ST. AGNES HOSPITAL
1. Target Overview & Investment Thesis
ST. AGNES HOSPITAL is a 183-bed suburban community hospital in BALTIMORE CITY, MD with $506.7M in net patient revenue and a -12.2% operating margin. The hospital serves a payer mix of 35.7% Medicare, 10.6% Medicaid, and 53.6% commercial.
Thesis: Undervalued. Our ML models identify $37.3M in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from -12.2% to -4.9% (+736bps).
| Net Revenue HCRIS | $506.7M |
| Current EBITDA COMPUTED | $-62.0M |
| Operating Margin COMPUTED | -12.2% |
| Occupancy HCRIS | 78.3% |
| Revenue / Bed COMPUTED | $2.8M |
| Net-to-Gross HCRIS | 72.1% |
| Distress Probability ML | 46.2% |
2. Market Context & Competitive Position
MD has 59 Medicare-certified hospitals with a median operating margin of -8.3%. The target's margin of -12.2% places it below the state median. Among 32 size-comparable peers (92-366 beds), the median margin is -7.9%. The target's below-peer margin suggests operational improvement opportunity.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (92-366), prioritizing same-state peers. 32 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| ST. AGNES HOSPITAL (Target) | MD | 183 | $506.7M | -12.2% |
| MERCY MEDICAL CENTER | MD | 173 | $561.3M | -3.3% |
| MEDSTAR FRANKLIN SQUARE MEDICA | MD | 354 | $537.6M | -5.7% |
| TIDALHEALTH PENINSULA REGIONAL | MD | 230 | $493.4M | 0.8% |
| BALTIMORE WASHINGTON MEDICAL C | MD | 314 | $440.2M | -7.9% |
| GREATER BALTIMORE MEDICAL CENT | MD | 265 | $420.3M | -48.5% |
| MEDSTAR UNION MEMORIAL HOSPITA | MD | 191 | $409.3M | -8.7% |
| ST. JOSEPH MEDICAL CENTER | MD | 225 | $398.0M | -3.2% |
| MERITUS MEDICAL CENTER | MD | 265 | $396.2M | 1.5% |
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: $37.3M (736bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $10.6M | +210bp | 18mo |
| Cost to Collect | 4.5% | 2.5% | $10.1M | +200bp | 12mo |
| Denial Rate Reduction | 12.0% | 6.5% | $10.0M | +198bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $6.2M | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $324K | +6bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $-62.0M |
| + RCM Uplift | +$37.3M |
| Pro Forma EBITDA | $-24.7M |
| Current Margin | -12.2% |
| Pro Forma Margin | -4.9% |
| WC Released (1x) | $19.4M |
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 | $-95.4M | $-36.3M | 0.00x | -100.0% |
| Base (11x exit) | 10.0x | 11.0x | $-95.4M | $-70.9M | 0.00x | -100.0% |
| Bull Case | 9.0x | 11.0x | $-85.9M | $21.1M | 0.00x | -100.0% |
| Bull (12x exit) | 9.0x | 12.0x | $-85.9M | $-2.3M | 0.00x | -100.0% |
| Bear Case | 11.0x | 10.0x | $-105.0M | $-191.8M | 0.00x | -100.0% |
| Bear (11x exit) | 11.0x | 11.0x | $-105.0M | $-245.0M | 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
- 32 hospitals with 92-366 beds
- Same-state prioritization (n=33)
- Comp margins: P25=-12.7% / P50=-7.9% / P75=-2.4%
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.