1M | +200bp | 12mo |
| Denial Rate Reduction | 12.0% | 6.5% | $13.0M | +198bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $8.0M | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $420K | +6bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $-161.4M |
| + RCM Uplift | +$48.3M |
| Pro Forma EBITDA | $-113.1M |
| Current Margin | -24.6% |
| Pro Forma Margin | -17.2% |
| WC Released (1x) | $25.2M |
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 | $-248.3M | $-581.4M | 0.00x | -100.0% |
| Base (11x exit) | 10.0x | 11.0x | $-248.3M | $-720.2M | 0.00x | -100.0% |
| Bull Case | 9.0x | 11.0x | $-223.5M | $-641.4M | 0.00x | -100.0% |
| Bull (12x exit) | 9.0x | 12.0x | $-223.5M | $-765.7M | 0.00x | -100.0% |
| Bear Case | 11.0x | 10.0x | $-273.1M | $-742.4M | 0.00x | -100.0% |
| Bear (11x exit) | 11.0x | 11.0x | $-273.1M | $-905.4M | 0.00x | -100.0% |
7. Key Risks & Mitigants
| Severity | Risk Factor | Mitigant |
|---|---|---|
| High | Negative operating margin | RCM uplift bridge shows clear path to profitability; working capital release provides near-term cash cushion |
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
- 1423 hospitals with 162-648 beds
- Same-state prioritization (n=5)
- Comp margins: P25=-13.1% / P50=-3.6% / P75=5.8%
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.