MERCY HOSPITAL IOWA CITY
1. Target Overview & Investment Thesis
MERCY HOSPITAL IOWA CITY is a 211-bed under-performing / distressed in JOHNSON, IA with $144.6M in net patient revenue and a -28.1% operating margin. The hospital serves a payer mix of 35.1% Medicare, 7.4% Medicaid, and 57.5% commercial.
Thesis: Undervalued. Our ML models identify $10.6M in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from -28.1% to -20.8% (+736bps).
| Net Revenue HCRIS | $144.6M |
| Current EBITDA COMPUTED | $-40.7M |
| Operating Margin COMPUTED | -28.1% |
| Occupancy HCRIS | 26.5% |
| Revenue / Bed COMPUTED | $685K |
| Net-to-Gross HCRIS | 22.6% |
| Distress Probability ML | 55.0% |
2. Market Context & Competitive Position
IA has 124 Medicare-certified hospitals with a median operating margin of -8.2%. The target's margin of -28.1% places it below the state median. Among 15 size-comparable peers (106-422 beds), the median margin is -12.8%. The target's below-peer margin suggests operational improvement opportunity.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (106-422), prioritizing same-state peers. 15 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| MERCY HOSPITAL IOWA CITY (Target) | IA | 211 | $144.6M | -28.1% |
| MERCY MEDICAL CENTER | IA | 216 | $401.1M | -12.8% |
| GENESIS MEDICAL CENTER - DAVEN | IA | 322 | $391.9M | -7.6% |
| MERCYONE NORTH IOWA MEDICAL CE | IA | 199 | $390.3M | -30.9% |
| ST. LUKES METHODIST HOSPITAL | IA | 281 | $374.8M | 23.6% |
| SOUTHEAST IOWA REGIONAL MEDICA | IA | 174 | $302.1M | -24.2% |
| MERCYONE WATERLOO MEDICAL CENT | IA | 134 | $283.3M | -5.1% |
| ALLEN MEMORIAL HOSPITAL | IA | 189 | $271.3M | 1.8% |
| MARY GREELEY MEDICAL CENTER | IA | 150 | $220.4M | -3.6% |
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: $10.6M (736bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $3.0M | +210bp | 18mo |
| Cost to Collect | 4.5% | 2.5% | $2.9M | +200bp | 12mo |
| Denial Rate Reduction | 12.0% | 6.5% | $2.9M | +198bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $1.8M | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $93K | +6bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $-40.7M |
| + RCM Uplift | +$10.6M |
| Pro Forma EBITDA | $-30.0M |
| Current Margin | -28.1% |
| Pro Forma Margin | -20.8% |
| WC Released (1x) | $5.5M |
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 | $-62.5M | $-161.7M | 0.00x | -100.0% |
| Base (11x exit) | 10.0x | 11.0x | $-62.5M | $-198.2M | 0.00x | -100.0% |
| Bull Case | 9.0x | 11.0x | $-56.3M | $-183.4M | 0.00x | -100.0% |
| Bull (12x exit) | 9.0x | 12.0x | $-56.3M | $-216.7M | 0.00x | -100.0% |
| Bear Case | 11.0x | 10.0x | $-68.8M | $-194.6M | 0.00x | -100.0% |
| Bear (11x exit) | 11.0x | 11.0x | $-68.8M | $-236.4M | 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 |
| Medium | Low occupancy | At 26.5%, 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 55.0% 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
- 15 hospitals with 106-422 beds
- Same-state prioritization (n=16)
- Comp margins: P25=-25.0% / P50=-12.8% / P75=-4.3%
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.