KEOKUK AREA HOSPITAL
1. Target Overview & Investment Thesis
KEOKUK AREA HOSPITAL is a 49-bed rural/critical access in LEE, IA with $7.2M in net patient revenue and a -100.0% operating margin. The hospital serves a payer mix of 65.6% Medicare, 1.1% Medicaid, and 33.3% commercial.
Thesis: Turnaround. Our ML models identify $541K in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from -100.0% to -92.6% (+749bps).
| Net Revenue HCRIS | $7.2M |
| Current EBITDA COMPUTED | $-7.2M |
| Operating Margin COMPUTED | -100.0% |
| Occupancy HCRIS | 3.4% |
| Revenue / Bed COMPUTED | $147K |
| Net-to-Gross HCRIS | 32.0% |
| Distress Probability ML | 61.2% |
2. Market Context & Competitive Position
IA has 124 Medicare-certified hospitals with a median operating margin of -8.2%. The target's margin of -100.0% places it below the state median. Among 75 size-comparable peers (24-98 beds), the median margin is -7.2%. The target's below-peer margin suggests operational improvement opportunity.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (24-98), prioritizing same-state peers. 75 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| KEOKUK AREA HOSPITAL (Target) | IA | 49 | $7.2M | -100.0% |
| TRINITY REGIONAL MEDICAL CENTE | IA | 44 | $140.4M | -6.8% |
| THE FINLEY HOSPITAL | IA | 66 | $121.7M | 0.1% |
| PELLA REGIONAL HEALTH CENTER | IA | 25 | $108.8M | -16.6% |
| SPENCER MUNICIPAL HOSPITAL | IA | 49 | $108.7M | -10.3% |
| TRINITY BETTENDORF | IA | 81 | $90.6M | -3.7% |
| GREATER REGIONAL MEDICAL CENTE | IA | 25 | $89.4M | -4.4% |
| ST. ANTHONY REGIONAL HOSPITAL | IA | 49 | $84.0M | -21.0% |
| WINNESHIEK MEDICAL CENTER | IA | 25 | $77.6M | -0.1% |
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: $541K (749bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $152K | +210bp | 18mo |
| Denial Rate Reduction | 12.0% | 6.5% | $147K | +204bp | 12mo |
| Cost to Collect | 4.5% | 2.5% | $144K | +200bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $88K | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $10K | +13bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $-7.2M |
| + RCM Uplift | +$541K |
| Pro Forma EBITDA | $-6.7M |
| Current Margin | -100.0% |
| Pro Forma Margin | -92.6% |
| WC Released (1x) | $277K |
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 | $-11.1M | $-42.3M | 0.00x | -100.0% |
| Base (11x exit) | 10.0x | 11.0x | $-11.1M | $-50.1M | 0.00x | -100.0% |
| Bull Case | 9.0x | 11.0x | $-10.0M | $-52.0M | 0.00x | -100.0% |
| Bull (12x exit) | 9.0x | 12.0x | $-10.0M | $-59.7M | 0.00x | -100.0% |
| Bear Case | 11.0x | 10.0x | $-12.2M | $-41.4M | 0.00x | -100.0% |
| Bear (11x exit) | 11.0x | 11.0x | $-12.2M | $-49.5M | 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 |
| Medium | Heavy Medicare dependence | Medicare comprises 65.6% of days; rate updates may lag inflation. Mitigant: CDI/CMI lever directly increases Medicare reimbursement |
| Medium | Low occupancy | At 3.4%, fixed costs are spread over fewer patient days. Mitigant: volume growth is an additional upside lever not modeled in base case |
| High | Elevated distress probability | Model estimates 61.2% 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
- 75 hospitals with 24-98 beds
- Same-state prioritization (n=76)
- Comp margins: P25=-13.3% / P50=-7.2% / P75=-2.9%
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.